← On Being with Krista Tippett
On Being with Krista Tippett
Atul Gawande — On Mortality and Meaning
01:02:48
We are strange creatures. It is hard for us to speak about, or let in, the reality of frailty and death — the elemental fact of mortality itself. In this century, western medicine has gradually moved away from its understanding of death as a failure — where care stops with a terminal diagnosis. Hospice has moved, from something rare to something expected. And yet advances in technology have made it ever harder for physicians and patients to make a call to stop fighting death — often at the expense of the quality of this last time of life. Meanwhile, there is a new longevity industry which resists the very notion of decline, much less finitude. Fascinatingly, the simple question which transformed the surgeon Atul Gawande’s life and practice of medicine is this: What does a good day look like? As he has come to see, standing reverently before our mortality is an exercise in more intricately inhabiting why we want to be alive. This conversation evokes both grief and hope, sadness at...
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- [00:00]
A
We are strange creatures. It's hard for us to speak about, let in the reality of frailty and death, the elemental fact of mortality itself. In this century, Western medicine has gradually moved away from its understanding of death as a failure. Where care stops. Hospice has moved from something rare to something expected. And yet advances in technology make it ever harder for physicians and patients to make a call to stop fighting death, often at the expense of the quality of the last time of life. Meanwhile, there's a new longevity industry which resists the very notion of decline, much less finitude. Fascinatingly, the simple question which transformed the surgeon Atul Gawande's life and his practice of medicine is this. What does a good day look like? As he has come to see, standing reverently before our mortality is an exercise in more intricately inhabiting why we want to be alive. This conversation evokes both grief and hope, sadness at so many deaths, including our species level losses to Covid that have not allowed for this measure of care yet. It includes very actionable encouragement towards the agency that is there to claim in our mortal odysseys ahead. I'm Krista Tippett and this is on Being Atul Gawande's writing for the New Yorker magazine and his books have been read by millions, most famously Being Medicine and what Matters in the End. He's currently serving as assistant administrator for Global health at usaid. When I interviewed him, he was practicing general and endocrine surgery at Brigham and Women's Hospital in Boston and also teaching at Harvard. I think we can just dive in and do you have any questions for me before we start?
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B
Yes. Are we mainly talking about being mortal or are we thinking we're going in a lot of different directions?
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A
Yeah. Well, I kind of just want you to put yourself into my hands and let me. Yeah.
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B
So you'll guide me?
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A
I will guide you, yeah. And it is really around larger theme, the theme of mortality. But I just want to go deep into that. I mean, I've been reading you for years and in the New Yorker and I like to kind of be more sweeping about how you think as opposed to just what the books are about.
- [02:47]
B
Awesome. Yeah, that's awesome. That's great. Yes. The full tippet.
- [02:52]
A
Yeah, the full tidbit. So perhaps you know that I always start every conversation with an inquiry about the religious or spiritual background of your childhood. However you think about that, however you would define that.
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B
My parents are Hindu. I grew up in rural Ohio. It's hard to grow up in my little town of Athens, Ohio. It's a college town in the Appalachian foothills near the West Virginia border. And it's hard to grow up a Hindu in rural Ohio. It's such a cultural religion. It's deeply embedded, even the way my mother, who comes from North India in a big city and her family managed temples to where my father came from in the middle of India in a very small village. And their own traditions of Hinduism are very different from one another, which gods they most revered and the prayers that they told. And then I didn't grow up with the language, so, you know, I grew up a Hindu, but I'm a sort of apostate Hindu of a religion that doesn't even know the idea of it being an apostate. It's such a wide open, ecumenical, welcoming religion. And so, you know, I still call myself a Hindu, but I'm not. I've never really been practicing, though my parents raised me, praying every weekend, and they prayed every day. And being sort of steeped in it.
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A
You know, I have actually found it's very hard to speak. I mean, I think this is true in general of religion, but it's hard to speak about it. But I think that that's true especially with Hinduism, because it is so much about practice and it is so wide open. Right. It's not ideas. Right.
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B
Yeah.
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A
Do you know what I mean?
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B
It's a way of. It's so embedded in the culture. And, you know, the line between how do you treat your mom and your dad and what are your, you know, how are you supposed to grow up? And your ways of praying, that's seamless. It's not easily separated. For example, I grew up that you never put your foot on a book because a book is spiritual and it's wisdom and it's meaningful. And so if I ever put a foot on a book, I had to apologize to the book, put my hand on it and apologize. And I grew up doing that. And 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.
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A
I suppose it's a whole different way of putting the word sacred and text together.
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B
Yes.
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A
I love that. You know, this whole matter of our mortality. I was looking at the, you know, just thinking about the title, being Mortal, and the fact that that is a fact that being alive is a fatal condition like that. We all do have a diagnosis that we will die. And that you experience again and again and write about how. And yet the people are almost always surprised. It's just so fascinating about us. And do you think, is it that we don't let it into our consciousness that we haven't gotten to the point where we can, or that we resist that?
