Dr. Atul Gawande’s book, Being Mortal, is a remarkable and provocative work.
The most remarkable thing about it, however, may be that everyone I know is reading it. It has been on the New York Times best seller list for 19 weeks and counting. Try this: mention end-of-life decisions to any random group of friends and someone will bring up Gawande. Far from ignoring their own mortality, it seems as if people are hungry to hear about it, talk about it, think about it. We are practically the preached-to choir. We get it. Our time here is not eternal. We more than get it. We know that acceptance of one’s mortality has consequences not just for those last hours, days, weeks or months, but for all of our time between now and then. Gawande’s book, then, does not reveal some great secret that we have not known; rather, he puts the topic front and center and asks us not just to engage philosophically, but to allow our sense of mortality to guide us in making decisions about how we shall live the latter part of our lives, including but not limited to our choices about medical care.
Since the general public seems ever more ready to talk about Being Mortal (and not just the book, but the concept), isn’t it time for doctors to get on board? If Gawande is correct, the world of medicine is some kind of scrimmage between patients who want the truth about treatments and death, and doctors who mostly want to avoid these conversations and press on with therapies of sometimes marginal value. (And yes, there are exceptions in both camps.) With these groups working at cross-purposes, in a setting where doctors still wield power and patients are very sick, is it any wonder that our last days are a mess?
Most surprisingly, doctors seem at a loss in discussing death with their patients. In a recent Frontline documentary based on the book, one sees doctors trying—and failing--to tell a patient that her life is coming to an end. They call in the cavalry in the form of palliative care specialists, who bring a unique set of talents to bear in communicating with sick people about death. In one scene in the film, the patient’s doctor stands by, sympathetic but awkward.
Gawande and others have made the point that physicians consider themselves to be healers, defined as warriors with tools to slay the dragons of suffering and death. What if healing was not just that? I say not just that because as a cancer survivor I fully appreciate my gladiator-physicians. Chemo is, however, not everything. Not only can there be more, there has to be some movement beyond the give-me-a-hammer-and-everything-requires-a-nail mentality in health care. In his book’s epilog, Gawande says “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.”
I have trouble with some of the things in Gawande’s book, like whether true assisted living is possible for the average, not rich, person. I more than quibble with the seeming false dichotomy between palliative care and death-with-dignity movements. All of that is ripe for discussion for another day. Gawande has courageously pulled back the curtain and presented an opportunity. Before Being Mortal drops off the best seller list, while a moment of heightened public awareness and maybe even acceptance exists, can we all—patients and doctors alike—keep a sustained focus on this issue? And as the discussion swirls around us, can we start to identify even small and thoughtful steps on how we are going to change any and all of it?