Being Mortal by Atul Gawande

Being Mortal by Atul Gawande is subtitled, Medicine and What Matters in the End. It is a book that is scientific, humanistic, and philosophical. The subject is how to deal with death. As a surgeon, Gawande brings a special perspective to bear on this topic because, as he illustrates, we in the U.S (and the West in general) have pathologized death. This is to say that we treat death as a medical issue, something we can treat and put off and perhaps even defeat.

Gawande argues that there is more to death than thwarting it, postponing it, or ignoring it by warehousing it in nursing homes where the corridors are lined with aged, infirm men and women in their wheelchairs.

He offers many compelling case studies that illustrate ways to provide better end-of-life care than simply trying the next exotic medical technique or pharmaceutical. He describes nursing homes that are more like homes than hospitals. He examines the statistical facts about hospice programs that often prolong and improve life better than desperate measures.

None of us likes to talk about death or imagine our demise or put our affairs and relations in order, and the worst time to do any of this is after receiving a grim diagnosis of cancer, heart failure, or some other fatal malady. Gawande can’t overcome this, but he does show ways in which end-of-life conversations can take place that focus on the priorities and quality of a given life as opposed to the protocols and pretensions of advanced medicine.

This isn’t a book that damns medicine. Medicine is a wonderful thing that offers cures in so many ways that it couldn’t be called into question except in this particular case: when death is almost certain, regardless of medical measures, how should the doctor, patient, and family proceed?

Gawande advances the argument, compiled by many experienced practitioners he has studied, that the most important thing to do when dealing with a dying person is to ask questions and listen, not push answers and talk. He notes that when we ship our mortally ill to hospitals, we sometimes rescue them, but in many, many cases we divorce them from the very stuff of their lives, meaning their familiar surroundings, their loved ones, their little pleasures, and their memories.

This is truly a profound book that reflects wisely on an issue the United States (and the West in general) has not come to terms with, although promising initiatives have been taken all over the country. When there is no reasonable expectation of survival, isn’t it best to focus not on the length of time remaining but rather on the quality of time at hand?

For those of us who have dealt with parents or loved ones who have died, this book speaks to a great deal of anguish. One of the maddening things about dying when you are old is that often you die of many things at once. This sometimes is called systemic collapse. That means that the bowels stop functioning and the blood stops flowing and the nerves stop working and the lungs stop pumping air, and everything becomes jumbled–what do you deal with first, second, third? When do you recognize that palliative care, which is care focused on minimizing suffering, is better than curative care?

Toward the end of the book, Gawande emphasizes the need for every individual to come to terms with the end of his/her life’s narrative, to find an ending appropriate to his/her values and responsibilities and aspirations. Medical schools too often fail when it comes to the meaning of existence; experienced doctors don’t know how to confront the dying on the dying’s terms, not on the terms established by their training. In this book, Gawande offers a different approach, one he has observed acutely and experienced just as acutely in losing his father. Again, ask, don’t tell; listen, don’t talk; try to find a way to do for the patient what the patient really wants in his/her final experience of life. A side benefit to this approach is that six months after someone passes away, the survivor’s are less likely to feel guilty and depressed because they know they forced senseless medical treatment on a loved one that made things worse, not better, in the final days of life.

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Conspirata by Robert Harris

In Conspirata Robert Harris has again written a novel of classical Rome that is rich with characters, atmosphere, historical detail, and plot. The book focuses on Cicero’s attempts to preserve the authority of the Roman Senate, and the Republic, against Caesar’s dictatorial machinations that flexibly reached both certain patrician quarters and vast tracts of the disenfranchised (but traditionally protected) popular classes, or plebes.

The major figures here are Cicero, Pompey the Great, Crassus, Cicero’s secretary Tiro, his wife Terentia, Cataline (here called Catalina), and many others, including the amoral Clodius and his sister Clodia.

