Bookshelf: The medicalization of aging and what to do about it

Michael Mechanic, Mother Jones - The latest book from surgeon and best-selling author Atul Gawande may not change your whole life, but it could very well improve how it ends.

In Being Mortal, Gawande, a longtime staff writer for the New Yorker, takes on the utter failure of the medical profession when it comes to helping people die well, and the short-sightedness of the elder facilities that infantilize people rather than bother to figure out what they actually need to maintain a modicum of meaning in what's left of their lives. In the process, he gives us a lesson on the basic physiology of aging and on the social and technological changes that led to most of us dying in hospitals and institutions rather than at home with our loved ones. And he chronicles the rise of the nursing home and the creation of assisted living as its antidote—if only it were.

The picture can seem pretty bleak. Many of Gawande's subjects are dealing with the always-hopeful oncologists who, rather than accept the inevitable, coax their patients into trying futile fourth-line chemotherapies that nobody can pronounce. And then you've got hospitals axing their geriatrics departments (aging Boomers be damned) because Medicare won't cover the extra costs of making someone's last years worth living. There's also a deeply personal aspect to the book, which goes on sale today. Gawande recounts the recent travails of his family, which began when his father, also a surgeon, was diagnosed with a cancer that would slowly eat away at his physical capabilities and ultimately end his life.

But Being Mortal is hopeful, too, and that's why it could make a difference. Most of the changes we need to make aren't expensive. Indeed, some of them could save us a bundle in cash and needless suffering. It turns out, for example, that terminal patients in hospice programs often live longer and better than their counterparts in treatment. In fact, the mere act of talking with caregivers about what you value as you near the end of your life leads to a longer one.

IEB WHITE

At seventy, men are just beginning to grow liberal again, after a decade or two of conservatism. Their usefulness to the state is likely to improve after the span of life which the Bible allows them to complete. The men of eighty whom we know are on the whole a more radical, rip snorting lot than the men of seventy. They hold life cheaply, and hence are able to entertain generous thoughts about the state. It is in his fifty-to-seventy phase that a man pulls in his ears, lashes down his principles, and gets ready for dirty weather. Octogenarians have a more devil-may-care tactic: they are sometimes quite willing to crowd on some sail and see if they can't get a burst of speed out of the old hooker yet.

A man's liberal and conservative phases seem to follow each other in a succession of waves from the time he is born. Children are radicals. Youths are conservatives, with a dash of criminal negligence. Men in their prime are liberals (as long as their digestion keeps pace with their intellect). The middle-aged, except in rare cases, run to shelter: they ensure their life, draft a will, accumulate mementos and occasional tables, and hope for security. And then comes old age, which repeats childhood - a time full of humors and sadness, but often full of courage and even prophecy. - EB White, 1937

CICERO

CATO, AGE 84 - You may be sure, my dear Scipio and Lælius, that the arms best adapted to old age are culture and the active exercise of the virtues. For if they have been maintained at every period - if one has lived much as well as long - the harvest they produce is wonderful, not only because they never fail us even in our last days (though that in itself is supremely important), but also because the consciousness of a well-spent life and the recollection of many virtuous actions are exceedingly delightful. . .

It is after all true that everybody cannot be a Scipio or a Maximus, with stormings of cities, with battles by land and sea, with wars in which they themselves commanded, and with triumphs to recall. Besides this there is a quiet, pure, and cultivated life which produces a calm and gentle old age, such as we have been told Plato's was, who died at his writing-desk in his eighty-first year; or like that of Isocrates, who says that he wrote the book called The Panegyric in his ninety-fourth year, and who lived for five years afterwards; while his master Gorgias of Leontini completed a hundred and seven years without ever relaxing his diligence or giving up work. When some one asked him why he consented to remain so long alive - "I have no fault," said he, "to find with old age." That was a noble answer, and worthy of a scholar. For fools impute their own frailties and guilt to old age. . .

[It is said that] old age withdraws us from active employments. From which of them? Do you mean from those carried on by youth and bodily strength? Are there then no old men's employments to be after all conducted by the intellect, even when bodies are weak?. . .