- [06:24]
B
I mean, I dove into that topic because I was as confused about it as you are. First of all, I didn't know what it meant to be a good doctor for mortal beings. The question of what does it mean to be competent with people who are going to have problems you cannot fix? What does it mean to go beyond competence and actually be really great at problems that people are going to die from? And also, how do you become competent and great at it if you don't know whether the problem you're dealing with with certainty, is one they're going to die from or not? And at the end of the day, that's why I write. Because those kinds of questions, I can't answer them straightforwardly sitting in my armchair or just doing my surgical thing. I get to go out. When I say, hey, I'm going to see you as a writer today. I get to go out and ask people tons of questions. And I think what came out of that for me was a general sense that peering in it. Why? Part of it was I slowly figured out we're just getting the question wrong. I thought of it as the situation to serve me the most were ones where someone would come in. They'd have a condition that I knew was incurable, a terminal cancer. But we don't know, is it gonna be a year? Is it gonna be three years? Is it gonna be five years?
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A
And therefore it keeps moving, right? All the time now?
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B
That's right. We have new technologies, and so we're gonna start trying stuff. And then I have so often been there when we said, let's try that one more thing, and they're in a bad situation, we say, well, should we try surgery? Well, yes, we have to give it a try. And then they never wake up again. And then you see the suffering that has come from that. Because we never once talked about the fact that their life might be mortal, is mortal. And I didn't even know how to begin to have that conversation. And they never woke up. They spent the next couple weeks in the icu, and then we unplugged the machine. They didn't get to say goodbye. They didn't get to say, I love you. They didn't get to say, I'm Sorry. And the families I see that they're tortured. But then you see also, like, when people have those kinds of endings, six months later, families are more likely to have PTSD symptoms and depression. And there was partly wanting to understand, how do I do better in that situation? What does it mean to be more confident and competent in those situations? But it also gradually came to. What I slowly realized is that it wasn't about having a good death. I interviewed more than 200 patients about their experiences with terminal illnesses and that world. And then scores of experts of various kinds. Palliative care doctors, hospice doctors and nurses and home health aides and so on. And what I realized is we were not really talking about death. We were talking about or dying. We were really talking about how do you live a good life all the way to the very end with whatever comes? And that's what you begin to unpack.
- [09:32]
A
And that's such a different question than, how do I fix this? How do I cure this? And, I mean, I've spoken to so many people across the years who were there at the advent of the hospice movement or had been involved in that. And, I mean, you even write about that, even when you were becoming a doctor, when you were going through your medical training, it was about, how do I fix this? And then death was a failure. Right. And at the point at which something was somebody who's definitely going to die, medicine stopped. Is that too. Is that.
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B
Yeah, that's exactly right. The conversation I felt like I was having was, do we fight or do we give up?
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A
Right, right.
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B
And the reality was, that was where you said something. You said, you know, that's such a different question. What it took me a long time to figure out was just the wrong question. It's not do we fight or we give up? It's what are we fighting for?
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A
Right.
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B
People have priorities besides just surviving, no matter what. You have reasons you want to be alive. What are those reasons? Because whatever you're living for along the way, we gotta make sure we don't sacrifice it. And in fact, can we, along the way, whatever's happening, can we enable it? And that sense that a conversation about the end of life is, do you want chest compressions? Do you want a ventilator? Do you wanna be shocked? That's not the conversation. No one has as their goal that I get shocked before I die. The conversation is as you face what you're facing as you go through what you go through, 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? And then can I make sure, to the extent of my abilities, the extent of abilities we have today in medicine, can I. Can we protect that for you? And the answer's often yes. And often the answers, sometimes the answers are technological, but they're often not. It's often just a matter of being humane. Someone said to me, I want to take my children to Disney World, my grandchildren. One thing I want to make sure I'm able to do is take my grandchildren to Disney World. And she was telling that to me in the hospital, emaciated, on her last days, she would die 48 hours later. And we had missed that. We had failed. We had never asked her to know that might have mattered to her because we could have made that possible for her a month before if those questions.
- [12:10]
A
Had been asked earlier.
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B
That's right. And so it wasn't about do we fight or not, it's that we missed the fight. The fight was to make sure, among other things, that, that she got to go take her grandchildren to Disney.
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A
When you're writing, you're often. I feel like there are moments when you really are redefining the purpose of medicine as you learned it. And it says, well, and a very modern definition. But, you know, you said we've been wrong about what our job is in medicine. We think our job is to ensure health and survival, but really it is larger than that. It is to enable well being. And well being is about the reasons one wishes to be alive. And it's not just about prolonging life.
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B
I ended up devoting a chapter to a psychologist from Stanford that it never occurred to me would be where the direction of the book would go. But her name is Laura Carsonson and she is the psychologist who's been following people across the course of their lives. She has a cohort of some 300 people from ages 18 and 94 when they started in her study, and she'd follow them all the way to the end of their life. And what was interesting to me was that as they got older, they became less healthy, no surprise. And they had some loss of function along the way. But they also had increasing sense of fulfillment in their life. Despite all of that, in some other studies, that after age 65, people were more likely to have love in their life. They were less likely to have anxiety and depression. They were focused less on acquisition and having all the material stuff.
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A
This is another one of These great secrets that growing old is actually a wonderful thing. And we're all about fighting aging.
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B
Right. And where it blew up. My whole sense of what I was doing as a doctor is I thought my priority was your health and your independence. And then that means that I was always lost. Like, what is my goal for people when they're not healthy anymore or they don't get to be independent? And then what she opened up for me was the recognition that wellbeing was really about getting to, you know, what made those people happy. And when they lost that happiness is when they no longer were having some control over their own story, that they were not getting to be the shapers of their own story. And that's what you see in people who are in hospitals or in many nursing homes, not all, where our goal is safety, survival and health. And that's why you can gradually lose some functions and have some health issues along the way and yet have great satisfactions in life.
