Saturday, January 3, 2015

Being Mortal, Atul Gawande

"What more is it that we need in order to feel that life is worthwhile?

"The answer, he believed, is that we all seek a cause beyond ourselves. This was, for him, an intrinsic human need. The cause could be large (family, country, principle) or small (a building, project, the care of a pet). The important thing was that, in ascribing value to the cause and seeing it as worth making sacrifices for, we give lives meaning.

"Royce called this dedication to a cause beyond oneself loyalty. He regarded it as the opposite of individualism. The individualist puts self-interest first, seeing his own pain, pleasure, and existence as his greatest concern. For an individualist, loyalty to causes that have nothing to do with self-interest is strange When such loyalty encourages self-sacrifice, it can even be alarming -- a mistaken and irrational tendency that leaves people open to the exploitation of tyrants. Nothing could matter more than self-interest, and because when you die you are gone, self sacrifice makes no sense.

"Royce had no sympathy for the individualist view. 'The selfish we had always with us,' he wrote. 'But the divine right to be selfish was never more ingeniously defended.' In fact, he argued, human beings need loyalty. It does not necessarily produce happiness, and can even be painful, but we all require devotion to something more than ourselves for our lives to be endurable. Without it, we have only our desires to guide us, and they are fleeting, capricious, and insatiable. They provide, ultimately, only torment. 'By nature, I am a sort of meeting place of countless streams of ancestral tendency. From moment to moment... I am a collection of impulses,' Royce observed. 'We cannot see the inner light. Let us try the outer one.'

 "And we do. Consider the fact that we care deeply about what happens to the world after we die. If self-interest were the primary source of meaning in life, then it wouldn't matter to people if an hour after their death everyone they know were to be wiped from the face of the earth. Yet it matters greatly to most people. We feel that such an occurrence would make our lives meaningless." p. 126-7

 "...those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives -- and they lived 25 percent longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality. If end-of-life discussions were an experimental drug, the FDA would approve it." p.178

"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 maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves." p. 238

"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?"

  -- Atul Gawande, Being Mortal

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