Before my departure for a trip to celebrate my mother’s ninety-eighth birthday, friends suggested that I read Atul Gawande’s Being Mortal. Since I also planned to visit a relative recently diagnosed with terminal cancer, I took the book along with great interest.
Gawande begins with the confession that he never learned how to treat mortality in medical school. To make up for this lack, he undertakes a diagnosis of how Americans deal with death, first examining patient-care in nursing homes, and then turning to end-of-life treatment in hospitals.
His descriptions of the American nursing homes are familiar. Anyone with a parent or grandparent in such an institution understands the reasons for his concern: impersonal care, neglect, isolation, absence of stimulation, anonymous routines, and regimentation. “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 writes.
Gawande compares the soulless institutions in America with the experience of his grandfather in India who lived to 110 at home. But he admits that this was made possible by his aunts and uncles. Gawande’s own father, on the other hand, lived and died in Athens, Ohio, while the son worked in Boston.
All my grandparents lived into their old age at home because there was a village to support them. But three years ago, after my mother had a stroke and heart attack at 95, my brother, sister, and I looked for a nursing home. We still confront the guilt of having taken our mother there, a person who had given so much and had asked for little in return.
Reading through Gawande’s prescriptions about old age, I kept asking myself what they had to do with my experience in my mother’s nursing home. He says, for instance, that rather than just ensuring their patients are safe, nursing homes should devote energy to making their lives meaningful.
This is a great and inspiring idea. But how does it apply to the residents on my mother’s floor who are in varying degrees of dementia or are withdrawn into cognitive inwardness? One man, paralyzed on one side, suffers from aphasia. Like a figure enduring endless punishment in Greek mythology, he has desires but is incapable of expressing them. What does meaning mean here? Where else can he be other than a nursing home? Even a village would have difficulties caring for him.
When Gawande moves on to the operating room, his analysis becomes more incisive. Here again he examines something that has been talked about for decades: Rather than dying at home, patients are experiencing their end with tubes snaking into their mouths, with doctors trying experimental treatments, with nurses trying to coax one last breath.
Gawande provides countless stories of confused patients, false hopes, and terrified family members. Particularly moving is the death of Gawande’s own father, himself a urologist. Here the doctor experiences the end of life from the perspective of a patient and comes to understand his feelings of helplessness.
But this section also highlights the book’s weakness—its over-reliance on anecdote. Being Mortal manifests the dominant tendency in American commercial publishing to prefer narrative to analysis. A discussion of terminal care in other countries, for instance, or of hopeful strategies being introduced in the United Sates is inevitably followed by another story of patients caught in the bureaucratic machine.
How many tales do you need to make your point? Should stories constitute two-thirds of your book? Gawande, his publisher, editor, and agent might think about these questions. For they subscribe to the assumption that mass-publication books can succeed only by trading in parables.
In one respect, this is understandable. We are story-telling animals, communicating through narrative. Life is itself a story, Gawande himself says, the direction of which we often lose towards the end of life.
When stories illuminate, say by revealing the failures of the American medical system, they are invaluable. But stories, through their very familiarity, repetition, and steady accumulation, can also block our understanding, making us numb to the pain they describe. This is what happens in this book. The narratives Gawande collects end up saying the same things but through different voices. We have all heard before from friends and family members or have experienced them ourselves.
To work stories have to entertain, that is, maintain our interest. We want to read about the man who mistook his wife for a hat or about how the urologist turns into a cancer patient. Our delight and insight paradoxically come from the suffering of others. Reading has an aesthetic dimension.
But sadness alone does not make a story stimulating. And many sad stories do not necessarily yield an effective book.
Homer, the master story-teller, understood the relationship between narration and human sorrow. In the Iliad Helen says to Hector, “Zeus planted a killing doom within us both,/ so even for generations still unborn/ we will live in song.” She suggests that the gods incited Paris to elope with her to create the pleasures of the story for future ages. And in the Odyssey, hearing a minstrel tell his own tale, converting his life into art, Odysseus says “that was all gods’ work, weaving ruin there / so it should make a song for men to come.” At the end of Mark Twain’s The Adventure’s of Huckleberry Finn Tom Sawyer wishes to prolong Jim’s imprisonment and humiliation for the sake of telling stories about freedom and enslavement.
The anguish of others can be converted into aesthetic enjoyment and human understanding. But these stories can also anesthetize us when they become commonplace, when they turn into routine, and when they just accrue. How different Gawande’s book would have been, had it been accompanied by a sustained discussion of issues relating to death and dying. But this seems difficult to imagine in American commercial publishing, its heart beating to an aestheticism that converts life into narrative.
As a teacher in the humanities, I welcome this development because it underscores the narratological aspect of existence. But at the same time, I am troubled by the patronizing assumption that readers can’t understand concepts unless told in simple parables.
Gawande’s Being Mortal rests on the supposition that a book will sell only by telling stories. In so doing, its success is only partial. While it enables readers to form empathic bonds with the individuals described in its pages, it leaves these readers waiting for wisdom on how to take care of ailing loved ones.