- [15:19]
A
Yeah, well, being. And it's very common, concrete too. I mean, enabling. Well, being is a very lofty idea. And then you talk about this woman who would have liked to have taken her grandkids to Disneyland, which is obviously a big undertaking, but it's so much. So many of the stories you talk about are just. It's about what. So you have these five questions to ask towards the end of life. And some of them are about your understanding of your illness, your fears or worries for the future, your goals and priorities, what outcomes are acceptable. But the fifth one, which seems to come through again and again, is what. What does a good day look like? You know, and I think about Annie Dillard saying how we spend our days is how we spend our lives. And you tell so many stories about how just allowing those days to be, to have the simple things that give people a sense of well being, that that is everything.
- [16:12]
B
Yes. And what I also figured out was that, boy, it's almost too late if you're only asking that question towards the end of life, because that you realize should have been. We should have been asking much earlier, especially at any. You know, this is the crucial question. At any moment that people need help and on average, we will come to the end of life. We actually spend less time in dependency now than we used to, but we spend eight years on average in needing the help of others over time. And when you start needing help and whether it's a home health aid or having to be in a nursing home or just having to see a clinician and put your health self in their hands asking those questions like, what does a good day look like? What are your priorities besides just surviving the next day and answering those questions? I found it's become my favorite dinner party question too, because what is the quality of life that you would live for if you couldn't do everything you wanted? And one person would say, well, it's being with family. My father said, for example, it's being at the family dinner table with family and friends and being able to enjoy some food and conversation and a connection that way. And then I wrote about the other person who said, well, if I can eat chocolate ice cream and football and television, that's good enough for me. And then I met a health minister and we were in his office and he had all these beautiful pictures of his family in the room. And I said, so what is the minimum quality of life? What is the good day for you? Is it, you know, is it being with your family? And he said, well, no, it's complicated.
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A
Yeah.
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B
He said, you know, honestly, if I can just have a good book and some quiet, I would give up a lot to still be able to have that. And, you know, it tells you so much about people and, you know, that's the powerful thing.
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A
Well, it does, but it also points out, I mean, that's so low tech, right? I mean, the medical options are so complicated and expensive and sophisticated. These are not unreachable goals, even for somebody who might be quite ill, to have a good book.
- [18:32]
B
Absolutely. And sometimes it does take that medical capability. I wrote about Peggy Bachelder, who was my daughter's. When she was 13, her piano teacher, who had a metastatic cancer and was laid up in the hospital for weeks on end, deteriorating with a tumor that had spread through her liver and was in her pelvis and made it so that she couldn't get out of bed. And she was incontinent, and none of the treatments were working and her blood counts were dropping and she had fevers every day. And neither she nor I had any imagination that there might be a life worth living for at that point. She just was miserable and angry and ultimately went home on hospice. And then the hospice nurse had that conversation, what does a good day look like? And then, let's have a go one good day. And then they worked on that. And at first was, we're going to get you in a bed on the first floor so you don't climb the stairs. We're going to get a bedside commode so you can get back to a toilet again. We're Going to arrange that you can dress for getting dressed and bathed. And after two or three days of that, she lifted her sights, and then she wanted to teach piano again. And the idea that that was possible, it was extraordinary. My daughter, she called our home and said, you know, would you be willing to let Hunter have piano lessons again? And so for four weeks, my daughter had the most extraordinary piano lessons. And then there was a recital. And at that recital, you know, they played Brahms and Chopin and Beethoven. And then Peggy took each child to the side and gave them. Well, gave each of them a personal gift. It was for my daughter, a book of music. And then told them, each one by one, you're special. And it reshaped my daughter's life. And that was the legacy Peggy wanted to leave. My daughter just entered two weeks ago, graduated from high school.
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A
Congratulations.
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B
And entered Berklee School of Music because of Peggy. They were together, you know, only a couple years, but it made that impact. And that was that idea that that was beyond us, you know, that was beyond. Well, so I was saying about medicine. Well, to teach that lesson, her nurse had to arrange that to figure out how to dose the morphine so that she wouldn't be in pain when she needed to teach the lesson, but wouldn't be so groggy that she would be slurring her speech and freaking out the kids and, you know, but could lift her up to arrive at that moment and then recover and get to the next one.
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A
That's beautiful.
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B
And that took real medical expertise, too.
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A
Yeah, that collaboration, you know, And I know you've thought about this too, but I mean, one of the things I want to spend a little bit of time on, because you also are very clear that in many ways what we're facing. I mean, I don't know that I think mortality and the fact of mortality has been this constant theme of philosophy and religion and even how we deal with money, like, forever. But the problem of death is we have a young, modern problem with death, but it's also. And it has many layers. And one of them. You talked about growing up in Ohio. You said the experience of a modern old age was entirely outside my perception because of changes in family and society and mobility. We're so segregated. We don't have that experience. So, I mean, I just think about your daughter also. The experience that she had with her teacher and of someone dying, living while dying.
