In the early 1990s, an upstate New York doctor became the medical director of a nursing home populated almost entirely by severely disabled elderly people. Unhappy about all the unhappiness he saw around him, the doctor launched an experiment. Shifting attention from “treatment” to “care,” he introduced plants in the living quarters, flowers and vegetables in the garden, and a veritable menagerie all around the property, including two dogs, four cats, and 100 parakeets. Eventually, he added an outdoor play area for the employees’ children. The results were surprising: greater contentedness in the home’s residents (measurable in part by a large decrease in the need for psychotropic drugs like Haldol), but also extended lives.
Atul Gawande believes in targeted fixes, especially small ones. His previous book, The Checklist Manifesto, detailed the outsize benefits of that favorite of highly organized people, the checklist. In Being Mortal, the writer-physician turns his attention to what happens when the elderly or infirm are granted a plant to look after, a chance to break an in-house rule, or even a sustained conversation about their future. His contention is that such little adjustments not only produce big payoffs for well-being, but also represent significant breakthroughs in terms of our thinking about questions of such daunting ethical and emotional magnitude that we generally avoid contemplating them at all. Questions like: What can we do to improve the existence of people in the final phase of life? How do we prepare others—and eventually ourselves—for the end?
Gawande has a philosopher’s as well as a clinician’s interest in death. His 21st-century ars moriendi, or guide to dying well, opens not just for show with reflections on Tolstoy’s Ivan Ilyich and his tortured, lonely struggle with his own mortality. All Ilyich wants in his last days, it turns out, are some comfort, some companionship, and a modicum of truth about his situation, none of which are in the offing. And with a modesty, artificial or not, that makes the reader like him from the start, Gawande details both what happens to the body as it ages and falls into decrepitude and his own intellectual evolution as a doctor. The all-too-commonplace young physician who takes his charge to be keeping the enfeebled patient alive, whatever the cost to that individual, matures into the medical professional and family member who wants to understand, when one’s final days are clearly numbered, what makes a life worth living and what does not.
This abstract bent is combined in Being Mortal with a social scientist’s concern for the institutional framework in which these issues are—or should be—routinely addressed: hospitals, nursing homes, housing complexes for the ill or disabled, assisted-living facilities (though Gawande, following Erving Goffman, sees all such “total institutions” as structurally related in largely negative ways). Gawande also exudes the novelist’s fascination with individual characters, whether patients, reformers, or his own family members. Or maybe he just has a smart sense that stories of lives lived, and their medical and human twists and turns as his subjects encounter the threat of death, are what will make his own largely nonmedical medicine go down.