Freedom and Mortality

Life before death and what matters in the end

Reading Arthur Brooks’ New York Times article “To Be Happier, Start Thinking More About Your Death” prompted me to pick up my copy of Being Mortal by Atul Gawande again.

I recommend both the article and the book. Both offer important and practical advice for a better life. Brooks’ point is that thinking about our death will refocus our priorities and invest us in the things that matter to a happy, satisfying, and productive life:

Paradoxically, this meditation on death is intended as a key to better living. It makes disciples aware of the transitory nature of their own physical lives and stimulates a realignment between momentary desires and existential goals. In other words, it makes one ask, “Am I making the right use of my scarce and precious life?”

Being Mortal is not so much about death as about dying — specifically, the long, protracted decline in health and abilities that increasingly precedes the average person’s demise in the West.

Gawande wants people to grapple not just with the end but with life before death. If you live long enough, there is much that will go wrong that is both inevitable and irreversible. Just consider our head:

In the course of a normal lifetime, the muscles of the jaw lose about 40 percent of their mass and the bones of the mandible lose about 20 percent, becoming porous and weak. ... By age sixty, people in an industrialized country like the United States have lost, on average, a third of their teeth. After eighty-five, almost 40 percent have no teeth at all. ...

Even our brains shrink: at the age of thirty, the brain is a three-pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room. That’s why elderly people ... are so much more prone to cerebral bleeding after a blow to the head — the brain actually rattles around inside.

The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized... By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia. ...

Hair grows gray ... simply because we run out of the pigment cells that give hair its color. The natural life cycle of the scalp's pigment cells is just a few years. We rely on stem cells under the surface to migrate in and replace them. Gradually, however, the stem-cell reservoir is used up. By the age of fifty, as a result, half of the average person’s hairs have gone gray. ...

The eyes go for different reasons. The lens is made of crystalline proteins that are tremendously durable, but they change chemically in ways that diminish their elasticity over time — hence the farsightedness most people develop beginning in their fourth decade. The process also gradually yellows the lens. Even without cataracts ... the amount of light reaching the retina of a healthy sixty-year-old is one third that of a twenty-year-old.

Your joints, skeleton, heart, muscles, veins, and arteries will all gradually soften, harden, swell, or shrink in ways that degrade their function.

Gawande wants us to stop deceiving ourselves with the endless parade of feel-good anecdotes about 90-year-old marathon runners and stories about lab mice that promise that science is about to magic up a pill or a genetic potion that will save us from this kind of decline. He quotes an expert on aging that there is “no single, common cellular mechanism to the aging process. … We just fall apart.”

Falling apart has consequences for how we live during old age. Gawande praises geriatric medicine as crucially important, but also points out that most of what the elderly need isn’t medical intervention. They need to carefully manage life on the decline. Falling — metaphorically and literally — can have devastating consequences for our quality of life in the last decade or more.

Gawande is particularly critical of the institutions that have been set up to care for the aged and infirm — nursing homes. Their failures are partly a result of people’s own unwillingness to acknowledge what’s coming and to plan for it. But their problems also derive from how the institution itself evolved.

Nursing homes, by his telling, were never primarily designed to help solve old people’s problems — to help them continue to live their lives and pursue their goals with more limited abilities. Rather, they arose to solve other problems created by a large population of elderly people that increasingly did not live out their final years with children.

Abuse and terrible conditions in poorhouses led many states to try to force their closure in the early and mid-20th century. This, combined with an explosion of hospital construction across the country in the 1950s, led to many former inmates of poorhouses being offloaded onto hospitals. Overcrowding caused administrators to set up special wards for elderly patients with chronic, non-emergency problems; thus “nursing homes” were born.

This did solve the states’ and the hospitals’ problem of “what to do with” old people. But, even though safety conditions and quality at nursing homes have hugely improved since their initial creation, it’s never satisfied the elderly themselves. And given that their wishes and desires were never the ultimate point, that’s not surprising.

This doesn’t imply the nursing staff are bad people — on the contrary, they are usually exceptionally dedicated. But however benevolent, the goals of the institution are fundamentally different from the goals of the individuals who reside in it — and the institution always wins in the end. This inevitably leads to conflict and unhappiness for adults who find their desires are no longer what matters most — who, for the first time in several decades, find they lack the ability to live a self-directed life.

Gawande tells the story of a woman who, after several falls, refused to relocate to the intensive nursing floor of her home. Finally, another fall snapped her femur, and she was left with no choice but to move upstairs.