- [22:14]
B
I think we've gone through really a generational change. In the 80s and 90s, when I was growing up, the world we were in was one where, well, let me Put this way, 1950, the majority of Americans, it was over 90% died in their homes. And it shifted to the majority, 80%, actually by 1990, died in institutions. So when I grew up on my street, people would get old and they'd just disappear. I remember a woman, she. You disappear in a nursing home or disappear in the hospital, and that was that. And I never saw that process. Whereas now today, America, you know, we sort of. We give the US A hard time for being death denying, but in fact, we're kind of ahead of the rest of the world in the sense that just in the last half decade or so we went from less than 20% being at home on hospice when they die to close to 50% being in hospice, either in hospice facility or at home with family and others around the, you know, that kind of way of coming to that end.
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A
Just really kind of in the last 20, 30 years, less than that.
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B
It's like less than a decade. The shift is happening.
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A
That's amazing.
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B
It is. And the result is my kids growing up who, you know, Hunter is our last one to leave the home. So they just, in the last five years, all of them when they were teenagers, were around when somebody died and were in and out of their house as they were going through it. You know, my daughter's best friend's mom died of an esophageal cancer. And, you know, my daughter was there through that year and a half of going through that and then having hospice and then her father calling Hattie and asking her to bring the friend back home because mom had passed away and Hattie was there with them. And, you know, that sense of it being normal and not a mystery and.
- [24:15]
A
Having a quality to it. Right. Seeing that that is actually a time of life that can have an amazing quality to it.
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B
I was going to ask what you meant by the quality and what do.
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A
You mean by the quality of life? I mean that there's meaning and dignity. Not just dignity, but real substance. Right. It's not just somebody is in bed dying that they're living and doing things that matter to them.
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B
And it's finding your way through that because there's plenty that also was not quality. Right. That she would arrive and Peggy had to work her way through some pain and work her way through some indignity, but then also find something really beautiful about that. Or in another case, sometimes see the struggle for that and have real conversations we'd have at home about why is it so hard and painful and reaching that Place where you say you could see people in denial about the situation and not being able to talk about it. They'd see families where they wouldn't be able to talk about anything except what's the next treatment we can try? Instead of saying, all right, what is the next treatment try? But also, what's possible today? What can we do today that also makes sure we're not missing the chance to enjoy the time we have?
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A
Yeah.
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B
And those aren't opposed to each other. And we start to see these conversations unfolding in multiple generations. And I think that's crucial. And 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. The place we've come is 18. You know, just a century ago, you only lived, on average, to your mid-40s in a place like the U.S. we now live past 80, and we are making it possible to have meaningful lives across that whole lifespan. And it's thinking about it and acknowledging it and then recognizing that what a good day looks like at age 10, age 30, and age 70 necessarily look like very different things.
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A
Yeah. But that there are very good days at age 70 and possibly even at 108. I mean, the other thing. Well, there's aging and dying, having a long life. And then there's another thing you write a lot about is this modern tragedy of lives that are extended kind of brutally, with all the best intentions and all the best aspirations and all of our best tools. I thought it's interesting that you note that when you have this process of asking patients about their priorities, you discover what they're living for. That often that very same process ends up identifying the limits to the kind of care that people want. That. That emerges in a humane and organic and very thoughtful way, in a way that it doesn't. When medicine is just in this battle mode of, well, how do you know what's the next fight?
- [27:23]
B
Yeah, this is really crucial because what we often think is that putting your quality of life as a consideration means you're sacrificing quantity of life. Because I'm thinking twice about whether to have that chemotherapy or undergo that operation. And the evidence is that it's not the case. There are many kinds of studies. The most powerful one for me was a study that Jennifer Temel, a Massachusetts General Hospital physician, did lead, which took care of stage four lung cancer patients. They lived only, on average, 11 months. It's a terminal condition. No one lived past about three years. And what she did was half of the groups were randomized to get usual oncology care, and the other half were randomized to get the usual oncology care, plus a palliative care clinician physician to see them early in the course of their illness. Now, usually as a cancer surgeon, I would say. I used to say that when they said, I want to see a palliative care clinician, I'd say, no, no, no, no. It's not time for that yet. We still have options. And it was only there for the end, you know, and so it was kind of a radical idea. See them from the very beginning. And what the group who saw the palliative care clinicians from the very beginning did end up stopping their chemotherapy. They were 50% less likely to be on chemotherapy in their last three months of life. They were 90% less likely to be on chemotherapy in their last two weeks of life. They were less likely to get surgery towards the end. They had one third lower costs. They started hospice sooner. They spent more time out of the hospital. They were less likely to die in the hospital or die in the icu. And the kicker was that they not only had overall less suffering, they lived 25% longer.
- [29:15]
A
Oh, my gosh.
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B
And that's. That's the thing we're missing out on.
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A
That's fascinating.
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B
It's like, if it were a cancer drug, if it were a pill, it would be this blockbuster company, and we'd all want stock in it, the whole thing. And then when I trace down, like, what are you guys doing? And how can I do it next week without having to be you guys? The answer was they were just having these conversations, identify their priorities.
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A
This is one person talking to another. One human being.
- [29:48]
B
Another human being and activating the thinking. You know, my good day is X. If I start feeling like my chemotherapy or my surgery is going to take that away from me, and that's not worth it to me. Stop. And then they stop and they feel better, and they do better for longer. Because the other thing it hooks up with is that we as clinicians are excessively optimistic about the power of what we're going to be able to do for you.
