“Being Mortal: Medicine and What Matters in the End” by Atul Gawande

Atul Gawande has a very direct and detailed delivery of his thoughts. His books focus largely on medical thoughts, from procedural focus to dealing with death. “Being Mortal” focuses on the latter. His other works that I’ve found great value in, “The Checklist Manifesto” and “Better”, focused more on improving medical efficiency and performance while not really touching on the themes of life and death and how to cope with all of our inevitable ends in a respectful and honorable manner. The concept of living longer because of technological advancements reminds me a of paper I collaborated on about soldier survivability. On the battlefield, we are able to treat such severe injuries that an injury that would have killed a soldier in WWII, a modern warrior can survive. Survival is only the first step of the issue however. Because modern soldiers are now able to live following gruesome injuries, we now must cope with the side effects of this survival, namely rehabilitation and post-traumatic stress disorder. If you’re interested in a more technical look at soldier survivability, please check out the paper I mentioned.

  1. As for the exclusive hold that elders once had on knowledge and wisdom, that, too, has eroded, thanks to the technologies of communication—starting with writing itself and extending to the Internet and beyond. New technology also creates new occupations and requires new expertise, which further undermines the value of long experience and seasoned judgment. At one time, we might have turned to an old-timer to explain the world. Now we consult Google, and if we have any trouble with the computer we ask a teenager.
  2. There is always some final proximate cause that gets written down on the death certificate—respiratory failure, cardiac arrest. But in truth no single disease leads to the end; the culprit is just the accumulated crumbling of one’s bodily systems while medicine carries out its maintenance measures and patch jobs. We reduce the blood pressure here, beat back the osteoporosis there, control this disease, track that one, replace a failed joint, valve, piston, watch the central processing unit gradually give out. The curve of life becomes a long, slow fade:
  3. The natural course was to die before old age. Indeed, for most of history, death was a risk at every age of life and had no obvious connection with aging, at all.
  4. When we study aging what we are trying to understand is not so much a natural process as an unnatural one.
  5. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, and living situations. And it requires each of us to contemplate the unfixables in our life, the decline we will unavoidably face, in order to make the small changes necessary to reshape it.
  6. It is not death that the very old tell me they fear. It is what happens short of death—losing their hearing, their memory, their best friends, their way of life. As Felix put it to me, “Old age is a continuous series of losses.” Phillip Roth put it more bitterly in his novel Everyman: “Old age is not a battle. Old age is a massacre.”
  7. You’d think people would have rebelled. You’d think we would have burned the nursing homes to the ground. We haven’t, though, because we find it hard to believe that anything better is possible for when we are so weakened and frail that managing without help is no longer feasible.
  8. As people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives—resisting the urge to fiddle and fix and control. When should we try to fix and when should we not?
  9. Most people with terminal illnesses in their countries would never have come to the hospital. Those who did would neither expect nor tolerate the extremes of multiple chemotherapy regimens, last-ditch surgical procedures, experimental therapies—when the problem’s ultimate outcome was so dismally clear.
  10. In 380 BC, Plato wrote a dialogue, the Laches, in which Socrates and two Athenian generals seek to answer a seemingly simple question: What is courage? The generals, Laches and Nicias, had gone to Socrates to resolve a dispute between them over whether boys undergoing military training should be taught to fight in armor. Nicias thinks they should. Laches thinks they shouldn’t. Well, what’s the ultimate purpose of the training? Socrates asks. To instill courage, they decide. So then, “What is courage?” Courage, Laches responds, “is a certain endurance of the soul.” Socrates is skeptical. He points out that there are times when the courageous thing to do is not to persevere but to retreat or even flee. Can there not be foolish endurance? Laches agrees but tries again. Perhaps courage is “wise endurance.” This definition seems more apt. But Socrates questions whether courage is necessarily so tightly joined to wisdom. Don’t we admire courage in the pursuit of an unwise cause, he asks? Well, yes, Laches admits. Now Nicias steps in. Courage, he argues, is simply “knowledge of what is to be feared or hoped, either in war or in anything else.” But Socrates finds fault here, too. For once can have courage without perfect knowledge of the future. Indeed, one often must. Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.
  11. 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. But even more daunting is the second kind of courage—the courage to act on the truth we find.

 


Being Mortal: Medicine and What Matters in the End

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