This year’s BBC Reith Lecturer is the American writer and surgeon Atul Gawande. Gawande, who works at Brigham and Women’s Hospital in Boston and is also a staff writer for the New Yorker, has chosen as his topic “The Future of Medicine”. His lectures will “examine the nature of progress and failure in medicine, a field defined by what he calls ‘the messy intersection of science and human fallibility’.” They are complemented by Gawande’s latest book, his fourth, which is entitled “Being Mortal: Illness, Medicine, and what Matters in the End.”
I met Gawande in London recently and talked to him about ageing, death and the need for medical practitioners to think harder about the nature of human wellbeing.
JD: Your 2002 book Complications: A Surgeon’s Notes on an Imperfect Science was about what surgeons and other medical practitioners can know with certainty. It was, you might say, a work of medical epistemology. Being Mortal, on the other hand, is a book about what it means to human, to be mortal. And also about how we—the medical profession in particular—manage mortality. You might say its focus is on metaphysics and/or ethics.
AG: Right. And I didn’t expect it to go there. I thought it was going to be about how you manage this very conflicted point—which is the decision point as you near death. But once I realised that people have priorities in their life that are bigger than just surviving and living longer, it extended a lot further… I came to see that our whole idea of what a good life is has begun to revolve around the notion that the only good life is a healthy and independent one. That was not the way people saw it in the 19th century and earlier, when your health was always at risk, when life was always fragile.
You’ve just drawn a distinction between the way we did our dying in the 19th century and the way we do it today. You also, in the book, draw a geographical distinction in these matters between the west and India, for example. Could you say a bit about that?
As I visited family and then did more formal investigation in India of what people are going through, I got to see happening live in India what we went through in the 19th century. When I visit India, I’m visiting an agricultural economy with a multi-generational family in the centre of it—which is pretty much where we were in the US and the UK in the 18th and 19th centuries. I describe [in the book] my grandfather dying at the age of 110, after 20 years of needing people to help him manage bathing, dressing, other things. But he could still be head of the household, at the head of the table, venerated and respected. At first, the way my family described it, was “We just know how to live and you guys don’t.” But now India’s going through the same thing we went through—the multi-generational family is breaking up, it’s becoming an urbanised society, many elderly people live alone. And there is no plan for what happens afterwards. When you become prosperous enough, you build a pension system so people don’t have to be in poverty just because of old age. Then, with more money, you build a health system. But none of us has had an answer for when you’re no longer healthy, no longer able to be totally independent—what is the plan? Almost by default, we decided that medicine would take care of that.
Staying with India for a moment. Of course, we can’t regret the advent of prosperity and economic growth there, which has lifted millions of people out of poverty. But I infer from the book that you do think there is some cause for regret about what one loses in the process, for example as far as the kind of inter-generational networks that sustained your grandfather are concerned.
Yes, although I end up with a complicated view. I describe a daughter in America trying to take care of her ageing father in his nineties. It’s a totally different job from what it was for [those family members who looked after] my grandfather. In a medical system where we have many different options, this was a man who had half a dozen specialists looking after him. His daughter was ferrying him to and fro while having a full-time job and then coming home and being expected to get her father through his bath and so on. She was being driven crazy by the amount of work and stress involved. Living in a world where most of us can live into our eighties and often longer, you can’t just say that the family will take care of you as it once did. In the 19th century, the average person died at less than 50 years old. You didn’t have to spend as much time as the child of an ageing parent devoting your life to caring for them.
Politicians often reduce the challenge posed by an ageing problem to a narrowly fiscal question don’t they? They, and we, tend to obsess about the fiscal question without addressing the question of what you call “wellbeing”, what it means for an elderly person’s life to go better rather than worse.
