Monday, April 13, 2015

Being Mortal by Atul Gawande

Being Mortal is subtitled “Medicine and What Matters in the End,” and author Atul Gawande’s arguments matter so much that I have been recommending this nonfiction title to nearly everyone. Gawande could well have called his book Being Human, as it speaks to our morality as much as it does our mortality. Specifically, the morality of how we deal with aging and dying. Though life expectancies and our medical ability to sustain life have increased, our ability to make these extended lives meaningful lags behind.

Nursing homes, even the best ones, often leave their residents depressed and isolated; these institutions focus so strongly on safety and standards that the humanity of their residents becomes secondary. A noted surgeon and author, Gawande makes this abundantly clear in his many interviews with and profiles of said residents, and he himself says it most clearly in these words:

“The terror of sickness and old age is not merely the terror of the losses one is forced to endure but also the terror of the isolation. As people become aware of the finitude of their life, they do not ask for much…They ask only to be permitted, insofar as possible, to keep sharing the story of their life in the world—to make choices and sustain connections to others according to their own priorities.” (146-147)

The hardest choices to make involve end-of-life issues and deciding when to stop pursuing treatments that may only make one’s final days worse; these choices become the focus of the second part of Being Mortal. Patients, particularly at this stage, desire what Gawande calls (using research from medical ethicists Ezekiel and Linda Emanuel) an “interpretive” relationship with their doctors, a relationship where doctors ask what is most important to patients and what patients are most concerned about before dispensing medical knowledge and advice.

Yet most doctors focus instead on attacking the medical problems at all costs (financial, emotional, mental, physical), which too often leads to the same cruel irony as our nursing home model: patients who feel dehumanized. They want their stories to be heard, they want to have a part in how the story of their final days will be told, and they want the stories of their final days to consist of more than their medical conditions and treatments.

Gawande comes to understand the importance of listening to these stories, admitting his own mistakes with previous patients, and allowing us a detailed look at the story of his father (also a doctor) as the elder Dr. Gawande deals with a painful and progressive spinal cord tumor. Being Mortal succeeds because Gawande argues not only as a doctor cautioning us against heedless attempts to forestall simply because we have the technology and medical ability to do so, but also as a son using the gutting story of his father’s death as its own intimate argument.

As a son, I could not read the second half of Gawande’s book without thinking of the story of my own father’s painful death from colon cancer, and I could not read the first half without thinking about my aging mother and the decisions she and my siblings and I will eventually have to make. Dying is part of all of our stories, but we have become increasingly uncomfortable discussing it. Gawande stresses that although we have learned how to live longer, we must relearn how to die. This learning must include having initially uncomfortable discussions about end-of-life issues. Patients and families must tell these stories. Doctors and families must listen to these stories. We as a society must honor the humanity of these stories.

As a teacher, I could not read Being Mortal without the stark recognition that Gawande’s diagnosis applies to our educational institutions as well. The reasons so many nursing home residents hate being there are the same reasons so many students (many more so than when I began teaching twenty years ago) hate school: Their autonomy is sacrificed for safety and order, their own stories are not valued, standards of humanity are sacrificed for standardized testing and curriculum.

Education becomes, as Gawande bemoans about medicine, “increasingly miscast in retail terms” (168). In education we push technology and data at the expense of humanity, just as medicine often does. Someone needs to write a Being Mortal for education, and Gawande’s subtitle needs only a tiny change: "Education and What Matters in the End." For what matters most in the end is a satisfying answer to the question at the heart of all our stories: What does it mean to be human?

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