being mortal

Atul Gawande's Being Mortal takes me back to grace and truth.

The author is concerned that we lack 'a coherent view of how people might live successfully all the way to their very end, (as) we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers' (9). Drawing a little on his alternative Indian heritage, Gawande grieves over the way 'old age and infirmity have gone from being a shared, multi-generational responsibility to a more or less private state - something experienced largely alone or with the aid of doctors and institutions' (17).

Gawande channels that grief into being one who provokes conversation and presses for change. This is how he writes and this is how we should respond.

But let's do it with grace, like Gawande.
His tone is irresistible. There is a combination of humility and compassion in the way he writes. He is learning as he writes. He is feeling as he writes. One of the stories of dying and death which he tells is that of his own father. It is so tender.

Then there are stories of other people with similar grace. My favourite would be the one about Bill Thomas (111-125) transforming a nursing home with plants and animals and children ('literally putting life into it' - 116). Green plants - and a bird - in every room. Vegetable and flower gardens instead of acres of lawn. Dogs and cats roaming the property. 'People who had been completely withdrawn and nonambulatory started coming to the nurses' station and saying, 'I'll take the dog for a walk''(122). Even on-site child-care for staff and an after-school programme for children, with residents helping children with their homework on World War 2. Gracious tone. Gracious stories.

Medical professionals are not known for their simplicity of language. Acronyms and polysyllabic constructions fill their sentences. Another expression of grace is the one shown to me as a reader. There are 12 pages stuffed with academic sources at the end - but you'd never know it. Gawande writes with such ease, seamlessly integrating the academic analysis into the narrative of peoples' lives. I grew a little weary of the stories after awhile - but loved these pauses to reflect and to conclude - and to skill me. It is a model for a similar discipline known for its complexity: theology.

There is one exception to all this. I don't know enough to recognise whether it is true beyond the United States - but Gawande is pretty tough on facilities like nursing homes. One is left wondering if they are all like the TV show, Keeping Up Appearances. Because here the grace is exchanged for some surprising invective at times: for eg., phrases like 'depressingly penitentiary' (129) ... 'a warehoused oblivion' (188).

Let's do it with truth, unlike Gawande.
OK - that is a bit tough on Gawande and I'll address that issue in a moment.

However, for me, as a committed Christian, this was such a dissatisfying book. It was so incomplete. I found myself longing to see theology in its words, the Bible in its footnotes, and Jesus walking through its pages. When it comes to dying well along that 'trajectory' towards death, there is so much more that needs to be said. What about God's sovereignty? God's eternity? God's providence? God's love? What about our union with Christ, in his suffering, death and resurrection - and the certain hope which this cultivates? What about the power of the Spirit, bringing comfort and enabling perseverance? What about the church waking from its slumbers and its preoccupation with youth? There were times when I felt so desperate for a little 1 Corinthians 12 and 15, a little Ecclesiastes 11 and 12, a little John 13 and John 20 ... and a whole lot of Psalms. I felt grief knowing there are millions of people reading this book without considering these truths.

Gawande writes as an agnostic (I think) and he must be true to who he is. But the majority of the world's people are spiritual believers and this book misses an opportunity to speak into that world. [Actually - there is a fabulous assignment here for a pastoral theology class. Imagine this book, with all its people and stories, being collected into a single picture ... and then have students go away and develop a biblical-theological frame which both draws out the significant hues in that picture and completes it.]

But this is not fair to Gawande. Biblical truths may be absent, but wisdom is still present - a wisdom about the world and the people in it whom God has made and wired. As 'all truth is God's truth', it is great to see Gawande uncovering the wisdom in these truths.

For example, the way the trajectory of death is 'less like a cliff and more like a hilly road down the mountain ... a long, slow fade ... the body's decline creeps like a vine' (27, 28, 42). Or, the echoes of Paul Brand in the way a close examination of the feet of the elderly tells so much of their story - and why keeping them from falling is such a gift (40-41). Or, the danger of succumbing to the belief that 'once you lose your physical independence, a life of worth and freedom is simply not possible' (75). Or, the brake applied to the euthanasia camp in his call for assisted living to take priority over assisted dying: 'our ultimate goal, after all, is not a good death but a good life to the very end' (245). Why not have both?!

There are a few sobering home truths for the medical profession. 'Medicine's focus is too narrow. medical professionals concentrate on repair of health, not sustenance of the soul ... (it should be about) helping people in a state of dependence sustain the value of existence' (128) ... and 'resisting the urge to fiddle and fix and control' (149).

There is some truth to be found in statistics, often as he integrates scholarly research. In a hospice, 'Ninety-nine percent understand they're dying, but one hundred percent hope that they are not' (161). Drawing on Susan Block's work - 'about two-thirds of patients are willing to undergo therapies they don't want if that is what their loved ones want' (186). What about the plummeting numbers of people entering geriatrics: 'a lot of doctors don't like taking care of the elderly ... 87% of medical students take no course in geriatrics' (52).
The battle of being mortal is the battle to maintain the integrity of one's life - to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe their job is not to confine people's choices, in the name of safety, but to expand them, in the name of living a worthwhile life. (141)
...our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one's story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone's lives. (243) 
nice chatting



Geoff New said…
Thanks Paul. This is an intriguing review and very helpful for me. It places Gawande in a wider context. I've just finished his book entitled "The Checklist Manifesto." Maybe he could have made his point in fewer chapters but I'll be employing some of his thesis from that book in my work. These blogs of yours are outstanding.
Heather said…
Dear Paul,

Thanks for this. It would be great if someone would do a theological analysis as you suggest!

I haven't read this book, but I heard his Reith lectures (2014, I think) and also a couple of long-form radio interviews with him. I've been very influenced vy his thinking as we seek to support my own parents as they age. He's made me think long and hard about what they want, and to try and get them to tell me what is important to them, rather than just thinking about their safety and the provision of their basic needs. In so doing, I've come to really appreciate how much helping others is key to their identity, and have given a lot of time to thinking about ways in which they could continue to 'give' as cognitive decline kicks in or when they lose the ability to drive.

But yes, it'd be great to have these ideas integrated into a Christian world-view, too!
Paul Windsor said…
Thanks, Geoff. While at home I chatted to a few Kiwi medical professionals who felt that Gawande is addressing an American context that is some way 'behind' New Zealand on these matters. Maybe. Maybe not. But whatever doubt there might be in the book's relevance to Kiwi medical professionals, there can be no doubt about its usefulness to pastoral professionals!
Paul Windsor said…
Thanks, Heather, I SO enjoyed seeing Martin earlier in the week...

Interesting to read your reflections, as looking past 'safety and the provision of their basic needs' is one of the key things I take away from the book when considering elderly parents. These are important - but this issue of purpose and significance and having ongoing opportunities to give stays with me. It was part of the thinking behind having that Open Home (to which Martin came) at my mother's place, giving her the opportunity to keep shining as the great hostess she has always been.

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