One of the finest writers of our time returns with a powerful reflection on the decline and death of the body
The good doctor
Atul Gawande, one of America’s leading surgeons and finest writers, begins his new book with a curious confession: “I learned about a lot of things in medical school, but mortality wasn’t one of them." Those training to become physicians, he goes on to add, must necessarily be exposed to the fact of death, to its causes and manifestations—perhaps even become inured to it, to an extent—but to fully grasp the truth of mortality, its slow but inevitable progress, is another matter.
Modern doctors, Gawande argues, may have access to sophisticated medicine and superior technology, but usually it is their most “basic responsibilities", such as their capacity for “honesty and kindness", that prove to be the most onerous to fulfil than the ability to administer a course of treatment. As a result, longevity and life expectations may have increased globally, especially in the West, over the last decade, but it has not necessarily improved the quality of end-of-life care.
Coming from a highly regarded member of the profession, such a claim may seem polemical, but there remains more than a grain of truth in it. In spite of the existing and continuing advances of science, none of which Gawande belittles, there is at the heart of modern medicine an ethical conundrum: Should the sole purpose of clinical practice be the extension of life? Or should it, rather, aim at sustaining a certain quality of existence? How are the ravages of the ageing body and that dreaded adversary—disease—to be fought? Persistently, without any relief, at the expense of causing immense pain and humiliation to the subject? Or should doctors know when, and how, to bow out, and allow alternative modes of palliative therapy, such as hospice care, which Gawande highly recommends, to take their course?
While mostly focused on the US, Gawande glances at the reality of India at certain key moments in the narrative, usually to highlight the contrast between attitudes to geriatric care in the West and the East, inflected by factors such as the tolerance of the spectacle of death (until recently, most deaths used to happen in the privacy of the home, among the company of loved ones than medical equipment and relative strangers). He also draws on his personal experiences, such as the difference between the last years of his grandfather who lived in India till the age of 110 and that of his wife’s grandmother who lived well into her 80s in the US. These recollections are intense, humane, and emotionally charged, without losing the medical perspective and the reason for which they appear in the narrative.
Most of us already have, or will have to, confront the mortal questions at some stage—for our own sake, or for those who are close to us. In Gawande’s case, such reckonings are part of his relationship with the world. As a general surgeon, he is exposed to the trials and torments of the body on a daily basis. He is required to break the news of terminal illness to patients and their families, judge the degree to which the fragile human frame can survive further wear and tear, and decide if it is worth subjecting it to the incision of scalpels, another drip of a cocktail of drugs, or attach it to multiple tubes to prolong its existence. Yet, when the time comes for him to face the fact of his father’s cancer, he finds himself faltering, unable to choose between immediate and invasive surgery or waiting till the disease had progressed far enough to require such a debilitating procedure on an otherwise largely active and fit man in his 70s.
Being Mortal presents several such case studies in which Gawande, and some of his colleagues from across the spectrum of history, are compelled to make hard choices—usually between subjecting an already suffering, and incurable, body to further indignities and recommending a set of actions that could help alleviate its discomfort, perhaps even make the rest of its days on earth more bearable and meaningful.
While respectful of her fierce desire to live, Gawande uses Monopoli’s case to put the larger medical community, and its practices, under the scanner. “Our ultimate aim," he writes, “after all, is not a good death but a good life to the very end." It is not only the duty of modern medicine, Gawande argues, to embrace this principle but also to interpret the idea of “the good life" in accordance with the fullest wishes of those who depend on it for relief and counsel. He goes on to use this premise to explore one of the most crucial but neglected phenomenon of contemporary life—geriatric care.
Being Mortal—Medicine And What Matters In the End:
296 pages, 599.
With increased lifespans, the chances of populations across the world living into ripe old age have become significantly higher—though the means of battling frailty and infirmity have not evolved commensurately. A recognized if unpopular branch of specialization in the West, gerontology grapples with the challenge of providing care to the elderly by creating safe environments for them to spend their last years. The common practice of sending them to “nursing homes" (especially in the US) emphasises the need for restrictions on their habits and movements, with the well-meaning intention to prevent falls and fractures—but ends up inducing depression and alienation.
Gawande discusses experiments by pioneering gerontologists like Keren Wilson Brown, Laura Carstensen, and Bill Thomas to make the habitations for the elderly more homely, while respecting the autonomy of the residents as much as possible. In each case, the innovations were the outcome of the physician’s encounter with the fate of a loved one or the realization of a patient’s trauma for having to surrender all decision-making powers to unimaginative carers.
While Wilson championed the cause of “assisted living" that allowed the elderly to continue living the way they wished as long as they could while having a support system close by should they need help, Thomas managed to convince the authorities of his crazy idea of introducing two dogs, four cats and a hundred parakeets into the nursing home where he was working. In spite of the “glorious chaos" produced by the animals, the home went on to record a drop in death rates and rise in the levels of good cheer.