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65. Being Mortal: Medicine and What Matters in the End

Rating:  ☆☆☆1/2

Recommended by:

Author:   Atul Gawande

Genre:  Non-Fiction, Medicine, Health, Public Policy

282 pages, published October 7, 2014

Reading Format:  Audio Book

Summary 

In Being Mortal, Gawande, a practicing surgeon, tackles the difficult issue of how medicine can not only improve life but also death.  While modern medicine has made amazing advances in the past few decades, it is still challenged when dealing with end of life issues where the interests of human spirit and dignity are often inadequately considered.  Nursing homes, preoccupied with safety, pin patients into railed beds and wheelchairs. Doctors, committed to extending life, often impose devastating procedures that may extend the quantity of life, but also severely impact the quality.  Gawande argues that quality of life is the desired goal for patients and families and offers examples of better models for assisting the infirm and dependent elderly.  He also explores hospice and shows that a person’s last weeks or months may be rich and dignified.

Quotes

“In the end, people don’t view their life as merely the average of all its moments—which, after all, is mostly nothing much plus some 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 the significant moments, the ones where something happens. Measurements of people’s minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence.  A seemingly happy life may be empty.  A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.  We have purposes larger than ourselves. Unlike your experiencing self—which is absorbed in the moment—your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. Why would a football fan let a few flubbed minutes at the end of the game ruin three hours of bliss?  Because a football game is a story.  And in stories, endings matter.”

“Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end.”

 

“Our ultimate goal, after all, is not a good death but a good life to the very end.”

 

“It is not death that the very old tell me they fear. It is what happens short of death—losing their hearing, their memory, their best friends, their way of life. As Felix put it to me, “Old age is a continuous series of losses.” Philip Roth put it more bitterly in his novel Everyman: “Old age is not a battle. Old age is a massacre.”

 

“Modernization did not demote the elderly. It demoted the family. It gave people—the young and the old—a way of life with more liberty and control, including the liberty to be less beholden to other generations. The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.”

 

“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 bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be. 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. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?”

 

“The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. If you don’t, mortality is only a horror. But if you do, it is not. Loyalty, said Royce, “solves the paradox of our ordinary existence by showing us outside of ourselves the cause which is to be served, and inside of ourselves the will which delights to do this service, and which is not thwarted but enriched and expressed in such service.” In more recent times, psychologists have used the term “transcendence” for a version of this idea. Above the level of self-actualization in Maslow’s hierarchy of needs, they suggest the existence in people of a transcendent desire to see and help other beings achieve their potential.”

 

“You may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.”

 

“We’re always trotting out some story of a ninety-seven-year-old who runs marathons, as if such cases were not miracles of biological luck but reasonable expectations for all. Then, when our bodies fail to live up to this fantasy, we feel as if we somehow have something to apologize for.”

 

“A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.”

 

“The battle of being mortal is the battle to maintain the integrity of one’s life—to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be.”

 

“Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life. When we forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.”

 

“People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete.”

 

“Your chances of avoiding the nursing home are directly related to the number of children you have.”

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64. Antifragile: Things That Gain from Disorder

Rating:  ☆☆☆

Recommended by:

Author:   Nassim Taleb

Genre:  Non Fiction, Public Policy

521 pages, published November 27, 2012

Reading Format:  Book

Summary 

In Antifragile, Nassim Taleb, the bestselling author of The Black Swan, writes about how some systems actually benefit from disorder.  Antifragile discusses how to gain from disorder and chaos while being protected from fragilities and adverse events. Taleb describes how “antifragile” systems benefit from adversity, uncertainty and stress, similar to human bones getting stronger when subjected to stress and tension.  Taleb posits that people, things and systems which are not antifragile will not survive.  Specifically, he looks at why the city state is better than the nation state, why debt is bad, and why almost everything modern is bound to fail.  Antifragile explores innovation, health, biology, medicine, life decisions, politics, foreign policy, urban planning, war, personal finance, and economic systems.

Quotes

“If you have more than one reason to do something (choose a doctor or veterinarian, hire a gardener or an employee, marry a person, go on a trip), just don’t do it. It does not mean that one reason is better than two, just that by invoking more than one reason you are trying to convince yourself to do something. Obvious decisions (robust to error) require no more than a single reason.”

