Inspirations: Atul Gawande on Numbered Days

  • Modern medicine can extend life beyond the point where the patient feels it is worth living.
  • The role of the doctor is to ask the patient how they want to spend what time they have left and to help them meet those goals.
  • How far should medicine go toward helping a person die when their life is no longer worth living?

Saving Lives

Dr Atul Gawande (Center for American Progress’s Photostream [CC / Flickr])

In the second post, I’m going to explore a theme that ran through Atul Gawande’s Reith lectures on The Future of Medicine, which is the tension between extending life and improving the quality of life. Before I do, here are the links to the lectures again:

Lecture 1: Why do doctors fail? Podcast Transcript

Lecture 2: The century of the system Podcast Transcript

Lecture 3: The problem of hubris Podcast Transcript

Lecture 4: The idea of wellbeing Podcast Transcript

The dilemma of Tithonus

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Ronn aka “Blue” Aldaman (CC / Flickr)

In Greek mythology, Eos the Titan begged Zeus for eternal life for her mortal lover, Tithonus. Having a warped sense of humour, Zeus took her literally and granted eternal life without stopping Tithonus from ageing. Tithonus spent centuries too weak and ill to move, begging for death. Eventually he turned into a cicada.

Modern medicine recreates the dilemma of Tithonus, as it can now extend life beyond the point where many people regard it as worth living. Gawande explores the question of when and if a doctor should allow a patient to die when she could keep him alive for a little longer. For the writers amongst us, it’s the sort of dilemma that forms the kernel of memorable fiction. For all of us, writers or not, it’s a dilemma we will have to confront sooner or later, on our own behalf or on behalf of people we love.

Ask the patient

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Derrick Tyson (CC / Flickr)

Gawande offers a simple solution: ask to the patient. At least, it seems simple until you consider that the outcome of the conversation may be that the doctors and nurses should allow a patient to die when they can keep them alive. Most of us regard death as an abstract proposition. We know we’ll run out of days sometime, but we don’t know when so we act as though we have all the time in the world. There’s nothing wrong with that. It keeps us happy.

When days are numbered, many people react by assessing what they want to do with that time. Gawande talks about a friend who wanted to carry on teaching music to children for as long as possible. Stephen Sutton famously devoted his last years to fundraising for cancer charities and completing his bucket list, achieving more in his 19 years than many people achieve in 90. Such objectives are likely to be at odds with medical advice that seriously ill people should conserve their strength.

If the job of medicine is to give the patient what they want, and if they are more interested in filling the time they have left with what they want than extending it, Gawande argues that is what medicine should do.

Assisted dying

It was the questions in the third lecture that followed the argument to its logical conclusion. When life has nothing left to offer but suffering constant pain while faculties and dignity slip away, many of us will follow Tithonus’s example and wish for death. Should it be part of the job of medicine to help us set our own schedule?

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sima dimitric (CC / Flickr)

Medicine goes part of the way there whenever a doctor asks a patient whether they want to be resuscitated if their heart fails. However, that cedes control to the caprice of the patient’s heart. One person may be overrun with cancer while his strong heart relentlessly pounds oxygen around his body while another has a heart condition that will carry him off fairly quickly. We have to ask whether it is satisfactory to leave the schedule in the hands of fate when medicine could put it in the hands of the person it most concerns.

Gawande raised an oft-repeated concern when he said that in the Netherlands, where euthanasia is legal, many people opt to die because they don’t want to be a burden on their families or society at large. Nobody wants to help inheritance-obsessed families to badger their relatives into euthanasia.

Facing death is easier than facing bereavement

My own experience of people choosing their fate is very different. I’ve known people with cancer who couldn’t face any more chemotherapy, who are still alive because their families begged them not to give up. That’s not to deny Gawande’s concerns. People are a diverse enough lot that the ugliest dynamic we can conceive of is bound to be played out somewhere.

While we may abhor the idea of someone choosing to die rather than being a burden on someone else, is it anyone’s choice but their own? Any able-bodied person has the right to commit suicide in practical if not legal terms, because there’s nothing anyone can do to stop them. Is it reasonable to deny that right to someone because they are infirm?

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sima dimitric (CC / Flickr)

Most people find it far easier to face their own death than losing someone they care about, but is that a reason to deny someone the chance to take control of what is left of their life?

When my time comes, I want to be in control. I may not choose euthanasia, but I want it to be my choice and I will argue strenuously with anyone who denies that it’s my decision to make.

The power of fiction is that it can place these dilemmas before characters who will have to face them in the way that real people can expect to, and give the reader a perspective that no amount of commentary on medicine or society in the general sense can offer.

Next week, something lighter!

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Posted in Inspirations, Wednesday Pontification

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