In today’s era, where concerns about depopulation loom large, our focus often centers on the productive age group. We worry about the declining workforce and its impact on the economy, selfishly contemplating how to maintain global prosperity. In doing so, we frequently overlook the older population, failing to recognize their critical role in society.
Being Mortal by Atul Gawande is a powerful book that talks about the struggle of being old. Gawande points out how aging has changed over time. We now rely heavily on medicine and public health to keep us healthy. He underscores our increasing reliance on medicine and public health advancements, which have indeed progressed remarkably. Today, many diseases can be cured or at least managed to extend our lives. However, Gawande reminds us that the ultimate goal is not merely to live longer but to live a life that is truly worth living.
Published in 2014, Being Mortal remains incredibly relevant, even as the concept of longevity gains popularity. If released today, I believe the book would undoubtedly include discussions on the phenomenon of longevity, a living disease-free that currently hype. Yet, Gawande’s primary focus transcends the idea of a disease-free existence. He talks about the basic human need to have a purpose in life, right up until the end.
Gawande’s narrative is both enlightening and deeply moving, urging us to reconsider our approach to aging and elder care. As a practicing surgeon, he suggests that we should not only aim to extend life but also to improve the quality of life. Through personal stories, medical insights, and thoughtful reflections, this book invites us to ensure that the elderly live with dignity, autonomy, and a sense of purpose.
Being Mortal is a must-read for anyone interested in the intersection of medicine, aging, and quality of life. Gawande fills a significant gap in the discussion of depopulation, urging us to value and care for our elderly population with the same attention we give to the young. It is a powerful reminder that a meaningful life is not just about how long we live, but how well we live.
Summary
The New Reality of Old Age
In the past, reaching old age was rare, and those who did were seen as special guardians of tradition, knowledge, and history. They held their status and authority as heads of the household.
However, today, old age isn’t as rare or valued. Technologies have eroded the elders’ exclusive hold on knowledge and wisdom. Most importantly, increased longevity has changed the relationship between the young and the old. Traditionally, surviving parents provided stability, advice, and economic protection for young families. But with parents living much longer, tensions have emerged. For young people, the family system has become less a source of security and more a struggle for control.
The power dynamics between generations have shifted. Modernization didn’t just reduce the elderly’s status; it changed the role of the family. It offered everyone, both young and old, more freedom and control over their lives, including the freedom to be less dependent on other generations.
Yet, there’s still one challenge: sooner or later, independence becomes impossible.
Medicine and Public Health: Transforming Lives and Facing New Realities
Medicine and public health have changed the course of our lives. While we all eventually die, medical advances have delayed many fatal moments and extended our lives.
Modern medicine has sparked two revolutions: a biological transformation of our life course and a cultural shift in how we perceive it. Yet, we often ignore the societal adaptations needed and miss opportunities to improve the aging experience. This progress has led to the “rectangularization” of survival. Imagine a device that wouldn’t extend life but would greatly reduce the chances of ending up in a nursing home or suffering from depression. We’d be eager for it.
In the mid-20th century, medicine was rapidly transforming. Before this, serious illnesses were usually treated at home, and hospitals were mainly for custodial care. However, hospitals began to eliminate infections, remove tumors, and fix bones, becoming the go-to place for medical issues, including those of the elderly.
Policymakers thought pensions would end poorhouses, but they didn’t address the final, infirm stage of life. As hospitals became more common, they lobbied for government help to handle chronic illness and aging. In 1954, funding was provided to build nursing homes.
However, these places weren’t truly designed for us. Rarely does anyone discuss what living a meaningful life means under such circumstances or help create a home where that life is possible. This is a consequence of a society that avoids thinking about the final phase of life: making it worth living when we are weak, frail, and unable to fend for ourselves.
The True Fear: Losing Life’s Essentials, Not Death
With good habits—like eating well, exercising, and controlling blood pressure—people can often manage to live independently for a long time. But eventually, losses accumulate to the point where daily life becomes too difficult to handle alone. Most of us will face periods where we’re too debilitated to live independently. We avoid thinking about this, leaving us unprepared when it happens. We rarely plan for how we’ll live when we need help until it’s too late.
