Medical opinion: Atul Gawande's prose is as sharp as his scalpel. Photo: Erik Jacobs/NYT/Redux/Eyevine
Show Hide image

Rock doc: surgeon and writer Atul Gawande on old age and dying

What should doctors do when the drugs won’t work? Often it’s easier to push one more treatment than to acknowledge that “people have priorities other than living longer”.

Choosing a soundtrack for the operating theatre is not easy. “It has to be the kind of music that the nurses and the other doctors go along with,” the American surgeon Atul Gawande explains. “Country tends to be out, and most hip-hop, too.” He usually goes for indie. A journalist once told him that his problem was that he was too old for his iPod (he’s 49), which amused him. Gawande, sharply suited and drinking orange juice in a London café, lists his current surgery favourites: Alt J, the National and Weezer.

His musical taste is just one way in which Gawande defies convention as a surgeon. He is also a bestselling author who has been a staff writer for the New Yorker since 1998, and he’ll be giving this year’s Reith Lectures. He has a knack for identifying grand themes – how checklists can save millions of lives lost through medical mistakes, why some ideas (such as anaesthetic) catch on quickly and others (such as antiseptic) don’t, what hospitals can learn from the fast-food industry – and exploring these ideas through the stories of the patients he has treated. His writing is often moving – sometimes in a stomach-churning way: his account of the woman with an unstoppable itch who scratched all the way through to her brain is, perhaps regrettably, unforgettable.

Gawande’s latest book, Being Mortal, explores how the medical profession, and modern society, approach the end of life. What should doctors do when the drugs won’t work? Often it’s easier to push one more treatment – an operation, another round of chemo – than to acknowledge that “people have priorities other than living longer”.

This is a book about the “good life” and even though often sad, it is uplifting, too. We are wrong to assume that in order to be happy you need to be independent and healthy: elderly people dependent on help often report higher levels of happiness than the rest of us. As we age, we care less about wealth and public recognition, valuing close friends and family more.

Gawande admires those thinking imaginatively about geriatric care: the man who introduced cats, dogs and birds into a nursing home, or the staff who make sure an 85-year-old dementia patient can go out drinking margaritas every Friday. “I have nothing against the tech entrepreneur who wants to discover the immortality pill,” he says, but adds that it is wrong “that we don’t think there can be innovation in what happens in the last five years of your life that can make it incredibly better”.

The tenderest passages are those in which Gawande writes about his father’s death from cancer. Atmaram Gawande died before the book was published, but Atul’s research helped him support his father better. Both were surgeons, but initially they “couldn’t even wrap [their] minds around how to talk about the tumour that was advancing”.

For Atmaram Gawande, medicine was a path out of poverty. He grew up in India and decided to become a doctor – although he’d never met one – after his mother died of malaria. He met Gawande’s mother in the US and settled in rural Ohio, where Atul grew up. “I’m the son of two Indian immigrant physicians. Which means you practically have ‘You are going to be a doctor’ stamped on your head at birth,” Gawande jokes. He initially resisted this pressure: starting a rock band, winning a Rhodes scholarship to study philosophy, politics and economics at Oxford, working in the Clinton administration and for Al Gore’s presidential campaign. But then he realised he was “good at certain things in medicine, better than I was as a philosopher”. He seems pretty successful at both. 

Sophie McBain is a freelance writer based in Cairo. She was previously an assistant editor at the New Statesman.

This article first appeared in the 20 November 2014 issue of the New Statesman, The deep roots of Isis

Photo: Getty
Show Hide image

Scotland's vast deficit remains an obstacle to independence

Though the country's financial position has improved, independence would still risk severe austerity. 

For the SNP, the annual Scottish public spending figures bring good and bad news. The good news, such as it is, is that Scotland's deficit fell by £1.3bn in 2016/17. The bad news is that it remains £13.3bn or 8.3 per cent of GDP – three times the UK figure of 2.4 per cent (£46.2bn) and vastly higher than the white paper's worst case scenario of £5.5bn. 

These figures, it's important to note, include Scotland's geographic share of North Sea oil and gas revenue. The "oil bonus" that the SNP once boasted of has withered since the collapse in commodity prices. Though revenue rose from £56m the previous year to £208m, this remains a fraction of the £8bn recorded in 2011/12. Total public sector revenue was £312 per person below the UK average, while expenditure was £1,437 higher. Though the SNP is playing down the figures as "a snapshot", the white paper unambiguously stated: "GERS [Government Expenditure and Revenue Scotland] is the authoritative publication on Scotland’s public finances". 

As before, Nicola Sturgeon has warned of the threat posed by Brexit to the Scottish economy. But the country's black hole means the risks of independence remain immense. As a new state, Scotland would be forced to pay a premium on its debt, resulting in an even greater fiscal gap. Were it to use the pound without permission, with no independent central bank and no lender of last resort, borrowing costs would rise still further. To offset a Greek-style crisis, Scotland would be forced to impose dramatic austerity. 

Sturgeon is undoubtedly right to warn of the risks of Brexit (particularly of the "hard" variety). But for a large number of Scots, this is merely cause to avoid the added turmoil of independence. Though eventual EU membership would benefit Scotland, its UK trade is worth four times as much as that with Europe. 

Of course, for a true nationalist, economics is irrelevant. Independence is a good in itself and sovereignty always trumps prosperity (a point on which Scottish nationalists align with English Brexiteers). But if Scotland is to ever depart the UK, the SNP will need to win over pragmatists, too. In that quest, Scotland's deficit remains a vast obstacle. 

George Eaton is political editor of the New Statesman.