A deep dive into the two big ‘unfixable’s—aging and dying, and the role of Medicine at the intersection of the two.
Title: Being Mortal: Medicine and What Matters in the End
Author: Atul Gawande
Genre: Nonfiction (Medical)
Originally published: 7 October 2014
Finished reading: April 2018
I wrote this book review—longer than my usual concise ones—in response to a series of prompts. I hope that the different (somewhat book club-ish) style will stimulate your thinking. Enjoy!
In your own words, describe what the book is about.
With nous and clarity, the writer delves into the meaning of mortality; the innate essence of which transcends the simple denotation that we typically ascribe to the state of being alive. As modern medicine advances at a staggering pace, life is prolonged so much so that our dying days—or years, even—take on new, unrecognisable forms. Accompanying this change is a slew of implications, especially for professionals in medicine and healthcare.
The writer first touches on the topic of ageing; through several narratives, he elucidates the plight of the elderly due to age-related frailty, and the woeful inadequacy of society’s response. He then transitions to exploring cases of terminal illnesses, and the repercussions of decisions made by medical professionals, family members and individuals in confronting the tragedy.
Omnipresent through the chapters is the central theme of “mortality”—and what “being mortal” means. Ruminating on this theme from different angles and through an array of nuanced real-life stories, the writer leads the reader deeper and deeper into his personal meditation on how we can better live as we near the end of our lives.
Who do you think the author intended to read this book and why?
I feel that “Being Mortal” is the writer’s cogitation over the limitations in modern medicine and his personal response to the perturbing trends he has observed in his own medical career. In writing this book, he shares his insights with the society at large. Many perceive the genesis of this book to be borne out of the diagnosis of his father’s inoperable, life-threatening cancer in the spinal cord. However, Gawande shared in an interview that there were other things as well—
I had reached a midpoint in my own surgical career where I felt very comfortable with everything except dealing with my patients who had terminal illness, and I wanted to explore that.
It is also a call for change in the philosophy of healthcare. The writer argues that as medicine has advanced, so must the system and, perhaps even more importantly, the mindset of healthcare professionals. Those involved in geriatrics, palliative care, and in fact all members of the medical profession, have been fundamentally wrong about the core purpose of their job. Gawande writes,
We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive.
In putting forth this central argument that the ageing and dying process has been “medicalised”, I feel that the writer was definitely addressing the medical community in part, to inspire conversations and galvanise action—thereby fuelling change.
However, his audience is not solely limited to the medical sphere. Anyone reading this book can gain insights into this issue; his evocative prose can start the reader thinking about the myriad of personal and societal implications that such issues inevitably create. After all, we will all have to face the reality of our bodies’ eventual decline. We will all have to face death—and the remaining days of our life before death.
The issues that Gawande has raised concern every single one of us; they concern our society and our culture as a whole. That is exactly why I found it an engaging, thought-provoking read. I believe that his writing is not intended for the medical community alone.
Did this book give you any new ideas about yourself? Why?
What left the deepest impact on me was how the meaning of mortality is brought into question. Reading the book gave me many insights into pertinent issues surrounding medicine that are not so much about professional knowledge or expertise, but rather the ethical and personal aspects of medicine and what it aims to achieve.
Medical professionals focus on the repair of health, not the sustenance of the soul. Their focus is narrow. But these are the people who largely define our waning days. Medicine has been increasingly taking on the power to push against biological limits, but this can have potentially devastating effects if it ultimately inflicts greater suffering and goes against the patient’s wishes of how he would want to spend the last days of his life. In the traditional setting, patients are never sought out on their hopes, their fears, and the trade-offs that they are willing to make to stay alive. They are never given full autonomy in deciding what mortality means to them. Being mortal encompasses much more than simply being alive.
These are things I have never really reflected on until reading “Being Mortal”. I am now inclined to think that although it would be tough, we should be offering patients more choices and a greater say in the treatments that they are subjected to, especially nearing the end of their lives. Often, particularly in cases of terminally ill patients, pushing to do more may not give the best outcome. The exact opposite could be true. As Gawande aptly puts it:
Our ultimate goal, after all, is not a good death but a good life to the very end.
There were several enlightening excerpts, very well-phrased ideas that I found myself inwardly agreeing with or relating to. One such instance was at the opening of Chapter Eight, when the writer touches on the meaning of courage—a few short paragraphs, but extremely well-worded and succinct. Another moment came for me later in the same chapter, when the writer arrives at the conclusion that people do not view their lives as merely the average of all its moments; that life is meaningful because it is a story.
What was the problem in the book, and how was it solved? Do you approve of the resolution?
It could be said that the ‘problem’ in the book was how to approach ageing and dying alongside the developments of modern medicine. The larger, underlying ‘problem’ in this quagmire is the entire question of the meaning of “being mortal”.
Throughout the book, the writer gives ideas on how things could be changed. In the concluding chapters and the Epilogue, as the book drew to a close, many of the ideas were very well summed up:
Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.
The writer encapsulates some of his most powerful insights in the closing.
Nevertheless, I do not think there was a real ‘resolution’; the ideas take on their own form and meaning in the reader’s mind.
Would you recommend this book to others? If yes, to whom? (in terms of age, gender, area of interest)
I would definitely recommend this book to others. As I have mentioned, it is not constrained by profession; whether you have knowledge of medicine or not is unimportant.
I would say that perhaps a certain level of maturity in thinking should be reached before reading this book, to be able to fully appreciate and comprehend the deeper meanings that the writer wishes to convey.
I have to admit that in my first reading of the book, I stopped halfway, as I found myself not so keenly interested in the lengthy discussions of the eldercare sector that formed the bulk of the first half. When I reread the book from the beginning, I also found deeper resonance with the ideas and stories in the second part, on dying and mortality. Notwithstanding this, I found the whole book of great value. New understandings came to me when I revisited Gawande’s writings about ageing.
I believe that many will find value and meaning in this book, and I would recommend it to anyone—in adolescence or beyond—who is interested to delve into the question of mortality.
My favourite quotes from this book
(All quotes are arranged in chronological order as they appear in the book, with the chapters indicated in parentheses.)
Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet—and this is the painful paradox—we have decided that they should be the ones who largely define how we live in our waning days.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Chapter 5: A Better Life)
All we ask is to be allowed to remain the writers of our own story. That story is ever changing. Over the course of our lives, we may encounter unimaginable difficulties. Our concerns and desires may shift. But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Chapter 5: A Better Life)
As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world—to make choices and sustain connections to others according to their own priorities.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Chapter 5: A Better Life)
Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Chapter 8: Courage)
In the end, people don’t view their life as merely the average of all its moments—which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people’s minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Chapter 8: Courage)
Our ultimate goal, after all, is not a good death but a good life to the very end.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Chapter 8: Courage)
Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Epilogue)
We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?
― Atul Gawande, Being Mortal: Medicine and What Matters in the End (Epilogue)