Atul Gawande’s Being Mortal is both ambitious and synthetic, qualities that well suit his difficult subject, death.  In Western culture, there are taboos against death because it fits neither into post-Enlightenment notions of progress and perfection nor into medical notions of control, even domination of human biology. A surgeon and an investigator, Gawande draws on his patients, his family, and travels to various hospitals and other caregiving places in order to confront death and see how approaches such as hospice and palliative care can improve our understanding, acceptance, and preparation for death.

Gawande has harsh words for contemporary medicine, the supposed caregiver for the dying and their families.  Relying heavily on technique and industrial models, it ignores the deep needs of the dying and provides, instead, versions of “warehoused oblivion” (p. 188), for example long, futile stays in ICUs.

As opposed to traditional societies like India, Westerners prize the independence of individuals, a status that is, of course, never permanent. In the chapter “Things Fall Apart,” Gawande describes how longer lives are now the norm but they include chronic illnesses and inevitable decline in vitality.  Our deaths are now routinely in hospitals, not at home, and often extended—sometimes brutally—by technical support and unwillingness of doctors and families to stop aggressive treatment.       
Also, sadly, there are fewer and fewer geriatricians at a time when there are more and more elderly.  A good geriatrician takes a long time with each patient, is not well paid, nor does s/he do income-generating procedures. Worse yet, some training programs are being discontinued.  

Gawande illustrates his ideas with case studies of patients and describes, from time to time in the book, the elderly journeys of his grandmother-in-law and his own father.  These passages make vivid the abstract ideas of the book. But it’s not just elderly patients who face death: health calamities can come to anyone, for example, a 34-year-old pregnant woman found to have a serious cancer. Various treatments are tried without success, but family and doctors act out “a modern tragedy replayed millions of times over” (p. 183) of a medically protracted death. Finally her mother calls a halt to treatment.
Family members often bear a heavy load in caring for a sick elder, but many nursing homes are often worse, designed for control, not support of the patients. 

The chapter “A Better Life” describes the first in a series of places that offer much improved settings for the elderly, with birds, animals, gardens, and, in general, richer lives that have a sense of purpose.  Gawande describes hospice care, palliative care, and advanced directives (including Do Not Resuscitate orders) as improvements needed to break the norms of “treat at all costs.” The old roles of Dr. Knows-Best and Dr. Informative need to give way to physicians and others who talk with patients and families about their values, their wishes for the last days, and their preparations for death. In short, aggressive treatment should no longer be the “default setting” for hospital care.     
The book ends with a dozen moving pages about the death of Gawande’s father. The “hard conversations” have clarified his wishes, and hospice care has provided “good enough” days.  Pain control has done well. Then, finally, “No more breaths came.” The family travels to India to spread his ashes on the Ganges. 


This is a powerful and important book.  While some sectors of society have already embraced the values Gawande argues for, many have not.  Many physicians treat dying patients endlessly by training and by law, a norm of maximizing that Gawande finds is often  “a fantasy.” Families, as well, may insist that surely something else may be tried, and they are “unprepared for the final stage” (p. 154). They are likely to be depressed after the death of their loved one. Gawande writes, “Our system of technological medical care has utterly failed to meet these needs” of top concerns that have been identified by surveys: avoiding suffering, strengthening family bonds, being mentally aware, and so on (p. 155). 

This book should be a routine part of medical education and continuing education for practicing doctors.  It should be read by nurses, hospital administrators, and policy makers. Any readers wishing sources and background may consult the dozen pages of notes at the end of the volume that support his arguments.

It seems odd that Gawande never mentions hospital chaplains or community clergy who are often involved with patient care. Typically these are already in agreement with him. In the book there are brief mentions of patients’ faiths, but his argument does not consider the roles of religious faith or spiritual paths. He finds some comfort in the Hindu rituals of the Ganges, although he is not a believer.

As in his previous books, Gawande offers engaging prose that explains technical issues clearly, takes us to a patient’s bedside or the OR with vividness, and quotes people so that they become real to us.  By using his father and grandmother-in-law as cases that continue throughout the book, we feel his own personal involvement with family well beyond his medical role.  As a general surgeon, he is suddenly drawn into the lives of patients, and he writes candidly about times he wishes he had done better in discussions with family about treatment. As the book progresses, we see his own evolution of values to avoid the “always treat” approach.               


Henry Holt and Company

Place Published

New York


Metropolitan Books

Page Count