- [30:17]
A
And physicians are authority figures, right? I mean, like, physicians are some of the people in the world who we just hand over and believe that they know. And, you know, you've said that. We imagine that we can wait until the doctors tell us that there's nothing more they can do. But rarely is there nothing more that doctors can do. I mean, the scenario that you're describing, where there's this conversation and this participation, it's like it gives the patient or the person their agency back.
- [30:46]
B
This was what has been most transformative in my practice that I did not understand. So what a clinician does, what we do with our authority has been a very tense issue over time. And by the 1990s, when I was in medical school, we had rejected paternalism. Rightly, the doctor knows best. I'm just gonna tell you what to do. We had replaced it with a belief in the patient's autonom and a way of activating that. And the way of activating that was to give you options, to tell you, here is your condition, here are the options. Option A, option B, option C. Here are the pros, the cons, the risks, the benefits. Now what do you want to do? And then what I found in the real world, like that was the way I was taught to exercise my authority was to give people knowledge and then ask what they want to do with it. But what I found in the real world was that patients would ask back, well, what would you do?
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A
Yeah, right, right. Because you still know better. You still know better.
- [31:52]
B
Yeah. And so what we're taught to say, so that you don't take away their agency was, no, no, no, this is not for me to decide. This is for you to decide. Only you know you. I don't know you. And you have to make the call here around what's more important to you. And people felt completely abandoned, and it never felt good. And what the palliative care clinicians, when I watch them or geriatricians, they would go one step farther. They would ask, not just tell you what your options are. They would listen to ask, what are your goals? What are your priorities? What really matters to you? Oh, you want to be at home. You don't want to. For you, your brain is really important, and you want to be as clear cognitively as possible. Okay? So now here are option A, option B, option C. This is the one that I recommend, based on my experience, is giving you your best chance of meeting your various goals. And that idea is that you are a genuine counselor. And the only way you can offer wisdom is by connecting what you know and have observed about what happens with various things to the goals that this individual person has. And the art of it is, can I extract. Can I listen well enough? Can I extract from this conversation enough to tell me what you really care about? To give you some guidance along the way here? And that, you know, is hard. I learned from the palliative care folks. Like one person said to me, the family conversation is my procedure. It takes as many of those family conversations learned with deliberate practice to be great at it as it takes for you to learn to do your cancer operations. And so think of it. That. Support for On Being with Krista Tippett comes from the Fetzer Institute. Fetzer supports a movement of organizations that are applying spiritual solutions to society's toughest problems. Learn more@fetzer.org.
- [34:19]
A
You know, as I was reading the way you redefine, you know when you say about medicine, we think our job is to ensure health and survival, but really it is to enable well being. I was thinking about I was very honored this year to be invited to give the commencement address at the University of Minnesota Medical School. And I was so impressed with the pledge that the students of the class of 2017 had written when they started. And then I think they also give the students the opportunity to rewrite that at the end, but they actually kept the one they had. I wanted to read a little bit of it to you because I wondered also if you think there's a generational shift. I was really stunned. So I'll just read it. So in the presence of our families, colleagues and communities, we take this oath in recognition of the honor and privilege of becoming a physician. We arrive at the threshold of our chosen profession, pledging to preserve our humility, integrity and all the values which brought us to the practice of medicine. We will engage in honest self reflection, striving for excellence but acknowledging our limitations and caring for ourselves as we care for others. We will collaborate with our colleagues, patients and communities to improve the practice of medicine. We will discover, innovate, learn and teach as responsible stewards of medical knowledge. And then they say 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.
- [35:54]
B
That's great.
- [35:55]
A
Isn't that good?
- [35:56]
B
That last part in particular, I think the place we are coming to that is when you take that pledge seriously and then really think about what the goals people have that it becomes a really interesting dialogue because people often are not sure about their goals or they have contradictory goals. I for example, will badger my patients about quitting smoking and wearing a seatbelt, but their actions are telling me they want to not wear the seatbelt or want to keep smoking. They're telling me what their priorities are, but there's first order priorities. I want to eat what's in the refrigerator. And there's higher order priorities. I really want to put a lock on the refrigerator.
- [36:43]
A
Right.
- [36:45]
B
And being able to recognize when should we be thinking about the bigger, longer term priorities and when do we think about the everyday priorities and joys and navigate between these pathways. And then there's some public health priorities. Like I want to be part of making sure that we're protecting people against diseases that are vaccine treatable. And so this complicated discussion about what are your goals and what are the ones we're going to arrive at and agree on are important. And sometimes if I'm an effective counselor, I might argue with you about your goals and that role as a clinician of all kinds, not just doctors, but it's nurses, psychologists, teachers, ministers. That is the. The deeper dialogue.
- [37:35]
A
Yeah, but that's the kind of arguing we do with people we love. Right. That's also a form of care.
- [37:42]
B
That is when it is health care.
- [37:44]
A
Right. Well, there you go. Did you know Sherwin Nuland? Shep Newland? Did you know him personally?
