12 DECEMBER, 2014
By: Maria Popova
How dying confers upon living “the courage to act on the truth we find.”
“I am not saying that we should love death,” wrote Rilke, perhaps humanity’s greatest sherpa of befriending our mortality, in a 1923 letter, “but rather that we should love life so generously, without picking and choosing, that we automatically include it (life’s other half) in our love.” In Being Mortal: Medicine and What Matters in the End (public library | IndieBound), second-generation surgeon Atul Gawande grants Rilke’s undying words a new dimension in his sublime contribution to the canon of befriending mortality, which stretches from Montaigne’s meditation on death and the art of living to Sherwin Nuland’s foundational treatise on how we die to Alan Lightman’s wisdom on our paradoxical longing for immortality. In his part-memoir, part-manifesto, Gawande sets out to shed light on our contemporary experience of dying — an experience that, it warrants remembering, begins at birth — and on “what it’s like to be creatures who age and die, how medicine has changed the experience and how it hasn’t, where our ideas about how to deal with our finitude have got the reality wrong.”
Gawande opens by noting the profound rift between anatomy and mortality in his medical education, bespeaking medicine’s general failure to prepare physicians for the most difficult yet deeply humanizing part of human life: our exit from it. “How the process unfolds, how people experience the end of their lives, and how it affects those around them,” he recalls, “seemed beside the point.”
But one particular work forever changed Gawande’s worldview as a student — and it wasn’t a medical text. It wasn’t written by a doctor, but by Leo Tolstoy, whose contemplation of the meaning of existence remains among the most important pieces of human wisdom ever committed to words. The work that so moved Gawande, however, was Tolstoy’s The Death of Ivan Ilyich and the following passage in particular:
What tormented Ivan Ilyich most 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.
Illustration from 'The Flat Rabbit,' an unusual Scandinavian children's book that helps make sense of death. Click image for more.
His tuition, Gawande suggests, went toward a similar deception — medicine’s insistence on isolating the inner workings of the body from the rich and often difficult inner life it houses, especially when that bodily abode begins to fall apart. He writes:
Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it.
Pointing out that over the past seven decades we have shifted from a culture where most deaths take place in the home to one where more than 80% occur in hospitals and nursing homes, Gawande laments our malignant attitude that casts death as a failure of both doctors and the dying:
Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.
You become a doctor for what you imagine to be the satisfaction of the work, and that turns out to be the satisfaction of competence. It is a deep satisfaction very much like the one that a carpenter experiences in restoring a fragile antique chest or that a science teacher experiences in bringing a fifth grader to that sudden, mind-shifting recognition of what atoms are. It comes partly from being helpful to others. But it also comes from being technically skilled and able to solve difficult, intricate problems. Your competence gives you a secure sense of identity. For a clinician, therefore, nothing is more threatening to who you think you are than a patient with a problem you cannot solve.
There’s no escaping the tragedy of life, which is that we are all aging from the day we are born. One may even come to understand and accept this fact. My dead and dying patients don’t haunt my dreams anymore. But that’s not the same as saying one knows how to cope with what cannot be mended. I am in a profession that has succeeded because of its ability to fix. If your problem is fixable, we know just what to do. But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering.
This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing.
You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.
Piece from Candy Chang's global art project 'Before I Die.' Click image for more.
And yet Gawande extracts the promising potential beneath this cultural failure:
I have the writer’s and scientist’s faith … that by pulling back the veil and peering in close, a person can make sense of what is most confusing or strange or disturbing.
To be sure, Gawande brings a singular lineage of perspectives to this issue — an accomplished practitioner of Western medicine, he was born to parents, both doctors, who immigrated to America from different parts of India. He recalls visiting his paternal grandfather in India — “a dignified man, with a tightly wrapped white turban, a pressed, brown argyle cardigan, and a pair of old-fashioned, thick-lensed, Malcolm X-style spectacles” — when he was older than a hundred. Gawande paints the stark contrast between how his grandfather’s culture handled human finitude and how his own does:
He was surrounded and supported by family at all times, and he was revered — not in spite of his age but because of it. He was consulted on all important matters— marriages, land disputes, business decisions — and occupied a place of high honor in the family. When we ate, we served him first. When young people came into his home, they bowed and touched his feet in supplication.
In America, he would almost certainly have been placed in a nursing home. Health professionals have a formal classification system for the level of function a person has. If you cannot, without assistance , use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk — the eight “Activities of Daily Living” — then you lack the capacity to live safely on your own.
Gawande turns to Plato’s dialogue Laches — a text written nearly two millennia ago — for enduring guidance on how to cultivate a healthier relationship with our mortality. In the ancient text, Laches and Socrates go on to propose, then dismiss one by one, a series of definitions of courage, from “a certain endurance of the soul” to “knowledge of what is to be feared or hoped, either in war or in anything else.” They come up with no definitive answer, but Gawande argues that the reader arrives at an implicit one, which he synthesis beautifully:
Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.
He considers how the notion of courage illuminates the ultimate act of showing up that is dying:
At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality — the courage to seek out the truth of what is to be feared and what is to be hoped. Such courage is difficult enough. We have many reasons to shrink from it. But even more daunting is the second kind of courage — the courage to act on the truth we find. The problem is that the wise course is so frequently unclear. For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most.
Gawande’s most emboldening point is that reframing our relationship with death, as well as our treatment of the dying, confers greater freedom upon life and more dignity upon the living:
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.
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?
If to be human is to be limited, then the role of caring professions and institutions — from surgeons to nursing homes — ought to be aiding people in their struggle with those limits. Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.
In the remainder of Being Mortal, which lives at the intersection of science and philosophy, Gawande goes on to illustrate these ideas with practical examples of better, less limiting, and more dignified models of caring for the elderly and easing our exit from being. Complement it with philosopher Joanna Macy on how death helps us dial up the magic of life.
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