Are you in health care? Then you should read “Being Mortal”. Do you take care of people with terminal illnesses? Then you should definitely read “Being Mortal”. No, that’s wrong. You must read “Being Mortal”. No, no. That’s wrong too. You MUST read “Being Mortal”. In fact, since most of us, health-care professionals or not, will at some time be involved with someone who knows that they’re going to die soon, not least ourselves, everyone should read “Being Mortal”.
“Being Mortal”, subtitled “Illness, Medicine, and What Matters in the End”, is Atul Gawande’s latest book, and his best . Indeed, it may be the best medical book I have ever read (and my reading list is long). If not, it’s certainly up there.
Gawande tells us, using paradoxically life-enhancing stories, not how to achieve a good death, whatever that may be, but how to achieve a good life during the final stages. Almost every page is thought-provoking, but one particular passage (page 174), although not the most revealing in the book, grabbed my attention:
“There is a school of thought that says that …[if] terminal patients—rather than insurance companies or the government—had to pay the added costs for the treatments they chose instead of hospice, they would take the trade-offs into account more. Terminal cancer patients wouldn’t pay $80,000 for drugs … offering at best a few months extra survival.”
Gawande doesn’t fully accept this argument, because “the people who opt for these treatments aren’t thinking of a few added months. They’re thinking years.” In other words, he thinks that they would pay. But when I hear oncologists, who should know better, shrilly complaining that NICE has rejected a new cancer therapy that prolongs survival by 2 months on average and isn’t value for money, or drug companies objecting to the omission of drugs from the Cancer Drugs Fund, a catechism comes to mind. It takes the form of a dialogue between a doctor (Doc) and a patient (Pat).
Pat: So what’s the outlook, Doc?
Doc: Well, I’ve seen patients with this type of tumour live up to a year or so, but on average the expectation is about 5 months.
Pat: You mean you’re giving me 5 months to live, Doc?
Doc: No, no, Pat. I’m not in a position to “give” you anything of that sort. I’m just saying how long people live on average after a diagnosis of this sort.
Pat: OK, Doc, but I don’t have to be average, do I?
Doc: Well, Pat, you may be better or worse than average. I don’t know.
Pat: Ah. So, do you have something to help me beat the odds, Doc?
Doc: Well, there is this new medicine that gives an extra 2 months on average.
Pat: On average, Doc? What’s the longest?
Doc: Well it could be as much as 6 months extra or as little as 2 weeks.
Pat: OK, Doc. No harm in trying then?
Doc: Well, Pat, there may be side effects and the trials were all in US patients younger than you, so I can’t say that the results would apply to you. And anyway the government has decided that it won’t pay for the medicine, because it isn’t value for money.
Pat: Too expensive for the NHS, eh Doc? Well I have some savings. Perhaps I could pay for it myself.
Doc: Well, that would be £50,000 for a course of treatment, Pat.
Pat: Wow! I’ll have to think about that.
Pat: OK, Doc, I’ve discussed it with the family, and we reckon we’ll go for it.
Doc: Really, Pat? It’s a lot of money for very little return.
Pat: Well, Doc, you see, my daughter’s getting married in 6 months and if this treatment turns 5 months into 7 we’re ready to pay, so I can give her away.
Doc: I can see that, Pat, but remember we’re just talking averages. You might pay for the treatment and still not get to the wedding. That would be a waste of £50K. Or you might get there without the treatment.
Pat: I know that, Doc, but I’m a bit of a gambler and I’d like to give it a go, whatever the odds.
Doc: OK, Pat, but let me make a suggestion. Why not give your daughter the £50K as a wedding present and take a chance on getting there without the treatment?
Pat: Well, Doc, we talked about that, and she wants me to take the treatment. She’s not interested in the money.
Doc: OK, Pat, but I have another proposal. I have two other patients, both young people with tumours that can be completely cured for £25K each. Why not give them the money instead?
Pat: Hmm. And you say I might make it to the wedding anyway, Doc?
Doc: I just don’t know, Pat. I just don’t know.
Is the idea of an opportunity cost (the loss of an opportunity by wanton expenditure) so difficult to understand? We constantly need to challenge those who clamour for cost-ineffective treatments to tell us which other patients they would deprive of cost-effective treatments in order to gain minimal benefits for their own patients.
And, as Gawande shows, there are other ways of achieving a good life in the run-up to death. Read his book.