In Atul Gawande’s thought-provoking book Being Mortal (2014), he confronts us with the reality of our own mortality through exploring illness, end of life care and death. As a surgeon, he’s witnessed first-hand how modern medicine has become so obsessed with prolonging life that we’ve lost sight of the importance of quality of life and how and where we’d like to spend our last moments. Gawande sets out to challenge the medicalization of ageing and dying and calls for fellow doctors and nurses, as well as the reader, to engage in uncomfortable conversations and face up to what lies ahead of us at the end of our lives.
Through rich and animated descriptions of various hospitals, care homes, institutions and individual case studies, interweaved with moving stories of his own family, Gawande highlights how reluctant we have become to face our own finitude in Western society. It has now reached a point where we allow “our fates to be controlled by the imperatives of medicine, technology, and strangers.”
The risks and interventions made in a bid to treat or cure someone need to be questioned if they don’t serve the larger aims of a person’s life. If that is forgotten then the suffering inflicted can be unbearable. As Gawande states in the epilogue: “If to be human is to be limited, then the role of caring professions and institutions – from surgeons to nursing homes – ought to be aiding people in their struggle with those limits.”
One of the ideas examined in the book that I found most interesting was around human motivation and fulfilment, especially in relation to ageing. In Chapter 4, Gawande ponders on the question: What makes life worth living when we are old and frail and unable to care for ourselves?
According to the influential psychologist Abraham Maslow’s A Theory of Human Motivation, published in 1943, there is a ‘hierarchy of needs’, which motivates people. In his pyramid, Maslow places basic tenets of human survival like food and water at the bottom, with self-actualization at the top. Maslow argued that people are motivated to achieve certain needs, and that some are prioritized over others. However, we must satisfy our lower needs before moving on to higher ones. Fulfilling unmet needs is what drives our motivation.
Gawande critiques this theory by pointing out that reality is more complex. For instance, people are willing to self-sacrifice for something beyond themselves such as family or country, and that our driving motivations change with age. The theory holds true for young people, who grow outward as they mature, seeking novel experiences and self-fulfilment. However, in later life, priorities strikingly alter as older adults narrow in. They reduce time and effort in expanding social networks and new experiences, instead focusing on family and established friends.
How can we explain this shift? Laura Carstensen, a psychologist at Stanford, studied the emotional experiences of a diverse group of 200 people, of all ages, over decades of their lives. If Maslow’s theory was right, people would grow unhappier as they aged, unable to achieve fulfilment through narrowing in their lives. Carstensen found the opposite: people reported positive emotions as they aged and were less disposed to feeling angry, anxious or depressed. As people got older, they moved towards focusing their energies on appreciating everyday pleasures and relationships rather than acquisitions and achievements.
Instead of growing wise with age or developing life skills over time, as some researchers had explained this shift, Carstensen argued it wasn’t to do with age per se, but perspective. Based on a near death experience and years of research, Carstensen formulated the theory:
how we seek to spend our time may depend on how much time we perceive ourselves to have.
When we’re young, we think we’ll live forever and don’t fear losing any of our mental or physical capabilities. We tend to delay gratification by investing years into gaining skills and resources, aiming for a brighter future. We seek new connections and widening our network instead of hanging out with parents. When we measure our life in terms of decades, we seek the ‘self-actualization’ at the top of Maslow’s hierarchy. But when we age and our life ahead shrinks and becomes uncertain, our focus shifts to the present moment, to everyday contentment, and close family and friends.
Carstensen tested what she called her ‘socioemotional selectivity theory’ in wide-ranging contexts. She and her team conducted studies with terminally ill HIV/AIDS men, healthy people ranging from 8 to 93 years old, and in different cultural locations such as Hong Kong. They consistently found that age differences disappeared and it was perspective that mattered most. They concluded that “when life’s fragility is primed, people’s goals and motives in their lives shift completely.”
This is important to bear in mind when thinking about ageing and death. When faced with our own mortality, we reorder our desires and priorities. What’s significant to us is quite simple: comfort and companionship. However, in our increasingly medicalized world this is often what gets lost in the focus on prolonging life for as long as possible. We need to remember and be willing to ask ourselves and each other what really matters.