10:00

thing was somebody who's definitely going to

10:02

die, medicine stopped. Is that

10:04

too, is that? Yeah,

10:06

that's exactly right. The conversation I felt

10:08

like I was having was do we fight or do we

10:10

give up? Right. And

10:15

the reality was, and that was

10:17

where you said something, you said, you know, that's such

10:19

a different question. What it took me a long time

10:21

to figure out was just the wrong question. It's not

10:23

do we fight or we give up, it's what are

10:25

we fighting for? Well,

10:28

priorities besides just surviving no matter

10:30

what. You have reasons you

10:32

want to be alive. What are those reasons?

10:34

Because whatever you're living for along the way,

10:37

we got to make sure we don't sacrifice

10:39

it. And in fact, can we along the

10:41

way, whatever's happening, can we enable it? You

10:43

know, in that sense that a conversation about

10:46

the end of life is, do you want

10:48

chest compressions? Do you want a ventilator? Do

10:50

you want to be shocked? That's not the

10:52

conversation. No one has as

10:54

their goal that I get shocked before

10:57

I die. The conversation

10:59

is, as you face what

11:01

you're facing, as you go

11:03

through what you go through, what are you

11:05

willing to sacrifice? And what are

11:07

you not willing to sacrifice along the way for

11:09

the sake of more time? What's

11:12

the minimum quality of life you're really going

11:14

for here that you would find acceptable? And

11:17

then can I make sure to the

11:20

extent of my abilities, the extent of abilities

11:22

we have today in medicine, can

11:24

we protect that for you? And the

11:27

answer is often yes. And often

11:29

the answer is sometimes the answer is technological, but

11:32

they're often not. It's often just a

11:34

matter of being humane. Someone said to

11:37

me, I want to

11:40

take my children to Disney World, my grandchildren.

11:42

One thing I want to make sure I'm

11:44

able to do is take my grandchildren to

11:46

Disney World. And she

11:49

was telling that to me in the

11:51

hospital, like, maciated

11:54

on her last days, she would die 48 hours later.

11:57

And we had missed that. and

24:00

her father calling Hattie and asking

24:02

her to bring the friend back

24:04

home because mom had passed away

24:07

and Hattie was there and with

24:09

them. That sense

24:11

of it being normal and

24:13

not a mystery. And

24:15

having a quality to it, right? Seeing that,

24:17

that is actually a time

24:19

of life that can have an amazing quality

24:22

to it. I

24:24

was going to ask what you meant by the quality.

24:26

What do you mean? When you use the word quality,

24:28

what? I mean a quality of life. I mean that

24:30

there's meaning and dignity, not

24:32

just dignity but real

24:34

substance, right? It's not just

24:36

somebody who's in bed dying that they're living

24:38

and doing things that matter to them. And

24:42

it's finding your way through that because there's plenty

24:44

that also was not quality,

24:46

right? Yeah. That

24:48

she would arrive and Peggy had to work

24:51

her way through some pain and work her

24:53

way through some indignity. But

24:55

then also find something really beautiful

24:57

about that. Or in another case,

24:59

sometimes see the struggle for that

25:01

and have real conversations we'd have

25:03

at home about why

25:06

is it so hard and painful and

25:10

reaching that place where you could see people

25:12

in denial about the situation and not being

25:14

able to talk about it. They'd see families

25:17

where they wouldn't be able to talk about

25:19

anything except what's the next treatment we

25:21

can try? Instead of

25:23

saying, all right, what is the next

25:25

human try? But also what's

25:27

possible today? What can

25:29

we do today that also makes sure we're not missing

25:32

the chance to enjoy the time we have? Yeah. And

25:35

those aren't opposed to each other. And we

25:37

start to see these conversations unfolding

25:39

in multiple generations. And I think

25:41

that's crucial. And

25:45

there's strong evidence behind what

25:48

a difference it is for the

25:50

experience that people have towards the end and even

25:53

what their survival rate is when

25:55

you have these conversations versus when you don't.

