How Would You Like to Die?

Atul Gawande offers a thoughtful exploration of end-of-life options

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How can we die well? This is the "fundamental question for everyone living in the era of modern medicine," writes surgeon-journalist Atul Gawande in The New Yorker.

Budget hawks urge us to face the fact that we can't afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they're debating the wrong question.

Modern medical science has "rendered obsolete centuries of experience ... about our mortality," and even made it difficult to determine who is dying and who isn't. Robbed of our moorings, we grasp at miracle statistics for the terminally ill and see death only as the "enemy." The problem, explains Gawande, is that "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." Rather, you just might want a general who makes it the best battle possible. In short, he sees hope in hospice care. There, patients get the mortality talks they so desperately need, and can enjoy life--and fill it with the things they actually care about--instead of combating death. "Curiously," it turns out hospice patients sometimes live longer this way, too.

In negotiating the personal and economic matter of "how to die," everyone has an opinion:

  • Must We Know Death Is Coming?  The Atlantic's Megan McArdle wonders if, drawbacks of "public paternalism" aside, the most humane and cost-effective solution to these problems would be for doctors to do what they used to do: not disclose patients' dire conditions and "let [them] enjoy [their] final days ... We romanticize the good death, but from what I understand, death has almost always been nasty and brutish, whether long or short.  How is it improved by knowing it's coming?"
  • Personally, I'd Want To  One of McArdle's commenters shares the story of his terminally ill girlfriend. It's easy to want to "avoid" the "horror" of the terminal diagnosis, he says, but there's also a "richness" to "life in the midst of death." Knowledge of her prognosis allowed his girlfriend to "grieve what she would miss," letting both of them appreciate what they had "all the more." Those who "[lose] their lovers to accidents," he says, "without exception ... envy" those who lose their lovers to "disease over time"; the latter get "the chance to say goodbye."
  • The Amount of Money Spent on Dying  Derek Thompson chimes in by reminding readers of a staggering figure: "25 percent of Medicare spending goes to the five percent of Medicare patients in the last year of life." He also points to the tragic irony found in the economics of the situation: "we're a victim of our own success." Increased longevity is a major driver of Medicare costs.
  • Approaching the Problem by Ignoring the Money  Clive Crook, also of The Atlantic, sees the unique thoughtfulness of Gawande's piece in its advocacy of the "practical" solution not because it is practical, but because it his humane. The message is this:
The money wasted on ill-advised end-of-life-care--colossal though the sums may be--ought not to be the main focus of discussion. It will have to be talked about, of course, but that framing of the issue is disturbing and divisive. Before we get to that, we should be talking about the patients' interests, as those interests would be judged by patients themselves, given all the facts. This is not about death panels. It is about patients' rights.
  • Approaching the Problem, at Least, with Greater Tolerance  End-of-life questions are extraordinarily difficult on their own, writes Ezra Klein, but, unfortunately, matters of "politics and economics ... [are] present whether we want them there or not." Our response, as a society, has been an unhelpful one of "ignoring the question, shouting it down when it comes up, and paying whatever's necessary to avoid a discussion we don't know how to have." Pointing to the panicked response to "death panels" last summer, he argues that ultimately, it's individuals and families--not just taxpayers--that wind up paying the ultimate price for our societal dithering.
  • Approaching It With Valor  The most eloquent articulation of the death-as-enemy argument, Gawande writes in The New Yorker, comes from paleontologist Stephen Jay Gould, who wrote the following after his own experience surviving a supposedly incurable cancer:
It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity. Of course I agree with the preacher of Ecclesiastes that there is a time to love and a time to die--and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy--and I find nothing reproachable in those who rage mightily against the dying of the light.
  • Approaching It with Realism  Gawande admits he thinks of "Gould and his essay every time [he has] a patient with a terminal illness." But here's his response: There's "nothing" wrong with holding out for that "long tail of possibility" on the charts--the miracle 1%... "unless it means we have failed to prepare for the outcome that's vastly more probable. The trouble is that we've built our medical system and culture around the long tail. We've created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets--and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win."
This article is from the archive of our partner The Wire.