A medic’s moving treatment of mortality offers us ways to improve the bedside manner. This is a thoughtful, and thoughtfully written, book: the prose is crisp and easily digestible, and Harvard Professor of Public Health (and giver of last year’s BBC Reith lectures) Atul Gawande is an absorbing story-teller, never making his personal anecdotes (his favourite form of delivery) too long or too moralizing. His subject: ‘the modern experience of mortality’. In this book, part-memoir, part-informative non-fiction, he records his own challenges in dealing with patients facing old age or terminal illness, describes the successes and failures in (mainly American) policy to bring purpose and satisfaction to the lives of such patients, and outlines his criticisms against the wholesale “medicalization” of mortality, how we are going wrong in our healthcare in preparing people for death.
A pathologist friend of mine recently remarked how hard it was becoming to die nowadays. Gawande would agree. Society is becoming “rectangularized” (think of the demographic pyramid: young at the bottom, old at the top), or less affectionately, there looms on the horizon a “silver tsunami”, and ours is the generation which will have to face it. Gawande doesn’t expressly address this burden awaiting public services; but he does set out (through both endorsement and critique, with many specific examples and statistics) the kinds of geriatric service which provide patients with spiritual nourishment and homely freedoms and the kinds which do not. His tussle is with the limits and possibilities of medicine as a discipline, as he returns to several times. ‘This experiment of making mortality a medical experience is just decades out. It is young. And the evidence is it is failing’ (p. 9). ‘The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had no view at all’ (p. 128). Lastly, in the 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’ (p. 259). In describing his own father’s late life, he records the opportunities given to him: surgery (followed by chemo); the choice of ten new doses or combinations of drugs; a later, different form of surgery (followed by chemo). At no point is a patient who faces a definitively or nearly definitely curtailed life-span given the option of walking away from the hospital without fear of abandonment. The choice, as Gawande has it, is ‘between neglect and institutionalization’, the problem is the ‘confusion of care with treatment’.
Doctors and surgeons, you realise, are not just prescribers of drugs and diagnoses; they are the modern-day psychopomps, and they require empathy and emotional judgment. Gawande candidly shows how difficult their jobs can be, and regularly are. He reveals his own struggles in learning how to deliver unwanted news both sensitively and clearly; he refers on more than one occasion to Tolstoy’s great novella, The Death of Ivan Ilyich (where the profound question is: how, if at all, can one die well?), in which the physicians all mutually and silently deny the medical reality: ‘the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill’. Gawande fights fiercely against this lie and self-lie, holding that though ‘a sense of mortality re-orders our desires, these desires are not impossible to satisfy’. Perspective, not age or illness, matters. This is a persuasive and at times a comic, not a sober or melancholy, read (honestly), recommended not just to all medical students (who, I’m sure, would find it instructive) but to anyone interested in exploring the contribution science can and cannot make to life (and emphasise, life) at the end.