Review of Atul Gawande’s Being Mortal

Atul Gawande, for those who have not yet read his books, is at once a writer, surgeon, and professor at the Harvard School of Public Health and at Harvard Medical School. Each of his prior books has been on the New York Times bestseller list: Complications: A Surgeon’s Notes on an Imperfect Science (2002), Better: A Surgeon’s Notes on Performance (2007), and The Checklist Manifesto: How to Get Things Right (2009). Not surprisingly, his latest work, Being Mortal: Medicine and What Matters in the End (2014), has followed the trend. It is about death, a difficult topic to treat well. But, according to reviews from literary giants like Malcolm Gladwell and Oliver Sacks, Atul Gawande has done so.[i]

Gawande writes about how medicine changed the way we see mortality. Before the advent of tested medication, diseases had to be waited out; now, however, doctors can draw from an enormous amount of research-based knowledge to treat patients. If a patient dies, it is often because the physician did not know enough—we say the doctor has failed. But, Being Mortal says this is the wrong way to see it. Mortality is unchangeable and should not be a doctor’s fault. Instead, he says, we need to learn to accept death as inevitable and understand that sometimes what makes life worth living should be valued over simple preservation.

“The one time I remember discussing mortality was during an hour we spent on The Death of Ivan Ilyich, Tolstoy’s classic novella,” writes Gawande.[ii] Ilyich is a character on his deathbed who suffers under the care of an endless series of doctors, none of whom can help. “What tormented Ivan Ilyich most,” Tolstoy writes, “was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result.”[iii] Gawande said his class interpreted this lack of acceptance (which, if had, could have given Ilyich peace) as a “failure of character and culture.”[iv] But, he also thinks we have not gotten much better— Gawande sees Ilyich’s story reincarnated in hospitals all the time. Medicine tries to prevent dying, but it does not bother with the process itself. In the rest of Being Mortal, Gawande addresses these questions: what is important in the end? And what can we do to preserve that?

Alice Hobson was Gawande’s grandmother-in-law. Her role in his book is to show that safety and comfort alone are not what people need to be happy, although we often think they are. Hobson was forced to leave her condominium because of her deteriorating health, chose a nursing home, and found she hated it. She passed away soon after arranging a ‘Do Not Resuscitate’ order for herself. Gawande writes, “The trouble was that she expected more from life than safety. ‘I know I can’t do what I used to,’ she said, ‘but this feels like a hospital, not a home.’”v What is it, then, that makes a rich and happy life?

Being Mortal theorizes that the answer depends on how we perceive our lives. Gawande describes a study done by Nobel laureate Daniel Kahneman and University of Toronto physician Donald Redelmeier, in which patients ranked their pain levels during and after colonoscopy and kidney stone procedures. One would think, he says, “that the final ratings would represent something like the sum of the moment-by-moment ones…but this wasn’t what the patients reported at all.”[vi] Kahneman and Redelmeier discovered a ‘Peak-End Rule’ phenomenon that went against this assumption. It turned out that patients’ final ratings were actually an average of only two moments: the worst part and final part of the procedure.

C.S. Lewis wrote about something similar in The Great Divorce. The following is a fictional conversation between two characters, the first of which is on a trip out of hell into heaven.

“But I don’t understand. Is judgment not final? Is there really a way out of Hell into Heaven?” “It depends on the way you’re using the words. If they leave that grey town behind it will not have been Hell…both good and evil, when they are full grown, become retrospective… Heaven, once attained, will work backwards and turn [temporal agony into glory]…damnation will spread back and back into their past and contaminate the pleasure [of sin].”[vii]

To put all this in a phrase, we see things in stories. We remember the periods in which things happen. “Time is this rubbery thing,” says David Eagleman in a New Yorker article by Burkhard Bilger. Eagleman is an assistant professor of neuroscience at Baylor College of Medicine. “It stretches out when you really turn your brain resources on, and when you say, ‘Oh, I got this, everything is as expected,’ it shrinks up.”[viii] When a man named Michel Siffre spent two months in a cave as part of an experiment, he left it thinking only one month had passed because everything had been so routine.[ix]

Gawande shows that safety and comfort are not the most important things in a meaningful life, and what does matter depends on how we perceive time. He draws on other sources to say what makes living worthwhile, including writing from 1908 by a Harvard philosopher named Josiah Royce. “We all seek a cause beyond ourselves. This was, to [Royce], an intrinsic human need…In ascribing value to the cause and seeing it as worth making sacrifices for, we give our lives meaning.” Royce says this loyalty does not necessarily make a person happier, but it makes life endurable. “Without it, we have only our desires to guide us, and they are fleeting, capricious, and insatiable…The only way death is not meaningless is to see yourself as part of something greater. If you don’t, mortality is only a horror.”[x]

Gawande is not a religious writer, but these conclusions make sense in a Christian context. David Foster Wallace noted in his famous commencement speech, “This is Water,” that “an outstanding reason for choosing some sort of God or spiritual-type thing to worship…is that pretty much anything else you worship will eat you alive…[Y]ou will never have enough.”[xi] Money, power, or intellect will consume you. What is worth your loyalties are other living things and God—sources of input to your life, things that can give back. And God, as this perfect entity, is the one thing for which this is true, that also will not die.