 

“So I follow the Lindy effect as a guide in selecting what to read: books that have been around for ten years will be around for ten more; books that have been around for two millennia should be around for quite a bit of time, and so forth.”

 

“Difficulty is what wakes up the genius.”

 

“This is the tragedy of modernity: as with neurotically overprotective parents, those trying to help are often hurting us the most.”

 

“The simpler, the better. Complications lead to multiplicative chains of unanticipated effects.”

 

“The world as a whole has never been richer, and it has never been more heavily in debt, living off borrowed money. The record shows that, for society, the richer we become, the harder it get to live within our means. Abundance is harder for us to handle than scarcity.”

 

“Never listen to a leftist who does not give away his fortune or does not live the exact lifestyle he wants others to follow. What the French call “the caviar left,” la gauche caviar, or what Anglo-Saxons call champagne socialists, are people who advocate socialism, sometimes even communism, or some political system with sumptuary limitations, while overtly leading a lavish lifestyle, often financed by inheritance—not realizing the contradiction that they want others to avoid just such a lifestyle. It is not too different from the womanizing popes, such as John XII, or the Borgias. The contradiction can exceed the ludicrous as with French president François Mitterrand of France who, coming in on a socialist platform, emulated the pomp of French monarchs. Even more ironic, his traditional archenemy, the conservative General de Gaulle, led a life of old-style austerity and had his wife sew his socks.”

 

“Steve Jobs: “People think focus means saying yes to the thing you’ve got to focus on. But that’s not what it means at all. It means saying no to the hundred other good ideas that there are. You have to pick carefully. I’m actually as proud of the things we haven’t done as the things I have done. Innovation is saying no to 1,000 things.”

 

“The psychologist Gerd Gigerenzer has a simple heuristic. Never ask the doctor what you should do. Ask him what he would do if he were in your place. You would be surprised at the difference.”

 

“Many people keep deploring the low level of formal education in the United states (as defined by, say, math grades). Yet these fail to realize that the new comes from here and gets imitated elsewhere. And it is not thanks to universities, which obviously claim a lot more credit than their accomplishments warrant. Like Britain in the Industrial Revolution, America’s asset is, simply, risk taking and the use of optionality, this remarkable ability to engage in rational forms fo trial and error, with no comparative shame in failing again, starting again, and repeating failure.”

 

“Modernity has replaced ethics with legalese, and the law can be gamed with a good lawyer.”

 

“The best way to verify that you are alive is by checking if you like variations. Remember that food would not have a taste if it weren’t for hunger; results are meaningless without effort, joy without sadness, convictions without uncertainty, and an ethical life isn’t so when stripped of personal risks.”

 

“Few understand that procrastination is our natural defense, letting things take care of themselves and exercise their antifragility; it results from some ecological or naturalistic wisdom, and is not always bad.”

 

“Further, my characterization of a loser is someone who, after making a mistake, doesn’t introspect, doesn’t exploit it, feels embarrassed and defensive rather than enriched with a new piece of information, and tries to explain why he made the mistake rather than moving on. These types often consider themselves the “victims” of some large plot, a bad boss, or bad weather. Finally, a thought. He who has never sinned is less reliable than he who has only sinned once. And someone who has made plenty of errors—though never the same error more than once—is more reliable than someone who has never made any.”

 

“The biologist and intellectual E. O. Wilson was once asked what represented the most hindrance to the development of children; his answer was the soccer mom. He did not use the notion of the Procrustean bed, but he outlined it perfectly. His argument is that they repress children’s natural biophilia, their love of living things. But the problem is more general; soccer moms try to eliminate the trial and error, the antifragility, from children’s lives, move them away from the ecological and transform them into nerds working on preexisting (soccer-mom-compatible) maps of reality. Good students, but nerds–that is, they are like computers except slower. Further, they are now totally untrained to handle ambiguity. As a child of civil war, I disbelieve in structured learning . . . . Provided we have the right type of rigor, we need randomness, mess, adventures, uncertainty, self-discovery, near-traumatic episodes, all those things that make life worth living, compared to the structured, fake, and ineffective life of an empty-suit CEO with a preset schedule and an alarm clock.”

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