- [37:53]
B
I did, I did. I got to. So Shep Newland, surgeon at Yale, read his book How We Die, which one I think was the 19th century or 82 or something, national Book Award winner, and it just blew the top off my head. That was the book that started me thinking hard about dying and what it means. I read it later. I was in medical school in the 90s and I had no idea I would get to meet him and know him then. But when I started writing for the New Yorker and then wrote my first book, Complications during my surgical residency, he wrote the review in the New York Review of Books and then reached out to me and it was this great, very special relationship. We met only once, actually, face to face. But we weirdly enough on Talk of the Nation, we ended up doing a regular thing where, you know, I was like, really? Yeah. Where he was the senior eminence and I was the junior pop doctor. And we would talk about a topic of the day, you know, every few months. It was now and again, but it became this dialogue that carried on and it would. Was such a huge admirer and someone who was navigating his own difficult paths. He had written about his deep depression and the conflicts he'd had in his life. And so he had a tough life and things he had to struggle through. And so that was very meaningful, influential relationship.
- [39:25]
A
I love thinking about that cross generational conversation between the two of you. I interviewed him years and years and years ago and actually went to College with his daughter. And then we had this beautiful correspondence. It's not like it was all the time, but. But I also just held him in great regard and with great fondness. The conversation I had with him was about some of the things he started thinking about later. We actually called the show the Biology of the Spirit. He was thinking a lot about our brains and about what spirit is. And what did he say? That the human spirit is an accomplishment of the human brain. Just with this awe of. Because he went on after he talked about how we died, about how the miracle of like how much works all the time, how we live. Right. He wrote that follow up book.
- [40:15]
B
Yeah. Which of course less people are interested in how we live.
- [40:20]
A
Yeah, Less people are interested. And it was just full of wonder. Yeah, yeah. I mean I just kind of offer. I'm just thinking of that because I want to ask you about this and I offer that as a way into this idea of spirit. Like, you know, whatever that is, if it is an accomplishment of our biology. But. But one of the things that I ended up talking with these medical students about was 50 years from now people will look back at the way we used to use this phrase mind, body, spirit, and think how primitive that was. Because so much of what we're learning is about the distinction between these things. Again, however you want to define spirit, we know what we're talking about, but that what we call emotion and spirit are as physical as they are mental. And that the brain lays physical pathways and takes bodily direction and that trauma and joy are in our bodies as much as they're emotional. I just wonder if you think about that because it seems to me that even though I don't know that I see you using that language very often, that this runs through your reflection. The wholeness of us, the kind of mysterious fullness of us.
- [41:25]
B
Yeah. There's many ways I wish. I find the word spirit so difficult to understand. I use it all the time.
- [41:35]
A
It's a squishy word. It is. It's a vague word.
- [41:39]
B
I use it when I. For example, one of the ways I use it is just simply to ask people after we're done talking about how are you doing? And people then tell me about their aches and their pains and what their temperature's been doing and so on. And then I'll say, how are your spirits? Or how is your spirit? And that's one level. But then there's this interconnected level. The sense of spirit at a. Kind of. Starts to become spiritual. Right. The ways in which there's some sense of something transcendent, at least across all of people, if not beyond that. And I grapple with it a little bit towards the end of the book.
- [42:16]
A
Yes, you do.
- [42:17]
B
When I take my dad's ashes to the Ganges.
- [42:19]
A
Exactly. Yeah. So, yeah, yeah.
- [42:22]
B
My father, so, you know, it's a. Again, I'm the apostate Hindu, you know, the ultra scientist and you know, what's the data? But. But for him and my mother, it was that you bring your ashes to the Ganges in order to allow yourself to be released from the cycle of birth and rebirth and enter the state of nirvana, where it's kind of like a heaven is the way I think about it. But there was for me a sense of the spiritual connected to going there on the Ganges in one of those little boats and undergoing a ritual that has been going on for hundreds of years, more than a millennia, at least, probably a couple thousand years. And people coming and bringing the ashes of family members and chanting these same chants and being connected to this whole chain of generations where there are things that, you know, my father completed that came from the generations before him. There are things that he was passing on to me and my sister that we are responsible for carrying on and that there is something much larger than us that matters. You know, I end up calling it loyalty. In the book I wrote about Royce, a philosopher who was at Harvard in the late 19th century and wrote a book at the very beginning of the 20th century called the Philosophy of Loyalty. And what it meant was that we all have a. He was arguing we all have a deep need to live for something larger than ourselves. And he went through a series of kind of thought experiments to demonstrate it. And one of them that really stuck with me was asking if after you die, you were told that the world were to be blown up, would blow up with everybody you know in it, would that matter to you? And for vast majority of people, it would matter. And the reason why it matters to people is that it feels like it takes away the meaning of your life would be gone. That there's something more than our survival, that's more evidence that we're not all, you know, at core, totally self interested creatures. That we have things we live for that are larger. Now, that's not the only piece of evidence. There's lots of others that he goes through and then others you can think about along the way. But that for me is part of that idea. It's the closest thing I come to, to being able to recognize that idea of Spirituality and connection and meaning that rises above your own.
- [45:25]
A
That's interesting to think about that there's this intuitive. Whether it has any kind of religious or spiritual formulation, this sense that how we are and that we live has some resonance beyond us, beyond our lifetime. Here's some very beautiful language. In your book you wrote. I don't know if this is in the book anyway, you said this or wrote this somewhere, that 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.
- [46:00]
B
Yes, a weird thought came to mind. So I just. I finished recently this three book series by a Chinese science fiction writer named Liu Cixin C I X I N It begins with a book called the Three Body Problem.
- [46:15]
A
I tried to read those books and I couldn't get into them.
