Book Review: Being Mortal by Atul Gawande

Being Mortal: Medicine and What Matters in the End by Atul Gawande
My rating: 5 of 5 stars

As an Anesthesiologist I am often confronted with salvage procedures and heroic measures that force me to wonder if there is no better way to care for those who are at the threshold passing mortality. The truest statement here in Atul Gawande's book is this: "Old age is not a battle. Old age is a massacre." We have become so accustomed to the radical, personal, and pervasive ways that technology has improved our daily lives that we expect Salvation from our technical tinkerers from Boston to San Francisco. This has blinded our modern society (especially modern medicine) to our limitations and more dangerously to the harm we do in our fevered pursuit of medical macguffins.

I noted with ironic melancholy the mission statement that was crafted by my Medical School class, which started thusly: "As Physicians we emerge like !SUPERMAN! from the phonebooth to save our patients from sickness. Like !SPIDERMAN! we gracefully swing in to the rescue of the sick."

My initial read of that was one of disgust. My first thought was, why not just surgically remove any semblance of humanistic sentiment from ourselves and raise ourselves out-of-reach in a superior pedestal as humanities savior? No, I thought, We need fewer superheroes in medicine and more frail Mother Teresas who know how to succor suffering and illness precisely because she draws from that deep well herself and not from the condescending super-patriarch -matriarch -noncisgenderiarch.

Instead of eliciting a patient's deepest hopes and understanding her foremost fears, we simply assign arbitrary value on our own prime directive: keep alive longer. In so doing we actually kill our patients sooner and with greater pain and suffering than the alternative: palliative care.

As Dr. Gawande notes the evidence from palliative care is incredible: people who have terminal illnesses e.g., terminal congestive heart failure, pulmonary disease, cancer malignancy, frail old age, etc., both live longer and higher quality lives than people who pursue medical treatment of their illnesses. All this at a significantly decreased cost! Indeed, if palliative care and geriatrics were a computerized device that one could implant into the human body then it would be quickly approved by the FDA and billions of dollars would be spent by Medicare implanting them into as many people as possible. Palliative care is so undercompensated that many major medical universities are unable to sustain a department -- all while medical sectors like plastic surgery and dermatology continue to remain the most popular, competitive, and well compensated fields of medicine.

Reading through Dr. Gawande's book I can't help but compare the current state of elderly care to the workhouses of Charles Dickens's Victorian society. While our society has made quantum leaps of progress in many areas of life, the care for the elderly remains often an unchanged dismal warehousing that it was years ago. Modern Medicine simply is cognitively unprepared to address the reality of our mortality.

One troubling moral minefield in this field of medicine, however, is how our values might sanctify or devalue human life. Where is the line between allowing a person to pursue their own values regarding not artificially prolonging their life and actively putting an end to their life? I can turn off a pacemaker of a patient who is 100% dependent on that pacemaker for cardiac function in accordance with their wishes not to have life-sustaining medical treatment. What is the difference between withdrawing treatment and giving a prescription that one knows will end a patient's life. My answer is that in the former we are adhering to the prime directive of medical ethics: FIrst do no harm--which argues for withdrawing or withholding medical treatments that would harm a patient's physical body or personal right to self-determination according to their values and ultimate meaning, and that the latter (to prescribe life-ending treatments) addresses the patient herself as the malady to be excised from existence. We can aggressively treat chronic pain and suffering that comes from extreme age, malignancy, disease, but the second we turn our medical expertise from treating the disease associated with a patient to treating the patient's existence as something to snuff out then we have crossed a line. Double-effect ethics are valid--we can treat pain and suffering that incidentally results in demise, but utilizing a patient's demise as the primary treatment modality for pain and suffering will lead to the dehumanization of the disabled and diseased. To move our focus from relieving pain and suffering of a patient by targeting the pain, suffering, and existential anxiety itself (in some cases) to removing the person who suffers divorces ourselves from the doctor-patient relationship and will inexorably lead to the dehumanization of our suffering patients.

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