Jennifer's Reviews > Being Mortal: Medicine and What Matters in the End

2.5 stars. Gawande has about three major points in this book, all of which were made in a news magazine article he wrote for the Atlantic: 1, We should have tough conversations with those in our lives about their vision for their end-of-life; 2, Doctors should also have these conversations with their patients; and 3, If we have these conversations, we can shift medicine and end-of-life care away from a stave-off-death model and towards a model that promotes humanity, autonomy, and dignity for the dying (and thus no longer need institutional nursing homes). I do not disagree, but the book itself is heavy on anecdotes and light on actual research or policy analysis.

My major stylistic critique is that Gawande buries his three points in pages of anecdotes about patients and memories of his own father's decline and death. I'm not being unsympathetic to the suffering of these colorful characters (and Gawande's own personal suffering), but I found the anecdotes long-winded, distracting, and ultimately boring. Gawande intended them to have emotional impact for the reader, but for me, the stories smacked of filling pages for the pure commercial gain of selling a book.

My major substantive critique is that Gawande spends too little time on policy, instead championing the heroism of individual doctors, caregivers, and entrepreneurs-- as if the system can be saved by some brave individuals. He is far too sanguine about the difficulty of changing institutions at the macro-level. Yes, Gawande mentions that these alternative living arrangements and alternative therapeutic approaches save money in the long run, but most of the initiatives Gawande covers were developed by private entrepreneurs, not governments (though some government funds may have been made available in the form of grants). Dramatic policy change would be needed to scale and fund these initiatives at the state or federal level, and I do not see the current vested interests in the healthcare lobby supporting these changes (nor does Gawande provide a path for fighting for policy change, besides mentioning the cost-effectiveness argument). The one scale-able initiative that Gawande discusses, Hospice, already exists-- but Gawande ignores that Hospice's ranks are often filled with low-skilled, under-paid, and over-worked caregivers who are hardly in the position to give the attentive, individualized care that Gawande received for his father.

Gawande is also too sanguine about the role of socioeconomic class, which is perhaps why his friends and his patients receive such excellent care. He is wrapped in a bubble of privilege -- access to the top surgeons and the most committed nurses. True, some of the alternative homes that Gawande mentions do take Medicaid, but these homes are so few that they have waitlists that are hundreds of names long. The type of "better death" that Gawande argues for so eloquently is available only to the wealthiest or the most educated (those empowered to fight the system and search for better options). Without a serious treatment of the nexus between healthcare policy, quality of life, and socioeconomic status, this book seems to me squarely in the realm of theory, not practice.