There is ~ nothing in the arguments of those who say that old age takes no part in public business. They are like men who would say that a steersman does nothing in sailing a ship, because, while some of the crew are climbing the masts, others hurrying up and down the gangways, others pumping out the bilge water, he sits quietly in the stern holding the tiller. He does not do what young men do; nevertheless he does what is much more important and better. The great affairs of life are not performed by physical strength, or activity, or nimbleness of body, but by deliberation, character, expression of opinion. Of these old age is not only not deprived, but, as a rule, has them in a greater degree. . .

Old men retain their intellects well enough, if only they keep their minds active and fully employed. Nor is that the case only with men of high position and great office: it applies equally to private life and peaceful pursuits. Sophocles composed tragedies to extreme old age; and being believed to neglect the care of his property owing to his devotion to his art, his sons brought him into court to get a judicial decision depriving him of the management of his property on the ground of weak intellect - just as in our law it is customary to deprive a paterfamilias of the management of his property if he is squandering it. Thereupon the old poet is said to have read to the judges the play he had on hand and had just composed - the Oedipus Coloneus - and to have asked them whether they thought that the work of a man of weak intellect. After the reading he was acquitted by the jury. . .

Nor ~ do I now miss the bodily strength of a young man ~ any more than as a young man I missed the strength of a bull or an elephant. You should use what you have, and whatever you may chance to be doing, do it with all your might. . .

At Olympia, Milo is said to have stepped into the course carrying a live ox on his shoulders. Which then ~ would you prefer to have given to you - bodily strength like that, or intellectual strength like that of Pythagoras? In fine, enjoy that blessing when you have it; when it is gone, don't wish it back - unless we are to think that young men should wish their childhood back, and those somewhat older their youth!

The course of life is fixed, and nature admits of its being run but in one way, and only once; and to each part of our life there is something specially seasonable; so that the feebleness of children, as well as the high spirit of youth, the soberness of maturer years, and the ripe wisdom of old age - all have a certain natural advantage which should be secured in its proper season. . .

We must stand up against old age and make up for its drawbacks by taking pains. We must fight it as we should an illness. We must look after our health, use moderate exercise, take just enough food and drink to recruit, but not to overload, our strength. Nor is it the body alone that must be supported, but the intellect and soul much more. For they are like lamps: unless you feed them with oil, they too go out from old age. Again, the body is apt to get gross from exercise; but the intellect becomes nimbler by exercising itself. . .

Far from being a charge against old age, that it does not much feel the want of any pleasures, it is its highest praise. But, you will say, it is deprived of the pleasures of the table, the heaped-up board, the rapid passing of the wine-cup. Well, then, it is also free from headache, disordered digestion, broken sleep. . .

The fact is that old age is respectable just as long as it asserts itself, maintains its proper rights, and is not enslaved to any one. For as I admire a young man who has something of the old man in him, so do I an old one who has something of a young man. The man who aims at this may possibly become old in body - in mind he never will. I am now engaged in composing the seventh book of my Origins. I collect all the records of antiquity. The speeches delivered in all the celebrated cases which I have defended I am at this particular time getting into shape for publication. I am writing treatises on augural, pontifical, and civil law. I am, besides, studying hard at Greek, and after the manner of the Pythagoreans-to keep my memory in working order-I repeat in the evening whatever I have said, heard, or done in the course of each day. These are the exercises of the intellect, these the training-grounds of the mind: while I sweat and labour on these I don't much feel the loss of bodily strength.

I appear in court for my friends; I frequently attend the Senate and bring motions before it on my own responsibility, prepared after deep and long reflection. And these I support by my intellectual, not my bodily forces. And if I were not strong enough to do these things, yet I should enjoy my sofa - imagining the very operations which I was now unable to perform. But what makes me capable of doing this is my past life. For a man who is always living in the midst of these studies and labors does not perceive when old age creeps upon him. Thus, by slow and imperceptible degrees life draws to its end. There is no sudden breakage; it just slowly goes out. . .