25:58

The place we've come is... You

26:00

know, just a century ago, you only lived on average

26:03

to your mid-40s in a place like the

26:05

U.S. We now live past 80, and we

26:08

are making it possible to have meaningful

26:10

lives across that whole lifespan. And

26:13

it's thinking about it and acknowledging it, and

26:15

then recognizing that what a good day looks

26:17

like at age 10,

26:19

age 30, and age

26:21

70 necessarily look like very

26:24

different things. Yeah, but that

26:26

there are very good days at age 70,

26:29

and possibly even at 108. Yes.

26:33

The other thing, well, there's aging

26:35

and dying, and having a long

26:37

life, and then there's another thing

26:40

you write a lot about is

26:43

this modern tragedy of kind of lives

26:45

that are extended kind of brutally, with

26:48

all the best intentions and all the

26:51

best aspirations and all of our best

26:53

tools. And that's interesting that

26:55

you know that when

26:58

you have this process of asking

27:00

patients about their priorities, you

27:03

discover what they're living for,

27:05

that often that very same

27:07

process ends up identifying

27:09

the limits to the kind of care that

27:11

people want, that that emerges in a humane

27:13

and organic and very thoughtful way in a

27:15

way that it doesn't when medicine is just

27:18

in this battle mode of, well, you know,

27:20

what's the next fight? Yeah,

27:23

this is really crucial because what

27:26

we often think is

27:28

that putting your quality of

27:30

life as

27:32

a consideration means

27:35

you're sacrificing quantity of life because

27:37

I'm thinking twice about whether to

27:39

have that chemotherapy or undergo that

27:41

operation. And the

27:43

evidence is that it's not the case. There

27:46

are many kinds of studies. The most powerful

27:48

one for me was a study that Jennifer

27:50

Temela, Massachusetts General Hospital,

27:52

a physician did, led,

27:55

which took care of stage

27:57

four lung cancer patients. They lived only on average 11.

38:00

at Yale read

38:02

his book, How We Die, which one I think was the

38:04

1980 or 82 or something, National Book

38:07

Award winner, and it just blew the

38:09

top off my head. That

38:11

was the book that started me thinking

38:13

hard about dying, what it means. I

38:16

read it later. I was in medical school in the

38:18

90s and I had no idea I would get to

38:20

meet him and know him then. But

38:23

when I started writing for The New Yorker and then

38:26

wrote my first book, Complications during

38:29

my surgical residency, he wrote the review

38:31

in the New York Review of Books

38:34

and then reached out to me. It

38:36

was this great, very

38:39

special relationship. We met

38:41

only once actually face-to-face, but we weirdly enough

38:44

on Talk of the Nation, we ended up

38:47

doing a regular thing where I was like...

38:49

Oh really? Yeah, where

38:51

he was the senior eminence and I

38:54

was the junior pop doctor and

38:56

we would talk about a topic

38:58

of the day every few months.

39:00

It was now and again. But

39:03

it became this dialogue that carried

39:05

on and it was such a

39:08

huge admirer and someone who

39:10

was navigating his own difficult paths he had written

39:12

about his deep depression and the conflicts he'd had

39:15

in his life. So

39:17

he had a tough life and

39:20

things he had to struggle through. So

39:22

that was a very meaningful, influential relationship. I

39:24

love thinking about that cross-generational conversation between the

39:27

two of you. I interviewed him years and

39:29

years and years ago and

39:31

actually went to college with his daughter and then

39:33

we had this beautiful correspondence. It's not like it

39:35

was all the time, but I

39:39

also just held him in great regard and

39:41

with great fondness and the conversation

39:43

I had with him was about

39:45

some of the things he started thinking about later.

39:48

We actually called the show The Biology of

39:50

the Spirit. He

39:53

was thinking a lot about our brains and

39:55

about what spirit is and what did he

39:57

say that the human spirit

39:59

is Yes,

52:00

and I mean, as

52:03

you write about, this is a sphere of

52:06

some of the most cathartic existential

52:11

and potentially meaningful moments

52:14

of being human, of

52:17

our whole lives take place in the

52:19

context of healthcare. That's

52:22

huge. That's why I feel

52:24

like I have the unfair advantage

52:27

of my fellow writers at The

52:29

New Yorkers. Like, I

52:31

live inside this material that is

52:34

extraordinary every day, and I get to

52:36

think about

52:40

all these really confusing, interesting,

52:42

sometimes distressing things like, do

52:47

we have a right to this stuff called

52:50

healthcare? But why

52:52

are the costs so high? Or why

52:54

do we itch? And what

52:56

the heck is going on there? And

52:59

how does investigating itching lead us

53:01

to the question of consciousness itself?

