The conversations of life

Being Mortal – have we forgotten?


The Sydney Writer’s Festival is on and, as a Sydney-sider, I have been fortunate to make it along to a couple of events – the opening address with Pakistani (British/American) novelist, Mohsin Hamid (who you may have caught on Q & A on ABC TV on Monday night) and then US surgeon, writer and public health researcher, Atul Gawande.

The 49 year old Gawande is one of those accidental literary success stories.  Having studied medicine at Harvard University, in his ‘main’ day job he is a surgeon at Brigham and Women’s Hospital in Boston, a hospital affiliated with Harvard Medical School.

Dr Atul Gawande Photo by Tim Llewellyn
Dr Atul Gawande Photo by Tim Llewellyn

He is also a Professor in the Department of Health Policy and Management at the Harvard T H Chan School of Public Health and the Samuel O Thier Professor of Surgery at Harvard Medical School

But in his spare time, he has always pursued his love of writing.  He writes principally about the ethical and philosophical challenges of medicine and healthcare.  He is a staff writer at The New Yorker magazine and the author of four books including, Complications, Better, The Checklist Manifesto: How to Get Things Right and most recently, Being Mortal: Medicine and What Matters in the End.

Gawande was at the Sydney Writer’s Festival this week to talk about this most recent book – an examination of the modern experience of ageing and mortality and largely what we are getting wrong.

“Death may be the enemy but it is also the natural order of things. […] There’s no escaping the tragedy of life, which is that we are all ageing from the day we are born.”

In this post, I’m not even going to try to tackle many of the questions and topics Gawande raises in Being Mortal. I want to return to them in detail over time. But I would like to reflect on his broad message at the Sydney Writer’s Festival event: that the medical profession has lost sight of the proper place of death in life.

Gawande laments that, while medical science has given us the power to push back the limits of our mortality, it “has turned the process of ageing and dying into medical experiences, matters to be managed by healthcare professionals.”

He says it is a paradox that our medical technologies and therapeutics have become so advanced that we can keep people alive for longer than ever before, yet we are not set up to care for those who become dependent through old age.

“Death is normal,” he says in Being Mortal.

“Death may be the enemy but it is also the natural order of things. […] There’s no escaping the tragedy of life, which is that we are all ageing from the day we are born.”

Missing skill set

With the exception of geriatricians and palliative care doctors, Gawande says that the skills for dealing with death, as a part of life, are sadly missing from the training for the medical profession. Instead, he says doctors are educated to view death as an indicator of failure – a failure of competence in the skills they are trained for.

For a profession that he said is “trained, rewarded and hired to be cowboys,” it is seen as conceding defeat.

This same professional arrogance, he says, has seen “everything (thrown) at the fancy last minute hospital stuff but nothing on primary prevention.”

In the medical paradigm of ageing, the goal and very language of care is ‘safety’, he says. And this is a goal that inevitably involves a fair bit of arguably unnecessary suffering in the last phases of life.

Ultimately, Gawande’s argument is that modern western medicine is languishing in a delusion that ageing needs the cowboy treatment and heroic interventions when, “it is pit crews that we need.”

I have to say that I am in agreement with him (of course! I’m a fan!). Doctors and other clinicians need to get better at helping people with prevention, management and then the inevitable endings to their lives, focusing on what individual people feel and want and need, right to that inevitable end.

At the end, says Gawande, it is a question of what matter most to each individual. What is important for them? What are the priorities? What are the things to avoid at any cost? Whose opinions count?

Gawande tosses up many issues and questions about the mainstream experience of ageing and I look forward to looking long and hard at a few of them in the coming weeks.

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