Has the author chosen a relevant topic? Check!
Does he have passion for the subject? Check!
Will the opening chapter grab the reader’s interest? Check!
Are the characters three-dimensional? Check!
Is the writing descriptive? Check!
Has newness (something novel) been given birth? Check! But this time, it’s death not birth.
Some five years ago, the pages of India Currents used the above framework for a review of The Checklist Manifesto. In that important book, Dr. Atul Gawande suggested that the practice of medicine, this life-giving and life-saving calling, would be greatly improved by the simple, unheralded, and largely untaught technique called a checklist. If only the end of life were so simple, then the good doctor’s latest book, Being Mortal need not have been written, reviewed, nor read. But neither life nor death are simple matters.
Is the book relevant? Unless death-defying cryonics blinds one to the realities of life’s end state, the relevance of this book is universal. Gawande looks to Tolstoy’s The Death of Ivan Ilyich to unmask the deception that so many of us are so willing to accept: “Ivan Ilyich has flashes of hope that maybe things will turn around, but as he grows weaker and more emaciated he knows what is happening. He lives in mounting anguish and fear of death. But death is not a subject that his doctors, friends, or family can countenance. That is what causes him his most profound pain.”
What about the author’s passion for his subject? Like so many of us with connections to the premodern world where death is a part of life rather than apart from life, Gawande looks back with common sense to look forward with empathic passion. Even in the United States, a mere half century ago most people died in their homes. Today, the percentage of deaths at home across the industrialized world has dropped precipitously into the low teens. Gawande passionately believes that this shift is not inevitable. Compassionately considered choice might result in more of us spending our last days with our loved ones, in our own homes. And while we patients may be very fond of our doctors and nurses, few of us would elect to spend our final days surrounded by clinical white coats and antiseptic white walls.
And how about that opening chapter? There are two quotes in the introductory chapter that grabs the reader and sets the tone for the rest of the book: “Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.” Sadly, medical professionals have been socialized into feeling that they have failed their patients and their patients’ families if somehow they don’t consistently perform life-saving miracles. “This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing.” Hopefully, by being in personal and professional dialogue with each other, we -caregivers, patients, and patients’ loved ones-can all find a way to our own sense of success during those waning days of life.
Any compelling characters here? While Being Mortal is about medicine, and thus inevitably the science, economics, and public policy of health care find their way into the book, it is Gawande’s personal response to death and dying that gives life to his words. In comparing how his grandfather (Sitaram) and his father (Atmaram) spent the last stages of their lives, Gawande gives the reader some compelling truths along with these two compelling humans.
Sitaram, a centenarian farmer living in a Maharashtrian village, “was surrounded and supported by family at all times, and he was revered-not in spite of his age but because of it…. When we ate, we served him first. When young people came into his home, they bowed and touched his feet in supplication…. In America, he would almost certainly have been placed in a nursing home…. But in my grandfather’s pre-modern world, how he wanted to live was his choice, and the family’s role was to make it possible.”
Ironically, postmodernism argues for choice, and yet Atmaram, a Ohio-based urologist lived his life and practiced his profession in America, a country where compliance with legal regulations and medical ethics would remove much of the decision-making from his hands. Faced with a slow-growth cancer, at first he resisted surgery for nearly half a decade. Eventually, Atmaram consented to surgery and follow-up radiation, neither of which moved the cancer into remission. Deterioration of his physical condition set in rapidly, and quality of life was greatly
diminished; but this merely emboldened Atmaram’s physicians to summon their considerable technical skills. Dr. Atmaram Gawande’s response was the very human, “I can’t do this. I don’t want this. I don’t want to go through this. I want to die rather than go through this.”
Despite his implorations, at the end, Atmaram was taken by his physician wife to a hospital where drugs delayed the inevitable; though the attending physicians proposed a ventilator in the ICU, Atmaram insisted upon returning home, where within a week’s time he would die. While the son does not write much about his own emotional response to his father’s final days, he does write that “endings matter.”
Is this work of nonfiction truly novel? Although there is nothing new about death, Gawande’s book has moved many to be in dialog with themselves, their loved ones, and their caregivers. In a world seemingly dedicated to prolonging life, and a profession somewhat in denial around the diminished value of delaying imminent death, conversation about being mortal is truly novel. And, thus, Being Mortal is itself novel.
While there is nothing new about dying, we all come to it in our own ways. While I need not be a prophet to know that death will come to me, when confronted by this reality I have always found comfort in the final pages of Kahlil Gibran’s The Prophet.
“This day has ended.
It is closing upon us even as the water-lily upon
Its own tomorrow.
What was given here we shall keep,
And if it suffices not, then again must we come
Together and together stretch our hands unto the giver.
Forget not that I shall come back to you….
Farewell to you and the youth I have spent
It was but yesterday we met in a dream.”
For Dr. Ahn, Dr. Bhalala, Dr. Kwaiben, NP Beck, Dr. Prasad, Dr. Rachamallu, and Dr. Singh. The Oza Family looks to these caring and careful caregivers for guidance on being mortal.