Of Mortality and the Limits of Medicine

We are struggling to cope with the constraints of our biology, with the limits set by genes and cells, flesh and bones. Medical science has remarkable power to push against these limits. But still, its power is finite.

Medicine can improve our life and it has done a lot of things in life; it reduced our pain and suffering and transformed infectious diseases from harrowing experiences to manageable conditions. But as regards aging and death, it often runs counter to the interest of the human spirit. Can medicine improve the process of life’s ending? This is the hardest challenge for those in the medical profession. Sophisticated medical care does not guarantee a good end of life; often it actually prevents it. Our daily experiences show that doctors who try their best to extend life carry out devastating procedures that often extend suffering.

In his new book, Being Mortal: Medicine and What Matters in the End, Atul Gawande, a surgeon by profession, compares popular attitudes towards ageing and death, using his experiences in the field and argues that acceptance of mortality must lie at the centre of the way we treat the dying. Doctors are trained to keep their patients alive as long as possible. But they are never taught how to prepare people to die.

“Health professionals have a formal classification system for the level of function a person has. If you cannot, without assistance, use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk – the eight ‘Activities of Daily Living’ – then you lack the capacity for basic physical independence. If you cannot shop for yourself, prepare your own food, maintain your housekeeping, do your laundry, manage your medications, make phone calls, travel on your own, and handle your finances – the eight `Independent Activities of Daily Living’ – then you lack the capacity to live safely on your own.”

How do we plan to care for our loved ones who are granted great longevity, though their bodies and minds are weakening? How do we manage the body’s decline when a cure is impossible or out of reach? Atul Gawande explores both in his book. “Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers,” he says.

Gawande says that medical profession’s desired goal must be to increase the quality of life of patients and families. He argues that medicine can comfort and enhance our experience even to the end, providing not only good life but also good death, Juergen Bludau, a chief geriatrician tells him: “The job of any doctor is to support the quality of life, by which he meant two things: as much freedom from the ravages of diseases as possible and the retention of enough function for active engagement in the world.”

Gawande writes: People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete. Our system of technological medical care has utterly failed to meet these needs… The question therefore is not how we can afford this system’s expense. It is how we can build a health care system that will actually help people achieve what is most important to them at the end of their lives. (Page 155)
What makes life worth living when we are old and frail and unable to care for ourselves?

He quotes noted American psychologist Abraham Maslow who published, in 1943, his hugely influential paper “A Theory of Human Motivation” which famously described people as having a hierarchy of needs. It is depicted as a pyramid. At the bottom are our basic needs – the essentials of physiological survival (such as food, water and air) and of safety (such as law, order and stability). Up one level are our needs for love and belonging. Above that is our desire for growth – the opportunity to attain personal goals, to master knowledge and skills, and to be recognized and rewarded for our achievements. Finally, at the top is the desire for what Maslow termed “self-actualization” – self-fulfillment through pursuit of moral ideals and creativity for their own sake. (Page 93)

Maslow argued that safety and survival remain our primary and foundational goals in life. Reality is more complex. People readily demonstrate a willingness to sacrifice their safety and survival for the sake of something beyond themselves, such as family, country or justice. This is regardless of age. Can we give autonomy to our elderly? “You may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.” (Page 210)

Atul Gawande’s book is about the modern experience of mortality – what it is like to be creatures that age and die, how medicine has changed the experience and how it has not. In his book, he has fearlessly revealed the struggles of his profession. The book shows that the ultimate goal is not good death but good life till the very end of the road.

Atul Gawande, Being Mortal: Medicine and What Matters in the End, Hamish Hamilton, an imprint of Penguin Books, 2014. 282 Pages.