Bar News - March 22, 2017
Book Review: Contemplate the Inevitable, Without Getting Depressed
By: Review by John Tobin
Medicine and What Matters in the End
By Dr. Atul Gawande
Metropolitan Books (2014)
Hardcover, 300 pages
The topic of this book could not be more serious – how much we and the modern high-tech medical world have to learn about preserving the quality, meaning, and dignity of our lives, as our bodies age and we face mortality.
But Dr. Atul Gawande, a contributing author for The New Yorker and the author of three other books about the practice of medicine, is an engaging, wise, and compassionate guide. His focus is on the limitations of the mechanistic and interventionist medical approach, but there are lessons that legal aid lawyers as well as doctors could benefit from. And anyone with aging parents or who has begun to feel the approach of their own old age will find valuable ideas for managing and making sense of the aging process that awaits us all, if we are fortunate enough to live long lives.
The son of Indian immigrants who were also doctors, Gawande has a deep understanding of the modern medical establishment, with its reliance on powerful surgical and pharmaceutical tools to pursue its core mission of “fixing” every medical problem that their patients present. But he can step back and see that many doctors cannot really admit and internalize the blunt and towering reality that they cannot (yet) conquer death. In wrenching stories, he describes doctors who are unable or unwilling to acknowledge or discuss a patient’s inevitable death, and instead embark on a vain attempt to prevent it. The result is an expensive and invasive intervention that cannot change the outcome, even as it inflicts great suffering and strips the patient of their independence, dignity, and enjoyment of the remaining simple pleasures of daily life.
As an important initial step in confronting our culture’s general reluctance to see that we are mortal, with bodies that will inevitably deteriorate, he includes a chapter, entitled “Things Break Down,” which describes in matter-of-fact physical detail how our teeth, bones, skin, eyes, and brains all decline as we age. He notes that much of this slowly begins to happen long before we consider ourselves as old. His tone is mild and he pokes gentle fun at those who romanticize 90-year-old marathoners and other examples of people who are supposedly defying the slow slide toward “decrepitude.” In his hands, I laughed at the absurdity of illusions of immortality in such circumstances, more than I felt beaten down by the ultimate prognosis we all face.
Much of the book is devoted to a range of approaches that aim to preserve as much as possible an aging or seriously ill person’s control over their lives, even if it means that they take risks by living alone or otherwise leading the kind of lives they chose. While hospitals and nursing homes need structure and schedules to operate, Gawande point out how much autonomy and happiness is lost when a person enters any such facility. As a doctor, he has learned that medicine simply does not have the answer to the question about how to live well as we age. Instead, he advocates for living arrangements and services that are not medically-based but are driven by the range of ordinary human needs and desires for privacy, flexibility, and as much or as little community life as the individual wants.
As a legal aid lawyer who spent more than a decade serving elders, this book brought home to me once again how important it is to put aside our impulse to quickly categorize the problems our clients bring to us and move right away to think of legal solutions for the problems we have just labeled. We need to listen to our clients carefully and fully, and especially to what they say their goals are. And we need to use our emotional intelligence and gentle questioning to assess what else they might need, beyond legal advocacy, to stabilize their lives. Meeting those other needs through services or assistance from family, friends, neighbors, or their religious community may prove more enduring than the legal solution we might also pursue for them. This is the approach that skillful and compassionate legal aid lawyers have always taken, but it is useful for all of us to be reminded about what a difference it can make.
While the issues are profound, this is not at all an intimidating book. Gawande makes his points through vivid and powerful stories, including moving portraits of his own family members wrestling with grave health issues and the vagaries of aging. He is a masterful writer who keeps his medical vocabulary under control. It is a short and easy-to-read discussion of the momentous final stages of life, with an ultimately inspiring and comforting impact that will stay with you.
John Tobin retired in 2014 after 18 years as executive director of New Hampshire Legal Assistance.