People with serious illnesses have priorities beyond just extending their lives. Surveys show their top concerns include avoiding suffering, strengthening relationships, staying mentally aware, not being a burden, and feeling that their life is complete. The very old don’t fear death as much as they fear losing their hearing, memory, friends, and way of life. Our current medical system fails to meet these needs, and the cost of this failure goes beyond money. The real question isn’t about the expense of our healthcare system; it’s about how we can create a system that helps people achieve what’s most important to them at the end of their lives.
Finding Meaning: What Makes Life Worth Living When We Are Old and Frail?
In his book A Theory of Human Motivation, Abraham Maslow describes a hierarchy of needs depicted as a pyramid:
- At the bottom are physiological needs like food and water.
- Above that are the need for love and belonging.
- Then comes the desire for growth—achieving personal goals, mastering knowledge and skills, and being recognized for achievements.
- At the top is self-actualization—fulfillment through moral ideals and creativity for their own sake.
Safety and survival remain our primary and foundational goals in life. Public policies focusing on health and safety for the elderly reflect these fundamental goals, assuming they are everyone’s top priorities. However, our motivations change over time, often in ways that don’t align with Maslow’s hierarchy. Understanding this shift is key to understanding old age.
Research on Maslow’s hierarchy found the opposite: people reported more positive emotions as they aged. They became less prone to anxiety, depression, and anger, finding life more emotionally satisfying and stable even as old age narrowed their activities. Further research revealed that perspective, not age, is what matters most.
Yet, our elderly often end up in controlled, supervised institutional settings, where life is medically designed to address unfixable problems. This creates a safe but empty existence, devoid of what they truly care about.
How to Live a Worthwhile Life
Provide Reasons to Live
We all seek a cause beyond ourselves, an intrinsic human need. This cause could be something large, like family, country, or a principle, or something small, like a building project or caring for a pet. The important thing is that by valuing this cause and seeing it as worth making sacrifices for, we give our lives meaning. Josiah Royce, a Harvard philosopher, called this dedication to a cause beyond oneself “loyalty,” viewing it as the opposite of individualism.
Finding Meaning in Mortality
The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. Without this connection, mortality is only a horror. With it, it is not.
The Role of Medicine
The problem with medicine and the institutions it has created for the care of the sick and the old is not that they have an incorrect view of what makes life significant. The problem is that they have almost no view at all. Medicine’s focus is narrow, concentrating on the repair of health, not the sustenance of the soul. Yet, paradoxically, we have decided that medical professionals should largely define how we live in our waning days.
Creating Meaningful Lives in Old Age
Making lives meaningful in old age is a new concept. It requires more imagination and invention than merely making them safe.
People don’t view their life as the average of all its moments, which are mostly mundane and include sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by significant moments where something happens. Measuring minute-by-minute levels of pleasure and pain misses this fundamental aspect of human existence. A seemingly happy life may be empty, while a seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.
When our time is limited, and we are uncertain about how best to serve our priorities, we are forced to deal with the fact that both the experiencing self and the remembering self matter. We do not want to endure long pain and short pleasure. Yet certain pleasures can make enduring suffering worthwhile. The peaks are important, and so is the ending.
Courage and Control
No one ever really has complete control. Physics, biology, and accidents ultimately shape our lives. But we are not helpless. Courage is the strength to recognize both realities. We have room to act, to shape our stories, even as time goes on and our confines become narrower.
Conclusion
Our greatest failure in treating the sick and aged is not recognizing that they have priorities beyond mere safety and longevity. The chance to shape one’s story is essential to finding meaning in life. We have the opportunity to transform our institutions, culture, and conversations to enhance the last chapters of everyone’s lives.
At its core, the debate is about which mistakes we fear most—prolonging suffering or shortening a valued life. We prevent the healthy from committing suicide because we recognize that their emotional suffering is often temporary. With help, most people saved from suicide eventually report being glad to be alive. However, for the terminally ill facing inevitable and increasing suffering, only the stonehearted can be unsympathetic.
By understanding these nuances, we can create a more compassionate and meaningful approach to end-of-life care, ensuring that everyone has the chance to shape their story and find meaning in their final days.
Author: Atul Gawande
Publication date: 7 October 2014
Number of pages: 282 pages
