On Being with Krista Tippett

Episode: Atul Gawande — On Mortality and Meaning
Date: June 27, 2024

Episode Overview

In this thoughtful and deeply humane conversation, Krista Tippett and Dr. Atul Gawande explore what mortality means in the modern era and how the inevitability of death shapes our understanding of meaning, wellbeing, agency, and care. Drawing from his experiences as a surgeon, writer, and public health leader, Gawande reflects on how confronting the limits of medicine—and life itself—can point us toward living more fully. The discussion traverses personal stories, the evolution of medicine’s approach to death, the role of spiritual and cultural background, and practical wisdom for individual and collective navigation through aging, dying, and what makes life meaningful to the very end.

Key Discussion Points & Insights

A. Spiritual and Cultural Grounding

• Atul Gawande’s Hindu Upbringing (03:11)
  • Growing up Hindu in rural Ohio, Gawande describes his experience as culturally infused but not deeply doctrinal.
  • Emphasizes Hinduism as lived practice—“It's such a wide open, ecumenical, welcoming religion.”
  • Example: Treating books as sacred (“I cannot to this day put a foot on a book. It’s just sacrilegious. It is dishonoring. Not only the book, but everything that matters behind it, and it’s inseparable. Right. It’s a way of living and a way of praying.” [05:02])
• Difficulty Articulating Religion and Spirit
  • Both Krista and Atul note how hard it is to separate spiritual, moral, and practical threads from one another—especially in Hinduism.

B. Confronting Mortality in Medicine

The Evolution of Medical Culture

• Death as Failure vs. Part of Care
  • Medicine’s traditional view: death as failure (“When you were going through your medical training…death was a failure…medicine stopped.” [09:31])
  • Modern shift: recognizing death as universal, and care as ongoing even in dying.

“What Are We Fighting For?”

• Reframing the Fundamental Question
  • “It's not do we fight or do we give up? It's what are we fighting for?” ([10:14])
  • Moves from focus on biological survival to asking about the person’s priorities, values, and the quality of life.
• The Good Day Question
  • “What does a good day look like?” emerges as transformational (15:19).
  • Gawande shares that asking this—with terminally ill patients and their families—reorients care toward individual meaning.

“People have priorities besides just surviving, no matter what. You have reasons you want to be alive. What are those reasons?... The conversation is: as you face what you’re facing, what are you willing to sacrifice and what are you not willing to sacrifice along the way, for the sake of more time, what’s the minimum quality of life you’re really going for here that you would find acceptable?” — Atul Gawande [10:27]

Case Study: Missed Opportunities for Meaning

• Example: A woman who never articulated her wish to take her grandchildren to Disney World (“We had never asked her…because we could have made that possible for her a month before if those questions had been asked earlier.” [12:10])

C. Redefining ‘Wellbeing’ in Medicine

Insights from Aging Research

• Referencing Laura Carstensen’s work: people often become more fulfilled as they age despite health decline (13:28).
• “After age 65, people were more likely to have love in their life…less likely to have anxiety and depression.” ([14:18])
• Wellbeing is tied to agency and the ability to shape one’s own story, not just health or independence.

The Practicality of Wellbeing

• Real-world examples: A good day might be as simple as reading a book, seeing family, or enjoying ice cream and football (16:12–18:01).
• Even very ill patients can reclaim moments of meaning through simple, tailored interventions.
• Story of Peggy, the piano teacher, whose hospice team enabled her to teach final lessons, profoundly impacting her student’s life (18:32–20:28).

D. Societal Shifts in the Experience of Death

Where and How We Die

• Drastic demographic change: from most Americans dying at home (pre-1950) to most dying in institutions, now shifting back toward home and hospice care (22:13–23:32).
• Gawande points to an emerging normalization for families and children being present with dying loved ones—shaping new generational attitudes toward mortality.

Agency and Honest Conversation

• Honest end-of-life discussions linked to better outcomes for both patients and families.
• “There’s strong evidence behind what a difference it is for the experience that people have towards the end and even what their survival rate is when you have these conversations versus when you don’t.” — Atul Gawande [25:35]
• “The quality of a last chapter is not opposed to fighting for life, but an essential part of it.” ([26:24])

E. Evidence for Early Palliative Care

Surprising Results

• Study of stage 4 lung cancer patients: Early palliative care led to less aggressive interventions at the end—but also to longer survival and lower overall suffering/costs ([27:23–29:17]).
• “If it were a cancer drug, if it were a pill, it would be this blockbuster.” — Atul Gawande [29:21]
• The magic isn’t technological; it’s personalized conversation and agency.

F. The Physician’s Role: From Paternalism to Partnership

From Authority to Counselor

• Gawande recounts the arc from doctors as paternalistic authority, to “autonomous option-giver” (give choices, step back), to “genuine counselor” who helps connect personal values/goals with medical choices ([30:46–32:52]).
• Key learning: “The family conversation is my procedure,” a palliative care physician told him, highlighting the skill and artistry required ([33:58]).