53:03

Right, right. That's what

53:05

you do. Yeah, right. I

53:08

want to say, too, I had

53:11

this realization, which seems so obvious now, but

53:13

I never thought about it this way before

53:15

getting ready to interview you, thinking about this

53:17

question of mortality and how

53:19

we struggle with it. And often

53:22

when there's a conversation about the medical

53:24

profession and how it has often seemed

53:27

very callous, right? And especially if we

53:29

look back at the way people used

53:31

to talk to people about the

53:33

fact that you're dying or how

53:36

that was treated, it's

53:38

about the callousness and kind of hubris of that.

53:42

But not considering that for

53:44

the same reasons that any person who's

53:46

a patient being told that they're dying,

53:48

that most of us for whatever reason

53:50

are surprised, doctors

53:52

are people too, right? So

53:55

this desire to fix it and cure

53:57

it was a manifestation of just the

53:59

other side of the same coin. Yeah,

54:02

and I think also I'm really

54:06

interested in the variation as well,

54:08

that there is this cruelty

54:11

that can go on and this kind

54:13

of inhumanity and I've seen it,

54:16

I see it still, where

54:18

people become treated as objects, they become treated

54:20

as their disease, you don't see the person

54:22

you disconnect, you

54:24

know, especially nowadays you can remote

54:27

control manage your patient from, you know,

54:29

your computer rather than go

54:32

in and see them and connect with them.

54:34

Like the medical corollary to drones? Yeah,

54:36

completely, and you know, well I have

54:39

too many people to see and really

54:41

well-meaning people, me, I can do this

54:43

right, and but

54:45

this general sense that there is

54:47

nonetheless wide variation over time, there

54:50

are moments where we become re-engaged,

54:52

and then there's also people who

54:55

have managed to avoid that entirely and find

54:57

ways in, and then variation shows you who

55:00

the positive deviants are, and those are the

55:02

people I really want to learn about. Seeing

55:05

all of the variation, how people cope

55:07

with all the technology and everything else

55:09

we're bringing to bear, and then you

55:11

know where we, you know,

55:13

sit there surfing Facebook rather than going

55:15

in to talk to my patient, what

55:19

are other people doing that are getting themselves

55:21

out of it, and then how do we

55:23

scale that? How do we get that to

55:25

become viral? How do we make that more

55:28

of what we do? It allows

55:30

us to start taking control

55:32

of what feels like it's

55:34

impossible, I don't have

55:36

influence over this, you know,

55:38

clinicians are callous or

55:41

are not being

55:43

humane enough, but there's always some who are

55:45

doing better, and then... And

55:48

always have been, always were. Yeah,

55:51

and I think the part of my attitude about it is

55:53

that they aren't necessarily

55:56

special people, there's nothing like magical

55:58

about them. It's often that

56:01

they simply have a different

56:04

viewpoint, a way of looking at it, or a

56:07

different system around them, or

56:09

a different environment that they've created or

56:11

someone else has created. And

56:13

if you can unlock that, you can bring

56:16

that elsewhere. And that's the optimism that

56:18

I feel and see that

56:21

energizes me. Yeah. I

56:26

think my last question, the

56:29

question of what it means to

56:31

be human, and a big

56:33

ancient question, it actually runs, it's not

56:36

just being mortal, but being human that

56:38

runs all the way through your work.

56:40

I mean, here's this, some

56:43

beautiful language from the epilogue of

56:46

being mortal. Being mortal is about

56:48

the struggle to cope with the constraints of

56:50

our biology, with the limits set by genes

56:52

and cells and flesh and bone. The

56:56

fact that we are limited is

56:58

something that you come back to.

57:00

I mean, I think you say to be human is to be

57:02

limited. That has informed

57:06

the way you have grappled with the definition

57:08

and practice of medicine. I'm

57:11

curious about how this fact,

57:13

this reality that to be human is to be

57:15

limited, which is also so hard for us to

57:17

take in, how that spills over into other aspects

57:19

of the way you move through the world, or

57:21

you move through the world as a human being.

