Medicine & What Matters in the End by Atul Gawande

Dyman Associates Publishing Inc. Reviews on Being Mortal -- Atul Gawande, a Boston surgeon explores the issues of aging and death in this book which, among other books dealing with the same subjects, echoes the driving desire for awareness of the human condition in terms of longevity and living a meaningful life.

We all want a long and meaningful life and yet the reality is that sickness and the onset of aging and its debilitating issues ironically and invariably reduces our capacity to achieve the second precondition: enjoying, not just enduring, life to the very end.

But who among the aged or the truly advanced in age have lived to savor life with the same zest or, if not, to a degree proportional to one’s age? For instance, we do not expect the aged to play tennis or to go kayaking as the younger do. But to play pingpong even for a few minutes or to take a leisurely boat ride would do for most elderly people as a worthwhile recreation. Opposed to sitting alone in one’s room or lying for days in bed, such interactive activities would make for a truly meaningful life for old people.

And this is what Gawande hopes to spell out in his book: the challenge of individuals, families and governments to shift the emphasis from merely attaining longevity to that of achieving quality life for the aged. That instead of “infantalising” the old, that is, treating them as delicate and vulnerable infants, we should make them feel they have the freedom and capability to do things within their capacity to perform and to accept the consequences as adults and not as mindless infants. In short, they deserve the respect they have achieved just by living long enough to know what they are willing to embrace and to take on whatever risks they choose to undergo. Some prefer to go out with their boots on; why cannot the old also do so wearing pants or skirts and not pajamas?

The author, in fact, points to the phrase “nursing home” as having an imbalanced priority in the minds of most people, particularly those who run them. The focus seems to be on “nursing”; hence, we have ended up with nothing more than institutions – no, virtual hospitals or prisons – where the aged are not allowed to lead completely normal lives but are literally confined or guarded as sickly or danger-prone people. There is no longer the desire to establish the real “home” which they and all of us deserve to have until we depart from this world.

Even Gawande, whose Indian descent has made him aware of the traditional role of the family as the caregiver of the aged, bursts the idea of that supposedly “better option” for the old. As if the traditional way was more representative of true love and caring for the old. The establishment of hospices and nursing homes in the west has, in a way, helped to sustain society’s concern for the aged, especially those who no longer have a family to support them in their late years. It is not, we are reminded, the institutions themselves that are wanting but the way we have run them and the way we have used them to perpetuate a misconceived attitude toward the old.

The paradox of modern health care then revolves around having reduced or eliminated the deadly diseases; yet, we have not totally solved the effects of aging, per se. In short, it is the ultimate “disease” we have been carrying around like a hefty bank deposit from the time of our birth which we spend as we wish until the time when we will have exhausted it and the great Banker in Heaven calls us for a final accounting. But Gawande’s, unfortunately, book does not deal with the spiritual aspect of aging or dying, only the medical dimension.

While the first part of the book deals with aging and how we can die with self-respect, the second part deals with palliative care (under the supervision of medical practitioners) and how we can die with grace. The author points the proverbial arrogance of doctors who cannot admit defeat in the face of terminal illness. Often, most doctors — and society, in general as well – have only recently recognized not just the need to prolong life but also to allow patients to flourish in life and to experience a “great death”.

We all want a great life; but not many would, as the ancient samurais cherished, to have a “good death”. It can happen in young age or later in life. But in the case of aging, what palliative care can do, which is what it should be good at, is to provide the complete care as well as the environment where the old can re-experience life within the limited or, what we could call the final dimension of living, they have been gifted with.

It seems ironic that the young have the energy yet lack the wisdom to savor life to the brim hwile the old have the wisdom but not the energy to re-experience life. Nevertheless, the old, with a little help from modern medicine, are on the verge of surpassing the young. And with the increasing population of the aged in almost all societies today, we are compelled to look at these issues and their future repercussions as Atul Gawande has done and to derive insights so that we can apply the lessons in our own lives and in the lives of those we care for.