All privacy and control were gone. She was put in hospital clothes most of the time. She woke when they told her, bathed and dressed when they told her, ate when they told her. She lived with whomever they said she had to. … She felt incarcerated, like she was in prison for being old.

This feeling was not mere hyperbole.

The sociologist Erving Goffman noted the likeness between prisons and nursing homes half a century ago in his book Asylums. They were, along with military training camps, orphanages, and mental hospitals, “total institutions” — places largely cut off from wider society.

“A basic social arrangement in modern society is that the individual tends to sleep, play, and work in different places, with different co-participants, under different authorities, and without an over-all rational plan,” he wrote.

By contrast, total institutions break down the barriers separating our spheres of life in specific ways that he enumerated:

First, all aspects of life are conducted in the same place and under the same central authority.

Second, each phase of the member’s daily activity is carried on in the immediate company of a large batch of others, all of whom are treated alike and required to do the same thing together.

Third, all phases of the day’s activities are tightly scheduled, with one activity leading at a prearranged time into the next, the whole sequence of activities being imposed from above by a system of explicit formal rulings and a body of officials.

Finally, the various enforced activities are brought together into a single plan purportedly designed to fulfill the official aims of the institution.

In a nursing home, the official aim of the institution is caring, but the idea of caring that had evolved didn’t bear any meaningful resemblance to what [she] would call living. She was hardly alone in feeling this way.

Caring is not enough. Being assiduously “cared for” is not what is good about life; it’s just passively treading water until you wear out.

I once met an eighty-nine-year-old woman who had, of her own volition, checked herself into a Boston nursing home. ... “I fell twice in one week, and I told my daughter I don’t belong at home anymore,” she said.

She picked the facility herself. It had excellent ratings and nice staff, and her daughter lived nearby. She had moved in the month before I met her. She told me that she was glad to be in a safe place — if there’s anything a decent nursing home is built for, it is safety. But she was unhappy.

The trouble was that she expected more from life than safety. “I know I can’t do what I used to,” she said, “but this feels like a hospital, not a home.”

It is a near-universal reality. Nursing home priorities are matters like avoiding bedsores and maintaining residents’ weight — important medical goals, to be sure, but they are means, not ends.

The woman had left an airy apartment she furnished herself for a small beige hospital-like room with a stranger for a roommate. Her belongings were stripped down to what she could fit into the one cupboard and shelf they gave her.

Basic matters, like when she went to bed, woke up, dressed, and ate, were subject to the rigid schedule of institutional life. She couldn’t have her own furniture or a cocktail before dinner, because it wasn’t safe.

Safety is important. But, as Gawande points out, safety is a means to our ends, not a goal in itself. It is a necessary but not sufficient condition for personal fulfillment.

The nursing home is an experiment with centrally planned society — a well-intentioned, watchful, and above all safe society, but one that is missing most of what we love about adult life: To have an open-ended day, to be spontaneous, to try new things, to choose our friends, to set and pursue goals, to create value and contribute, to have private time, and especially to act without permission.

At some point, we forget what life was like as a child — we scoff about surly kids, ungrateful that everything is being done for them — and overlook why we were desperate to escape the cocoon of dependency and authority that shaped our early lives.

To have our desires respected as meaningful by others, to make our own choices, was the first intoxicating high of freedom. There’s something uniquely horrible about doing this in reverse — experiencing independence for six decades, and then having it taken away — because there is no possibility of ever getting it back.

This isn’t some sinister plot, of course. Many old people really shouldn’t drive or control their own finances, and in the end, most of us will be flatly unable to perform the basic tasks we have done ourselves since childhood. But that doesn’t make the prospect of losing our autonomy any less tragic.

Brooks recommends practicing the “last year test,” evaluating our choices by imagining that this is our last year on earth. Contemplating the end is a wonderfully clarifying exercise because it encourages us to focus on the things that matter, before we are no longer able to do them.

Few of us are really in our last year; most can confidently expect to live into our seventies or beyond. But that doesn’t blunt the point. When we contemplate our mortality, we should consider that there is quite a bit that we won't be able to do while we are still alive. We have less time than we think, because we will all lose much of our freedom and independence before we lose our lives.

How we handle that — how we plan or fail to plan for our own infirmity and loss of control — will make a huge difference to our happiness in the end. How well we absorb the lessons of life before death will make a huge difference to the health of our society and its ability encourage human flourishing.