Cicero is an unlikely hero in many ways, astute and yet shaky politically, not a soldier in a martial culture, and given to anxiety and unattractive dealmaking. But this makes him all the more interesting. He detects Cataline’s plot to storm and dismantle Rome and thwarts it, but this goes too much to his head, so he isn’t quick or flexible enough to outwit the triumvirate of Caesar, Pompey and Crassus, and by the end of this book, he is heading into exile (though history tells us he came back, perhaps as influential as ever.)

The novel is fast-paced and well-informed without being too technical and overly detailed. Harris does an excellent job in fleshing out characters like Crassus, Cato (the very younger), Caesar, and a raft of miscreants and plotters.

My passage through translating Cicero’s great speeches from Latin into English fifty years ago did seem to me more vivid than what I encounter here, but I’m not sure there’s much a modern author can do about this. A single Ciceronian sentence can go on for ten or fifteen lines of text. That doesn’t make for good novelizing. But at the same time, Cicero would pack so much into his long sentences that finding an end to them brought a fantastic sense of relief and understanding. He possessed a rhetorical mind equal to any. Think of Churchill because Churchill thought of Cicero; think of many another great Western orator, because they, too, thought of Cicero.

One aspect of life in Cicero’s Rome that comes through Conspirata with disturbing clarity is how dangerous and fickle it was. Cicero defended governance by the upper class, not a popular stance today, but one can see how tense and ready to burst Rome was as its wealth and decadence grew. Pompey the Great brought fantastic riches to an empire that still thought of itself as a kind of city. Caesar capitalized on the instability this wealth engendered. Then he was killed. Finally, Augustus established order, but the beloved Roman Republic was dead.

One of Cicero’s greatest legacies was bringing Greek philosophy into the Latin language and amplifying Latin to accommodate it. He was, as Harris portrays him, a thoughtful man of public affairs. Today we can look around and find few public leaders with a broad intellectual horizon. Though he does not flaunt it, Obama has such an horizon. Churchill had it and so did Woodrow Wilson. Sometimes this is a weakness, perhaps more often than not, but it’s a fascinating characteristic and introduces a kind of melancholy into learned leadership. Such figures know the outer limits of what philosophers can dream, and they know the limits of what politicians can accomplish. All too often the ultimate agent of change is war, and no one who is widely read can be an enthusiast of violence rather than reason. (

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Becoming Freud by Adam Phillips

