Being Mortal

by

Atul Gawande

Being Mortal: Chapter 1 Summary & Analysis

Summary
Analysis
When Gawande was in college, he began dating a girl named Kathleen and met her 77-year-old grandmother Alice Hobson. Alice was spirited and independent: her husband died in 1965 of a heart attack, when Alice was 56. She was able to live off his pension and keep her home. Her son, Jim, lived nearby, but she remained completely autonomous. She even mowed her own lawn and fixed her own plumbing.
In introducing Alice, Gawande establishes how, in the modern era, independence even into old age is a crucial part of people’s well-being. Alice enjoys being able to live alone and take care of her own home.
Themes
Safety vs. Autonomy Theme Icon
Gawande eventually married Kathleen, and as the years passed, he started to wonder how long Alice would be able to live independently. She became arthritic and lost weight. When Gawande’s father met Alice, he was surprised to learn she lived alone. Coming from India, Gawande’s father felt it was the family’s responsibility to take care of the aged and give them company.
Alice’s living situation affords her autonomy, but Gawande’s father’s attitude comes from his own preconceived notions about elder care. Where he is from in India, living with children is considered more appropriate because it is safer for the parent, setting up a tension between safety and autonomy.
Themes
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Gawande’s grandfather, Sitaram, had a traditional old age that seems idyllic. He was a farmer in a rural village in India. Gawande met him on a visit to India when Sitaram was over 100 years old. Sitaram walked with a cane, was hard of hearing, and was very weak. But he was surrounded and supported by family at all times, and he was revered for his wisdom. The family consulted him on all important matters.
The picture of Sitaram’s old age in India illustrates how different cultures treat the process of aging and dying. In the modern U.S., this situation is growing rarer. But in India, it is still the family’s role to care for the elderly.
Themes
Safety vs. Autonomy Theme Icon
The Evolution of End-of-Life Care Theme Icon
In America, Sitaram would likely have lived in a nursing home. If a person can’t use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, or walk, then they lack the capacity for physical independence. If a person cannot prepare food, shop, do laundry, manage medications, travel alone, and handle finances, then they lack the capacity to live safely alone. Sitaram could only perform some of the basic measures and a few of the complex ones.
This passage establishes the guidelines in the United States for ensuring that someone can live autonomously, again positioning autonomy in old age as a threat to safety. If a person cannot perform these basic actions, they are considered to be unable to ensure their own safety.
Themes
Safety vs. Autonomy Theme Icon
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Living with family allowed Sitaram to manage his farm, which he built up from nothing to become one of the richest landowners in the village. Every day he rose before sunrise, and each night he inspected every acre of field on horseback—even at 100. Had he lived in the West, doctors would insist he live in a nursing home, but in Sitaram’s world, he lived how he wanted to live and the family was meant to make that possible. He died at almost 110: he hit his head falling off a bus while he was going to a courthouse in a nearby town on business.
Because Sitaram lived with family, he was able to maintain the parts of his life that were most meaningful to him. Yet those meaningful routines, such as maintaining his farm, were ultimately what put him in danger and ended his life. It’s difficult for an aging person to have both safety and autonomy, and this passage suggests that it’s crucial to consider their own desires for their quality of life when making decisions about how they live.
Themes
Safety vs. Autonomy Theme Icon
For most of history, Sitaram’s experience was the norm. Elders were cared for in multigenerational systems. One child, often the youngest daughter, remained in their family’s home—this is what happened to Emily Dickinson, who lived in her parents’ house until they died. It was understood in both these cases that parents would keep living in their home, assisted by the children they’d raised.
History confirms the traditional pattern of parents living with children through their old age. But Emily Dickinson’s example is emblematic of the fact that sometimes it is the children who lack autonomy as a result of taking care of their parents.
Themes
Safety vs. Autonomy Theme Icon
Now, old age has changed. In the past, surviving into old age was uncommon. In 1790, people 65 or older were less than 2 percent of the population; now they are 14 percent. And thanks to technology and modernity, old age and wisdom isn’t as revered—teenagers have just as much access to certain information as the elderly. As a result, traditional family systems have become more strained, as young people lost freedom about how to live their lives and battles emerged over land and money.
Gawande illustrates how society’s perspective on aging is changing thanks to modern technology. Technology allows people to live longer and makes old age more common. In addition, technology means that wisdom is more equally distributed; older people no longer have disproportionate access to wisdom simply because they’ve experienced more.
Themes
The Evolution of End-of-Life Care Theme Icon
Meanwhile, global economic development has put pressure on young people to move in search of greater opportunity—like Gawande’s parents, who left India for professional opportunity in the United States. Gawande’s father sent money home to help his family in India, but he never went back. Sitaram’s situation was only possible because Gawande’s aunts and uncles did not leave home. And even then, tension emerged between Sitaram and Gawande’s uncles, who didn’t always agree on how to run the farm.
The contrast of Gawande’s father with his siblings shows how children risk losing some of their own autonomy in caring for their parents. The siblings had to give up some aspect of independence in remaining at home with their father, and even as they became middle-aged and older, they could not make their own decisions about their home and their business.
Themes
Safety vs. Autonomy Theme Icon
The Evolution of End-of-Life Care Theme Icon
While many believe that they might want the old age Sitaram had, in reality, the historical pattern shows that people generally don’t want this kind of living situation. Elderly parents discovered economic benefits to children leaving as well: they could rent or sell their land instead of handing it down. Rising incomes and pensions enabled people to accumulate savings and maintain economic independence. Retirement began to take shape.
When given financial independence, the elderly did not want to remain with their children. This fact suggests that they also found some cost to their autonomy in living with their children for their entire adult lives. In addition, greater financial independence, combined with greater longevity, allowed modern retirement to take shape.
Themes
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The Evolution of End-of-Life Care Theme Icon
Quotes
Life expectancy, which was under 50 in 1900, climbed to 60 by the 1930s. Family sizes fell and women stopped having children at a younger age. As a result, more people now see all of their children live to adulthood. With new economic opportunity and fewer children, many aging parents found freedom in separation from their children—a worldwide pattern.
It isn’t just medical advancements that change the way people live out the final phase of their lives. The changes to the traditional family structure also contributed to retirement homes’ advent and the desire for greater independence among aging people.
Themes
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The fact that the elderly and the young both have more choices and independence is a sign of progress. The elderly can choose a retirement community or remain independent in their own homes, like Alice Hobson. But there is one problem with this way of living. Even though people can be independent longer, sooner or later, independence becomes impossible.
The changing demographics and family structures are a sign of progress, as Gawande notes. But as he also suggests that this progress has created its own problems surrounding what to when elderly people can no longer remain independent—problems with which society is still grappling.
Themes
The Evolution of End-of-Life Care Theme Icon
In 1992, Alice turned 84. She was in striking health, going to the gym, doing her own shopping, and taking care of her house. Soon, things began to change, however. On a mountain vacation with the family, Alice became confused and went into the wrong cabin. Then the family noticed bruises on Alice’s legs when they visited her—she fell going down the stairs. Soon, she had more falls and a doctor found that she had thinning bones. He gave her medications, but in reality, he didn’t know what to do: Alice was simply getting old, unsteady, and her memory was slipping. Her independence wasn’t sustainable, and it was not a fixable problem.
Here Gawande shows how end-of-life care is often medicalized. It’s hard for doctors to know how to treat the elderly, because they don’t necessarily have discrete, fixable problems—often they are simply facing the danger of living alone as an old person. But there is often a breaking point between allowing people to maintain their independence and creating a safer environment for them.
Themes
Medicine, Survival, and Well-being Theme Icon
Safety vs. Autonomy Theme Icon