57:28

The first way that

57:31

I think about it is, number

57:33

one, well, two things jump to mind.

57:35

Number one, in my

57:37

public health work, it's about the idea

57:39

that we're also incredibly limited and

57:42

yet there are ways that

57:44

we string together and are almost unlimited

57:46

as groups of people. It's

57:50

the kind of magic of when that happens, when you

57:52

all start pulling together and then you eradicate polio from

57:55

the world, which we're almost on the verge of doing.

57:58

That's just freaking amazing. Like when you

58:01

see that happen and how

58:03

these limited flawed and and

58:05

to me that was the amazement of surgery like we're

58:08

these Smart great people,

58:10

but you know, we're all

58:13

limited and yet can

58:15

pull off these

58:19

Incredible risky

58:21

complicated operations

58:23

and and forms of

58:26

care that Give people back their

58:28

lives and and give them many

58:30

years of better life. So that's

58:32

one that's the first One that I

58:34

went to and then the second direction. I was

58:36

quite the opposite which is that as

58:40

I walk through the world, I'm constantly

58:42

combating the fact that I feel you

58:44

know the sense

58:47

of Coping

58:49

with that limitation and being constantly aware

58:51

of those limitations one of

58:53

my favorite New Yorker cartoons which in many

58:55

ways encapsulates me is a Gravestone

58:58

that reads he kept his options

59:00

open Yeah, and my

59:02

way of navigating through limitation is

59:05

trying as much as possible to keep

59:07

my options open like Try

59:10

to navigate with as minimal

59:12

risk as possible, which means you don't accomplish

59:14

anything. So I'm always fighting that

59:16

sense of of Needing

59:19

to take the leap despite the

59:21

reality of imperfection of mistakes and

59:24

and push forward Make your bets,

59:26

you know have to

59:28

make my bet without 100% of

59:31

the information and certainty and That's

59:34

in many ways to go full circle The

59:36

attraction to me about going into a field like

59:38

surgery was very similar the ones that drew me

59:40

into the world of politics Which is that the

59:43

best people I saw in surgery Were

59:45

like the best leaders and

59:48

politicians I saw who Recognized

59:50

that we're limited that you

59:53

don't have all the

59:55

knowledge that your your abilities are

59:57

imperfect The information is

59:59

incomplete And yet, there

1:00:01

are times when acting is

1:00:03

the better choice than not to

1:00:06

act. And then you live with

1:00:08

the consequences and learn from them, take

1:00:10

ownership and responsibility and move on. And

1:00:13

that sense of enacting

1:00:16

that in our lives feels really

1:00:18

important for me to aspire to. Atul

1:00:33

Gawande is Assistant Administrator for

1:00:35

Global Health at USAID. He

1:00:39

previously practiced general and endocrine surgery

1:00:41

at Brigham and Women's Hospital in

1:00:43

Boston and was a professor at

1:00:45

both the Harvard Medical School and

1:00:48

the Harvard TH Chan School of

1:00:50

Public Health. He was

1:00:52

a longtime staff writer for The

1:00:55

New Yorker magazine and is the

1:00:57

author of four books including The

1:00:59

Checklist Manifesto and Being Mortal, Medicine

1:01:02

and What Matters in the End. The

1:01:17

on-being project is Chris

1:01:19

Hegel, Laurenne Drummerhausen, Eddie

1:01:22

Gonzalez, Lucas Johnson, Zach

1:01:24

Rose, Julie Seipel, Audrey

1:01:26

Gotuma, Gautam Srikishin, Cameron

1:01:28

Musar, Kayla Edwards, Tiffany

1:01:31

Champion, Andrea Pravo and Carla

1:01:33

Zanoni. On-Being is

1:01:35

an independent nonprofit production of

1:01:38

the On-Being project. We

1:01:40

are located on Dakota land. Our

1:01:43

lovely theme music is provided and

1:01:45

composed by Zoe Keating. Our

1:01:47

closing music was composed by Gautam

1:01:49

Srikishin. And the last voice you

1:01:51

hear singing at the end of our show is

1:01:53

Cam Ren Kinghorn. Our funding

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partners include the Hearthland Foundation,

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Find them at fetzer.org. Kaliya

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