Book Review – Being Mortal: Medicine and What Matters in the End

Being Mortal: Medicine and What Matters in the End.

By Atul Gawande. New York: Metropolitan Books, 2014.

In Tolstoy’s masterful novella The Death of Ivan Ilyich, the main character, Ivan, falls off a ladder and develops a pain in his side. The pain, nonetheless, is not assuaged as time goes on; it worsens. Ivan grows depressed, debilitated, and his friends and colleagues avoid him. After a series of ever more expensive doctors attempt to diagnose and treat him, unsuccessfully, Ivan rages over his situation. However, Tolstoy writes that what bothered Ivan the 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.” Indeed, death was not a subject that his physicians, family, or friends could tolerate.

Tolstoy’s story of Ivan Ilyich is a tale of those around him failing to acknowledge what was happening to him. In a similar manner, Atul Gawande, a general surgeon at Boston’s Brigham and Women’s Hospital and professor at Harvard Medical School, in his latest work, Being Mortal: Medicine and What Matters in the End, has a similar diagnosis for modern medicine. Gawande’s exploration of aging, disease, death, and his profession’s mishandling of these is profoundly insightful and deeply personal. Masterfully weaved throughout Gawande’s book is the story of his own father, also a surgeon, and the trials he experienced when faced with his own mortality and the reality that what medicine can do often runs counter to what it should. As Gawande notes, oftentimes modern medicine sees death as a failure. While death may be the ultimate limitation of his profession, Gawande recognizes that “Death is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things” (8).

In this manner, Gawande’s book is a call for reform in the philosophy of healthcare. As Gawande sees it, “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 almost no view at all” (128). He suggests the idea that a life worth living is possible for all stages of life. The job of medicine is not simply to ensure health and postpone death, but to enable well-being. The well-being that Gawande speaks of is elucidated in the form of engaging stories from his own medical practice and personal experience. Gawande trails a hospice nurse as she attends to patients, visits a geriatric physician for greater perspective, and writes at length about the abundant need for nursing home reform. It is through these various stories, carefully intertwined throughout his book, that Gawande is able to clarify his idea of well-being and that the ultimate goal of humankind is not a good death but a good life.

Near the end of his book, Gawande offers a brief discussion of euthanasia. While Gawande flatly states that he would support laws of assisted suicide, a view undoubtedly contra the Judeo- Christian tradition, he critiques end-of-life policy in the Netherlands. “[T]he fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success. It is a measure of failure. Our ultimate goal, after all, is not a good death but a good life to the very end” (245). Gawande questions whether the Dutch have been slower than other countries to develop palliative care programs because “their system of assisted death may have reinforced beliefs that reducing suffering and improving lives through other means is not feasible when one becomes debilitated or seriously ill” (245).

Being Mortal is an esteemed contribution to the rather sparse literature on aging and death. Gawande is a gifted storyteller, and he does not spare the reader from descriptions of bodily aging. Identifying no perfect solutions to the problems inherent in bodily decline, Gawande asks his reader to commit to making choices with the goal of a purposeful life in mind. His writing is certainly intellectually provocative as it confronts the reader with their own mortality and the limits of medicine and themselves.