- [46:18]
B
Did you love them? Did you know what I'm talking about? Oh my God, I totally fell into it.
- [46:23]
A
I love the title, the Three Body Problem. I was really drawn to that.
- [46:27]
B
Right. The characters are unbelievably cardboard. Like, you know, they have no depth whatsoever. But part of was. It has this extraordinary scale of time, partly because, yes, the three body problem is this other planetary system which has three suns. And this planet is captured by the gravity of each of those suns. And so every day you're never sure when the sun is going to come up, what the temperature is going to be, whether it's going to be 300 degrees or minus 300 degrees, and how long the day will last, all those things. And will it be a habitable climate or not? And the creatures will. Will dehydrate when it becomes terrible. And then when water appears again, they rehydrate and then continue civilization. But the span of this book, because it's all about the idea that a message passes from this three body planetary system to Earth and what the consequences of that are. But even our earthling lives in that book, they unfold over thousands of years. And he describes what happens over those thousands of years. And it pushes the questions, because what he's imagining is the extinction of human beings, but the continuance of other forms of life and how wide our imaginations go towards bringing those in and making them feel that they are part of our chain of being. Can you have a chain of being that feels connected to people? Not even people, these sentient creatures that can communicate with you who are in the fourth dimension or look nothing like us? And can we have A chain of being that goes on 15 billion years that go beyond. You know, Earth is extinguished and humanity's extinguished, but we still feel there's spirit in some way. I don't know, it made me think of that and I kind of believe in that. I found it really beautiful that it managed to expand my mind, to make me feel that I'm part of life and that even after human beings are gone, that their is meaning in our little contributions.
- [48:39]
A
You know, sometimes you are called, I don't know if you refer to yourself this way, a public health journalist. In addition to being a physician, obviously I'm starting to think of you. I like this language of, you know, citizen scientist. I kind of feel like citizen physician would be a good thing to call you. To me, public health journalist doesn't do it just feels kind of clinical. Sorry to use a medical term. I mean, one thing I'm thinking about a lot is how we so collapsed our imagination about the language of public life in recent generation and we've collapsed into political life. And political life is so dysfunctional. So that's despairing. Right. If we now just completely identify public life with political life. But of course, public life is so much bigger than political life. And to me, you know, you are opening up medicine and healthcare and these webs of relationship that we have with caregivers and doctors and nurses and even our families in the context of our health as also public life. And it is. I mean, I don't know, I'm just.
- [49:46]
B
Well, the word that I really liked you used was citizen. And what I'm partly trying to do is open the portal both ways. The. But the world of what happens to you in the course of Our average, currently 80 plus year existence is one where the people that are part of that relationship on the clinical side are also people themselves who are journeying through that pathway, Right?
- [50:10]
A
Yes.
- [50:12]
B
And I'm fumbling for this a little bit, but the sense that the portal that I hope I open is that I'm speaking not only as a physician to the outside world, but I'm also opening the outside world to us as physicians and nurses and others to think of ourselves as just citizens and to break down that inside, outside, and to make it all kind of seamless and it's a sensibility more than anything I'm trying to make happen.
- [50:42]
A
It's a porousness though too. And it's a conversation that you're kind of curating, making possible.
- [50:49]
B
Yeah. And the sense of I like getting down into the microscopic of the real Stories of what happens when human beings care for one another and entered into these kinds of relationships. And you see everything that flows through there, money and jealousy and politics and misunderstanding and conversation and et cetera. And then you can lift out of it and say, okay, but what are really our goals? And then furthermore, we're this interplay of knowledge and technology and trying to make. Trying to function in a world where none of us have a full handle on it all. And we're inside a system and we have to have some agency in that system. And how do we not be powerless? And how do we shape that thing we're part of? And so I'm interested in not only the sense of inside and outside. I'm also interested in the sense of the microscopic to the telescopic and starting to arrive at a way that we feel connected and we know the meaning and the feelings as well as the data about what's happening.
- [52:00]
A
Yes. And I mean, as you write about, this is a sphere of some of the most cathartic, existential, and potentially meaningful moments of being human, of our whole lives take place in the context of healthcare. That's huge.
- [52:24]
B
That's why I feel like I have the unfair advantage of my fellow writers at the New Yorkers. Like, I live inside this material that is extraordinary every day. And I get to think about all these really confusing, interesting, sometimes distressing things, like, do we have a right to this stuff called healthcare? Why are the costs so high? Or why do we itch? And what the heck is going on there?
- [52:59]
A
And how does investigating itching lead us to the question of consciousness itself?
- [53:04]
B
Right.
- [53:05]
A
That's what you do. I want to say, too, I had this realization which seems so obvious now, but I'd never thought about it this way before. Getting ready to interview, thinking about this question of mortality and how we struggle with it. Often when there's a conversation about the medical profession and how it has often seemed very callous, and especially if we look back at the way people used to talk to people about the fact that you're dying or how that was treated, it's about the callousness and kind of hubris of that, but not considering that for the same reasons that any person who's a patient being told that they're dying, that most of us, for whatever reason, are surprised. Doctors are people too. Right. So this desire to fix it and cure it was a manifestation of just the other side of the same coin.
- [54:02]
B
Yeah. And I think also I'm really interested in the variation as well, that there is this Cruelty that can go on and this kind of inhumanity. And I've seen it, I see it still where people become treated as objects, they become treated as their disease. You don't see the person, you disconnect. You know, especially nowadays you can remote control manager, patient from, you know, your computer rather than go in and see them and connect with them.
