How surprised have you been by the success of your book Being Mortal, which is, after all, an unvarnished account of how we age and die?
The book was delayed a little, which meant it came out in the holiday season. The marketing people at the publisher were like, “We are bringing out a death book for Christmas?” I wrote the book with no intention of making it easy on people. The most surprising thing was it seems people have been giving it as a gift to each other: kids to parents, and parents to kids.
As a culture, we tend not to talk about the question that has always obsessed humans: what makes a good death?
It’s more that as a culture I think we get the question wrong. The question is not how to have a good death, but how to have a good life right to the very end. We are, given advances in medicine, most of us going to spend a good deal of time with serious life-threatening illness. The key question we need to ask is what are people’s priorities when they have to deal with that? I tell the story of a man who said: “I only want to stay alive as long as I can watch football on television and eat ice-cream.” Fine. That would not have been enough for my dad. He said he would like to live as long as he could sit around a dinner table with friends and family and have a proper conversation.
Am I right to say that the genesis of the book grew out of your father’s diagnosis of inoperable cancer of the spine?
That was one thing. I started thinking about the book in 2009. We hadn’t accepted yet that his illness was terminal. There were other things. I had reached a midpoint in my own surgical career where I felt very comfortable with everything except dealing with my patients who had terminal illness, and I wanted to explore that.
Your medical training addressed none of those issues, you say. Is that still the case?
It hasn’t changed that much. The idea when we came to medical school was the heroic one of learning what illnesses people had and how to fix them. To the extent that we were taught anything about how people die, I think it was just considered irrelevant.
We tend to believe that the answer to mortal questions is always more medicine. The book is a good corrective to that idea…
I hope that is the single most important thing that people take away. We take for granted that what matters most as people get older is simply their health and safety, their survival. You know, the first thing they do when you go in a nursing home is take away your choice to drink or smoke. Tell you that you have to take your meals and medicine at a certain time. Why, as you become older and sicker, should you give up your autonomy? People of any age have priorities beyond simply living longer.
There is a great section in the book about a man called Bill Thomas, who insists on introducing dogs and cats and a hundred parakeets into the nursing home he works at…
Institutionalisation is the removal of spontaneity, and the removal of the idea that it might matter. What [Bill Thomas] did was act on the idea that people, all people, need something beyond themselves to live for. And beyond that, people need the sense that something unpredictable might happen every day. That is life. People in his home went from being slumped over in their chairs to, you know, looking after the birds and taking the dog out.
In part, that sense of unpredictability characterised the old age your grandfather enjoyed: he lived in his Indian village until the age of 110 surrounded by his extended family. Should we be nostalgic for that?
My grandfather had an amazing life. He worked the farm right up to the end of his days, helped by his children and grandchildren. He was still the head of the dinner table, revered, people came to him for advice. He had some problems with his memory and his mobility of course, but no one ever thought that the answer might come from a nursing home. In [the west] we tend to never ask people: “What is a good day for you?” Instead we say: “This is what the doctor says you have to do to stay healthy.”
Did writing the book give you a greater sense of your own mortality and frailty?
Oh my God yes. But it also made me less afraid of what will happen.
You run a research facility as well. Do you trial some of these ideas there?
Yes, we are running a large study in hospitals. We have trained the clinicians to ask patients who are likely to die what we see as the key questions that are not always asked – What’s your understanding of your health at this time? What are your fears for the future? And: what are you willing and not willing to go through for the sake of a bit more time? We are finding that patients value that approach enormously. If those conversations happen early enough, we find that people will choose not to have the most aggressive therapies, the fourth round of chemotherapy when three have failed. They will spend more time at home and less at the hospital. They are less anxious and, as a result, they live longer, amazingly.
As a surgeon, you have to cultivate a degree of emotional distance. Does writing about it help you conversely to think of patients as whole people?
When I am in the operating room I am obviously not thinking: this would be an interesting story! But when I step back, writing is the way of thinking out loud about the problems that confuse me in my work. I just got lucky that those things are also interesting to people more generally.
If you had to give up writing or surgery, which would you choose?
I feel in a way the most important thing I do is the writing – if I were knocked down by a bus, my surgery schedule for Monday would not even be delayed, but the writing would never be done. But then, every time I think I have understood the world as a writer I sit down with a patient and find the reality is slightly different again. I think I need both…
Being Mortal by Atul Gawande is published in paperback by Profile/Wellcome Collection (£8.99). Click here to buy it for £7.19. Gawande will be speaking at Bristol festival of ideas on 9 October. To book: ideasfestival.co.uk/events/atul-gawande
