In chapter 1, Gawande compares the aging experiences of two individuals. His grandmother-in-law grew old independently in America, living alone and providing for herself into her 80’s. Meanwhile Gawande’s grandfather lives co-dependently to the age of 110 in a pre-modern Indian province.
I call his grandfather’s living situation co-dependent because while he lived with one of his sons and his son’s family, he still attended to his own business and personal affairs until his death. His extended family helped him with basic living needs, and he was lucky to remain active and healthy until the very end.
This comparison gives Gawande a framework to begin introducing some of the changes wrought by modernity. He makes the important point that these changes have occurred across all Western cultures, and is now taking place in China and other Asian countries as well. And these changes have created a new experience of growing old.
In this chapter, Gawande explains how doctors assess a person’s ability to care for themselves and live independently. He writes:
Had [my grandfather] lived in the West, [inspecting his property on horseback every day] would have seemed absurd. It isn’t safe, his doctor would say. If he persisted, then fell, and went to an emergency room with a broken hip, the hospital would not let him return home. They’d insist that he go to a nursing home” (p.16).
This quote introduces the central question we all must address: who actually gets to decide how we age and grow old and die?
Is it really up to doctors and hospitals to decide whether someone is “allowed” to go home versus going to a nursing facility? How so? Who decides which risks are worthwhile versus foolhardy? How can healthcare professionals work with their patients instead of dictating to them?
If we value our independence and resiliency above all else, at what point can or should we open ourselves to the possibility of limitations? Do we force circumstances to determine this? Do we act in advance to prevent greater infirmity or do we embrace the risks and the greater possibility of loss?
Humans are famously incapable of making good judgments about personal risk, and yet we resist efforts to outsource those judgments. How do we make this judgment call for ourselves or our loved ones? Can we create flexible systems to help people live with support at the same time that they live with some level of acceptable risk? What is acceptable?
Who decides how we’re going to live, how we’re going to age, and how we’re going to die? I’d like to say we each can make that decision, but I feel this may work only if we’re willing to consider the possibility of individual risk and take the steps to manage risk rather than ignore or hide it.