Generational Change & New Professional Ethos

• Medical students’ oath: “We will seek to heal the whole person rather than merely treat disease, committing to a partnership with our patients that empowers them and demonstrates empathy and respect. We will cure sometimes, treat often, and comfort always.” — University of Minnesota Medical School class oath, read by Tippett [35:30]
• Reflection on how priorities and health goals can be multi-layered and at times contradictory, making clinician–patient partnership crucial ([36:44]).

G. Spirit, Meaning, and Connection

The “Spirit” in Medicine & Life

• Gawande is cautious using spiritual language, but finds “spirit” in:
  • Asking patients about their spirits as part of care, not just their symptoms ([41:38])
  • Participating in rituals that transcend generations—such as scattering his father’s ashes on the Ganges ([42:17])
• Draws on philosopher Josiah Royce: our deep need to live for something larger than ourselves ([44:21]).

“We are a link in a chain and making a contribution that goes well beyond our own life. And that’s part of what makes dying tolerable. That’s what makes being a mortal creature tolerable.” — Atul Gawande [45:24]

The Chain of Being & Science Fiction

• Gawande references The Three Body Problem novels to illustrate our ability to imagine meaning beyond an individual or even humanity itself ([45:59–48:39]).

H. Public Health, Citizenship, and Agency

Medicine as Public, Not Just Clinical, Life

• Tippett proposes the idea of Gawande as a “citizen physician” (48:39), expanding care into the civic/public sphere.
• Gawande stresses breaking down boundaries between clinician and citizen, inside/outside, and between “the microscopic and the telescopic” (50:10–52:00).
  • Connecting real human stories with systems thinking, data, and policy.

I. Mortality, Humanity, and Embracing Limits

Embracing Limitations

• Central insight: To be human is to be limited, but relationality and collective effort have near “unlimited” potential (57:28).
• Reflection on how personal and professional navigation of imperfection, risk, and incomplete knowledge is at the center of both medicine and life.
• “My way of navigating through limitation is trying as much as possible to keep my options open…But I have to make my bet without 100% of the information and certainty…The best people in surgery and public life recognize the need to act, own the consequences, and try to learn and move on.” — Atul Gawande [59:01–60:32]

Notable Quotes & Memorable Moments

• “Being alive is a fatal condition…we all do have a diagnosis that we will die.” — Krista Tippett [05:40]
• “It's not do we fight or do we give up? It's what are we fighting for?” — Atul Gawande [10:14]
• “What does a good day look like?” — Atul Gawande (the pivotal question) [15:19]
• “We will cure sometimes, treat often, and comfort always.” — University of Minnesota Medical School class oath [35:53]
• “We are a link in a chain and making a contribution that goes well beyond our own life. And that’s part of what makes dying tolerable.” — Atul Gawande [45:24]
• On palliative care as transformative:
  “If it were a cancer drug…it would be this blockbuster company, and we’d all want stock in it…the answer was they were just having these conversations, identifying their priorities.” [29:21]
• On limitations and agency:
  “To be human is to be limited…yet we are almost unlimited as groups of people…” — Atul Gawande [57:28]

Timestamps for Key Segments

• [03:11] – Atul Gawande’s spiritual and cultural upbringing
• [06:24] – How doctors and patients perceive mortality
• [10:14] – Reframing “fight or give up” to “what are we fighting for?”
• [12:10] – The importance of understanding individual wishes at end-of-life
• [13:28] – Stanford psychologist Laura Carstensen’s research on aging and fulfillment
• [15:19] – The “good day” question as a tool for wellbeing
• [18:32] – The story of Peggy, the piano teacher on hospice
• [22:13] – Societal changes in dying at home versus institutions
• [27:23] – The stage 4 lung cancer study on early palliative care
• [30:46] – The evolution of the physician’s role in patient autonomy
• [35:53] – Medical students’ oath and generational change
• [41:38] – Talking to patients about “spirit” and spiritual care
• [42:17] – Gawande’s journey to the Ganges with his father’s ashes
• [44:21] – Philosophy of Loyalty and living for something larger
• [48:39] – The importance of “citizen physician” and public life concepts
• [57:28] – The paradox of human limitation and collective accomplishment

Final Takeaways

This episode invites listeners to re-examine their relationship with mortality—not as a medical failure or an occasion for despair, but as an inescapable part of human existence that can clarify what matters most. Meaning is made possible not by the extension of time, but by honoring individual priorities and connections, however simple, and through candid, compassionate dialogue. Medicine, in Gawande’s vision, is a humane practice lived at the intersection of expertise, agency, spirit, and shared humanity.