- [54:33]
A
Like the medical corollary to drones.
- [54:36]
B
Yeah, completely. And you know, well, I have too many people to see and really well meaning people. Me, I can do this.
- [54:44]
A
Right.
- [54:45]
B
But this general sense that there is nonetheless wide variation over time. There are moments where we become re engaged and then there's also people who have managed to avoid that entirely and find ways in. And then variation shows you who the positive deviants are. And those are the people I really want to learn about. Like seeing all of the variation, how people cope with all the technology and everything else we're bringing to bear. And then where we sit there surfing Facebook rather than going in to talk to my patient. What are other people doing that are getting themselves out of it? And then how do we scale that? How do we get that to become viral? How do we make that more of what we do? It allows us to start taking control of what feels like it's impossible. I don't have influence over this. Clinicians are callous or are not being humane enough, but there's always some who are doing better.
- [55:48]
A
And always have been, always were.
- [55:51]
B
Yeah. And I think the part of my attitude about it is that they aren't necessarily special people. There's nothing like magical about them. It's often that they simply have a different viewpoint, a way of looking at it, or a different system around them or a different environment that they've created or someone else has created. And if you can unlock that, you can bring that elsewhere. And that's the optimism that I feel and see that energizes me.
- [56:26]
A
I think my last question, the question of what it means to be human, a big ancient question. It actually runs. It's not just being mortal, but being human that runs all the way through your work. I mean, here's some beautiful language from the epilogue of Being Mortal. Being Mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bo. The fact that we are limited is something that you come back to. I mean, I think you say to be human is to be limited. That has informed the way you have grappled with the definition and practice of medicine. I'm curious about how this Fact, this reality that to be human is to be limited, which is also so hard for us to take in, how that spills over into other aspects of the way you move through the world. You move through the world as a. As a human being.
- [57:29]
B
The first way that I think about it is number one. Well, two things jump to mind. Number one, in my public health work, it's about the idea that we're all so incredibly limited, and yet there are ways that we string together and are almost unlimited as groups of people. And it's the kind of magic of when that happens, when you all start pulling together and then you eradicate polio from the world, which we're almost on the verge of doing. Right. It's just freaking amazing when you see that happen and how these limited, flawed. And to me, that was the amazement of surgery. Like, we're these smart, great people, but we're all limited and yet can pull off these incredible, risky, complicated operations and forms of care that give people back their lives and give them many years of better life. So that's one. That's the first one that I went to. And then the second direction is quite the opposite, which is that as I walk through the world, I'm constantly combating the fact that I feel in, you know, the sense of coping with that limitation and being constantly aware of those limitations. One of my favorite New Yorker cartoons, which in many ways encapsulates me, is a gravestone that reads, he kept his options open.
- [59:01]
A
Yeah, right.
- [59:02]
B
And my way of navigating through limitation is trying as much as possible to keep my options open. Like, try to navigate with as minimal risk as possible, which means you don't accomplish anything. So I'm always fighting that sense of needing to take the leap despite the reality of imperfection, of mistakes and push forward. Make your bets. I have to make my bet without 100% of the information and certainty, and that's in many ways, to go full circle. The attraction to me about going into a field like surgery was very similar to the ones that drew me into the world of politics, which is that the best people I saw in surgery were like the best leaders, politicians I saw who recognized that we're limited, that you don't have all the knowledge that your abilities are imperfect, the information is incomplete, and yet there are times when acting is the better choice than not to act. And then you live with the consequences and learn from the. Take ownership and responsibility and move on. And that sense of enacting that in our lives feels really important for me to aspire to.
- [60:33]
A
Atul Gawande is Assistant Administrator for Global Health at usaid. He previously practiced general and endocrine surgery at Brigham and Women's Hospital in Boston and was a professor at both the Harvard Medical School and the Harvard T.H. chan School of Public Health. He was a longtime staff writer for the New Yorker magazine and is the author of four books, including the Checklist Manifesto and Being More Medicine and what Matters in the End. The On Being Project is Chris Heagle.
- [61:20]
B
Loren Drummerhausen, Eddie Gonzalez, Lucas Johnson, Zack Rose, Julie Sipel, Padre Go Tuama, Gautam Srikishan, Cameron Musar, Kayla Edwards, Tiffany Champion, Andrea Prevot, and Carla Zanoni.
- [61:35]
A
On Being is an independent nonprofit production of the On Being Project. We are located on Dakota Land. Our lovely theme music is provided and composed by Zoe Keating. Our closing music was composed by Gautam Srikishan, and the last voice you hear singing at the end of our show is Cameron Kinghorn. Our funding partners include the Hearthland Foundation, Helping to build a more just, equitable and connected America. One creative act at a time. The Fetzer Institute Supporting a movement of organizations applying spiritual solutions to society's toughest problems. Find them@fetzer.org Kaliapeia foundation dedicated to reconnecting ecology, culture, and spirituality. Supporting organizations and initiatives that uphold a sacred relationship with life on earth. Learn more@kaliopeia.org and the Osprey Foundation A catalyst for empowered, healthy and fulfilled lives.
- [62:39]
B
On Being is produced by On Being Studios in Minneapolis, Minnesota.