We keep reducing it to, “we can’t afford it, we can’t afford it.” This is going to be a phase in our lives that most of us will pass through—it’s going to be a fifth of our life in which we’ll be dealing with illness, frailty, some diminished capacities. There are a couple of really striking things here. One is the research I talk about in the book. One researcher, Laura Carstensen, has tracked people [over many years] as they age. Even though people might have diminished health, even though their abilities might diminish, they become happier, they have lower rates of depression and anxiety. They have different desires than others; they’re not as acquisitive or as focused on public recognition and achievement. But they are focused on being connected to the people who are close to them. When we foster those capabilities, people are less miserable. And it’s often not about cost.
Is there a sort of technological or medicalising fallacy involved in the way we often approach the treatment of people in old age? You say that it’s natural for human beings to think that we can control the end of life. Does the technology available to us today make that even more of a temptation than it might otherwise be?
The technological temptation is to think that we can always do one more thing—there’s always one more treatment we can go for in a last-ditch effort, without ever asking: What is the thing most important to this person? Now, the reason I say it’s a technological temptation is because it’s a misuse of technology. One hospice nurse I spoke to explained it very well: she said medicine sacrifices your time and quality of life now for the sake of possible time in the future. But she sees her job as using medical capability and other capabilities to ensure you have the best possible day today—regardless of the effect on the [amount of] time available to you in the future. Some of what she employs is technology—increasing doses of pain medication. I describe the case of a piano teacher in which they not only increase her medication, but they also give her Ritalin—medication to combat the stupor from the morphine—so that she can continue to teach piano, which [for her] was the most important thing that she could do, even as she was declining from her cancer. The issue isn’t technology or no technology. The issue is what are we using technology to accomplish in a person’s life? What is the life that we are fighting for?
And answering that requires a wider, richer notion of wellbeing?
Exactly. Wellbeing is bigger than health and safety.
I was struck just now by your use of the notion of “capabilities” when you were unpacking the concept of wellbeing. Do I detect the influence of Amartya Sen there?
He’s been a huge influence on me in understanding not only that capabilities and wellbeing are important, but even more in recognising that routes to capability are often indirect. Think, for example, of his work showing that democracy is the biggest protection against famine. Now that’s not what you expect. You’d think that the biggest protection against famine is giving more food aid. Similarly, here, you’d think that the biggest protection against suffering at the end of life is going to the hospital. Take the idea that you can have capabilities, even if you’re in a wheelchair, that are important to you, or even if you have a brain tumour that’s constricting your life severely. Now our basic failing is not the technological fallacy or temptation, it’s the failure to imagine that people could have a purposeful and meaningful life even under very trying circumstances.
Does the considerable value that we place in liberal societies on personal autonomy make it that much harder to acknowledge or recognise that?
This is something I’ve grappled with. The primacy of the individual and the respect we give individuals in a liberal democracy are very important, fundamental values. But understanding what that means requires some teasing out. [In one construal of the notion of autonomy] I have control over my life and my world without any impingement from other people. I’m free of interference. What’s hard is that this leads us to think that the only good life is a totally independent life. But none of us is ever totally independent. We’re completely enmeshed in the world around us. In fact, we depend in many ways on the world around this. This just becomes clearer when our bodies begin to fail.
This is also a book about the process of ageing isn’t it?.
Ageing is the breakdown of a complex system. The beauty of the 21st century is that the vast majority of us now live until the point when things start to break down. We even get to replace many of the parts—knees and hips and so on. As things wear down, the assumption is that either we will always find replacement parts or that if we can’t, the result must be misery.
You’re talking about decline. Now one of the interesting points you make in the book is that doctors and other medical practitioners are much less good at thinking about and dealing with gentle and not so gentle decline than they are at dealing with acute illness.
Most of us did not go into the profession to manage the demise of people. We went in to be heroes—no one more so than a surgeon! Yet there are geriatricians, palliative care physicians, people who have made it their speciality to figure out how to help people achieve quality of life regardless of the time of life. And what’s striking is how effective they are. But we’re not focusing enough on building and teaching those skills and capacities.
Atul Gawande’s “Being Mortal: Illness, Medicine and What Matters in the End” is published by Profile Books (£15.99). The first of his Reith Lectures will be broadcast on BBC Radio 4 on 25th November at 9am. For more details, click here.