If we see things in stories (as evidenced by Kahneman’s ‘Peak-End Rule’ and Lewis’s ideas on retrospection), then the shape of our narratives determines whether our lives have meaning. Andrew Stanton gave a TED Talk in 2012 about what makes a good character, part of which is copied here. Stanton works for Pixar, and has written or been a part of writing A Bug’s Life, Finding Nemo, WALL-E, the Toy Story films, and Monsters, Inc.

“I took a seminar…with an acting teacher named Judith Weston,” he said.

“She believed that all well-drawn characters have a spine…an inner motor, a dominant, unconscious goal that they’re striving for, an itch that they can’t scratch…It’s something that always drove all [the characters’ choices].”

Stanton readily applied Weston’s idea to his own work. “Wall-E’s [spine] was to find the beauty. Marlin’s, the father in Finding Nemo, was to prevent harm. And Woody’s was to do what was best for his child.”[xii]

We are drawn to stories and see our lives in stories. “In the end, people don’t view their life as merely the average of all of its moments,” writes Gawande. “Life is meaningful because it is a story…its arc is determined by the significant moments, the ones where something happens. A seemingly happy life may be empty. A seemingly difficult life may be devoted to a great cause.”[xiii] As Lewis said, a great cause might redeem any suffering for it, and endings can redeem pain. If we are Christians, we know our endings—so how should that shape our lives? By knowing which moments are going to matter, versus the ones that are totally ephemeral, how does this change the way we live? And if we are not Christians, how would our priorities shift as a result?

Our personalities and lives are made up of our memories, which are further split into two parts: the experiencing self and the remembering self, as Kahneman and Gawande define them. The experiencing self is gone as each moment passes, whereas the remembering self is the one that follows these stories so closely. Yet, Gawande says, both the experiencing self and the remembering self factor in when we make decisions. Since the remembering self is so biased, it cannot always make the best choices—at the same time, as noted before, the experiencing self is gone the moment it has existed. It is hard to decide whether to treat a patient or not; a doctor does not know whether the treatment will be worth the risk. Many times, it is not. And short pleasures, living a meaningful life up until the end, can sometimes make up for prolonged suffering. So, dying in hospice, at peace with a good ending and with family and friends, is not implicitly a medical failure. Gawande, however, does add this:

I am leery of suggesting the idea that endings are controllable…But we are not helpless either… Our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life.[xiv]

i. “Being Mortal: Medicine and What Matters in the End,” Atul Gawande, 12 January 2015,<atulgawande.com/book/being-mortal/>.
ii. Atul Gawande, Being Mortal: Medicine and What Matters in the End (New York: Metropolitan Books, 2014), 1-2.
iii. Lev N. Tolstoy, The Death of Ivan Ilyich, trans. Louise and Aylmer Maude (An Electronic Classics
Series Publication, 1998-2013), 41.
iv. Gawande, 1-2.
v. Gawande, 74-5.
vi. Gawande, 237.
vii. C.S. Lewis, The Complete C.S. Lewis Signature Classics (New York: HarperCollins Publishers, 2002), 502-503.
viii. Burkhard Bilger, “The Possibilian,” The New Yorker, 12 January 2015, <www.newyorker.com/magazine/2011/04/25/the-possibilian>.
ix. Joshua Foer and Michel Siffre, “Caveman: An Interview with Michel Siffre,” Cabinet Magazine, 12 January 2015, <www.cabinetmagazine.org/issues/30/foer.php>.
x. Gawande, 126-7.
xi. David F. Wallace, “Transcription of the 2005 Kenyon Commencement Address – May 21, 2005,” Purdue University, 12 January 2015, < http://web.ics.purdue.edu/~drkelly/DFWKenyonAddress2005.pdf>.
xii. Andrew Stanton, “The Clues to a Great Story,” TED Conferences, 12 January 2015, <www.ted.com/talks/andrew_stanton_the_clues_to_a_great_story>.
xiii. Gawande, 238.
xiv. Gawande, 243.

 

Chenchen Li ’18 is from Richland, WA. She is a prospective major in Physics modified with Biology.

Tags: , , , , , , , , , , , , , , , , , , , ,