Justin Review of Books #1: Being Mortal
My first book review is Being Mortal: Medicine and What Matters in the End by Atul Gawande.
Note: many of my first book reviews, including this one, will be “from memory,” meaning that I am not actively referencing the book as I write it. This is decidedly non-scholarly and may result in some missing or inaccurate details. But, I think there is some value in seeing, realistically, what kind of impression and key takeaway messages a book leaves on someone.
Being Mortal is not just a hugely important book, it’s also very popular. I see it in nearly every bookstore I go to, including airport bookstores, which generally limit themselves to business books and bestsellers. However, the thought of reading a book about death was enough for me to resist reading it for a while.
I finally bit the bullet, strangely enough, because I was going to attend a conference on human-robot interaction. How social robots can assist in elder care is a major research area, so I thought this book might serve as good background reading. It was a great decision and I’m glad to make this book my first review.
Atul Gawande is a surgeon who also writes about public health issues. I had heard of him before, mostly from his articles for the New Yorker, but possibly through other means as well. He is an excellent writer, a rare example of a practicing professional who is also a good storyteller and communicator. Being Mortal exemplifies this: it makes a convincing argument based on Gawande’s career as a doctor, and it was written so powerfully that I found myself crying with every chapter.
Being Mortal upends views on how people want to die
The book is split into roughly two sections: one on elder care and one on end-of life care. The thesis statement of the elder care section can be boiled down to a quote that someone told Gawande: “We want safety for others but autonomy for ourselves.” Our instinct is to try to maximize the physical health of old folks by putting them in facilities where they will be watched over. We want to limit their ability to do “dangerous” activities like eating junk food, drinking, or having pets. But studies show that this can be depressing, and that mental health is tied to physical health. Instead, we should try to promote greater autonomy among the elderly and focus more on their psychological needs. This could lead to even better physical health outcomes than focusing on physical health alone.
The theses of the second section are similar: 1) we should have honest conversations with the dying about how they want to die, and 2) focusing on quality of life may be more important than physical health and quantity of life.
The first point is that most people don’t want to have the uncomfortable conversation about dying. This leads to families not knowing how the dying person actually wants to be treated in case of an emergency. In the absence of this information, people and doctors both assume that they should pursue any treatment that might extend the dying person’s life. But, this runs into a couple of problems. First, there is considerable cost associated with this. Most medical spending is spent on the last year of people’s lives. And second, modern medicine is more limited in its effectiveness than medical dramas might lead us to believe. Life-saving operations are often painful and traumatizing, which degrades the quality of the dying person’s life, and additionally do not actually extend a person’s life by much.
Having conversations about death, Gawande finds that most people actually do not want various life-saving operations if it leads to the loss of their dignity or to further pain. So, just having a simple conversation not only saves money but is more in line with people’s wishes. A useful tool for talking about death, Gawande finds, is to ask a someone what goals they have before they die. Often, these goals are simple, like handing off a project or being able to attend a wedding. However, they are critical for framing the discussion of how much treatment the person is willing to undergo in order to achieve these goals.
Gawande also presents some evidence and personal anecdotes on how palliative or hospice care, care designed to manage pain but not necessarily to “cure” a patient, can actually be more effective than pursuing treatment. This was mind-blowing to me, but it made sense when I thought about how mental and physical health are entwined.
The book ends with an absolutely gut-wrenching story of how Gawande dealt with his own father’s death. He found himself falling into some of the old traps, but eventually applied the lessons he learned to help his father live his last days on Earth happily.
Being Mortal connects with other books on health and capitalism
I hope to share in my reviews how I connected the book to my personal life or to other books.
A rather silly example of how the book came up in my life was when our lab’s PR2 robot started having problems. The PR2 is an expensive research robot, and it was the first robot I had worked with. As I might with an old friend, I had built a collection of fond memories with it. However, it was having some issues with age. We had upgraded the software, so its wireless networking stopped working. Then, its wheels broke, so it was incapable of driving. One day, I was debugging the wheel issue when the robot suddenly turned off. I had unplugged it from power, but it was supposed to run on its batteries for hours. Instead, I figured out that its batteries were also too old to hold any charge.
When I realized this, I started to feel a bit of despair. I experienced a symptom that Gawande used to describe how the dying often feel: One Damn Problem After Another. This refers to the fact that, in a dying patient, even as you treat one problem, other problems start arising in different parts of the body. No matter what you do, everyone will eventually succumb to the breakdown of the body.
I recognized this feeling and thought about applying Gawande’s idea of goal-oriented thinking. Should we go through the lengthy and expensive process of replacing the robot’s wheels, and its batteries, and its wireless networking? Thinking through this, I found that I would be satisfied if we just fixed the wheels. The robot could remain tethered to wall power and an ethernet cable, so we wouldn’t have to fix the batteries or the wireless internet. The PR2 wouldn’t be able to venture far, such as when we used to drive it upstairs to do demos, but it could still maneuver itself in a limited space for various experiments in the lab.
Beyond this, Gawande’s notion that often simpler fixes are better is related to his other book, The Checklist Manifesto, which explains how a simple and inexpensive checklist can be a valuable tool for improving health.
I was also reminded of this book when I read James Hamblin’s If Our Bodies Could Talk, which, among other things, discusses how psychological health and the environment we live in is important to overall health.
Finally, Being Mortal explains how advertising, TV medical dramas, and doctors’ incentives all contribute to a culture in which people think they can just buy a solution to their problems, including the medical problems of the dying. It’s easy to see the connection to other books about how capitalism affects our culture, which I will review in the future.
Being Mortal is definitely one of the best books I have read recently. Just be prepared to cry a lot!