Becoming Freud by Adam Phillips is an exceptionally interesting biography about a man whom I had put aside some time ago, having read most of his work and discussed him sufficiently to think I was done with him. Phillips, a psychoanalyst and writer/editor, takes a uniquely thoughtful approach to Freud, however. He recognizes that Freud himself had little time for biography in the sense that biography is something we all choose about ourselves. We have many biographies and decide which one works best, discarding irrelevant material and highlighting what we take to be the essential. This gives us the birth of today’s trope “the narrative,” as in Obama’s narrative and Oprah’s narrative and so forth.
As a practitioner and man of letters, Phillips homes in on Freud’s rich contradictions. Yes, sexuality plays a determinative role in Freudian thought, but beyond that we enter a world of representations, diversions, symptoms, jokes and dreams, all of us struggling with two fundamental things: need and desire. In a sense this is the human evolution of Darwinian evolution, the way we humans do it. Freud struggled early in his career to be part of what we now call “hard science,” the process of discovering universal facts that can be reconfirmed through subsequent experimentation. He became a doctor for this reason, but late in his life, he wryly commented that he hadn’t much use for his medical degree and hadn’t been much of a doctor.
The problem with Freud (and Jung and many others) is that he saw relatively few patients, each of whom was incomparable, so he had no way of testing his findings except through observation. And then he stopped trying to test findings because his observations proved sufficient for the enveloping theories he constructed.
Phillips deals with this issue head-on. We’re a hundred years into true brain science, but the matter of a human body is easier to confirm than interpret, and here is where Freud excelled, using language (“the talking cure”) to probe what language conceals . . . or letting the patient achieve that end.
Phillips writes subtly. Sometimes he is so subtle and precise that the book is slow going, but always interesting. He spends time on “the dog that didn’t bark.” Freud wrote little about his wife, for example. That’s a dog that didn’t bark. Or his six children, six puppies who didn’t bark. But he was a man so focused on his work that he not only paid them as little attention as possible but also played no role in the intellectual/artistic world of Vienna, sticking to his patients and his writing.
For me one of the key sentences in the book is Freud’s view that we don’t live so much in culture as culture lives in us—and therefore each of us has problems fitting culture’s demands within our needs and desires. Culture is a generality. We are specific. Our lives, shorn of overarching religious interpretation in a secular world, therefore require multiple forms of narrative construction, sometimes contradictory, and our narratives inevitably change somewhat as we move through the life cycle. The fact that our awareness is greater than our immediate consciousness is obvious to us; we pick up more than we know. Thank Freud for that. When we joke, we are attempting to make unacceptable views acceptable. Thank Freud for that. When we dream, we are redescribing the previous day’s events and also demonstrating, though our fantastic imagery and bizarre stories, tremendous artistic powers, hard to understand and harder to access and employ when we are awake. Thank Freud for that.
Phillips follows Freud through his most productive psychoanalytic phase up to age fifty. After that Freud began applying his interpretations to broader life matters—“Civilization and Its Discontents,” for example. Phillips makes the canny point, however, that if Freud had died at fifty, he’d still be a foundational thinker. And he was—a thinker, a philosopher, a mind in search of meaning more than facts.
If you’re still interested in Freud, this is a good book to read. If you’re not still interested in Freud, it’s also a good book to read. I’d like to know Adam Phillips. The quotes he places at the head of his chapters, for example, demonstrate exceptional breadth of knowledge and wide reading. They alone would merit a few hours discussion.

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Claudius the God by Robert Graves

Recently I read and reviewed I, Claudius, which I found much more interesting than its sequel, Claudius the God. The problem with this novel is that it defers too much to the pedantic character of Claudius himself, spending excessive time recounting battles in Germany and Britain. You would have to have a great interest in Roman history to enjoy these disquisitions, and even then, there are original sources to turn to that Graves excavated with excruciating accuracy. Claudius as emperor is a sensible, somewhat easily fooled, ruler who rather thinks Rome ought to return to being a republic. Tiberius thought the same thing, but both emperors found themselves entangled in the day-to-day struggles of governance that make wholesale transitions in forms of government difficult and often not with the effort. Toward the end of the book, Claudius begins to act like an autocrat and becomes more interesting, if more dislikable. This transition should have been the heart of a shorter novel–a study in a man corrupted by his power. I wouldn’t recommend reading Claudius the God as either a novel or history. It’s just too tedious.

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Conspirata by Robert Harris

In Conspirata Robert Harris has again written a novel of classical Rome that is rich with characters, atmosphere, historical detail, and plot. The book focuses on Cicero’s attempts to preserve the authority of the Roman Senate, and the Republic, against Caesar’s dictatorial machinations that flexibly reached both certain patrician quarters and vast tracts of the disenfranchised (but traditionally protected) popular classes, or plebes.

The major figures here are Cicero, Pompey the Great, Crassus, Cicero’s secretary Tiro, his wife Terentia, Cataline (here called Catalina), and many others, including the amoral Clodius and his sister Clodia.

Cicero is an unlikely hero in many ways, astute and yet shaky politically, not a soldier in a martial culture, and given to anxiety and unattractive dealmaking. But this makes him all the more interesting. He detects Cataline’s plot to storm and dismantle Rome and thwarts it, but this goes too much to his head, so he isn’t quick or flexible enough to outwit the triumvirate of Caesar, Pompey and Crassus, and by the end of this book, he is heading into exile (though history tells us he came back, perhaps as influential as ever.)

The novel is fast-paced and well-informed without being too technical and overly detailed. Harris does an excellent job in fleshing out characters like Crassus, Cato (the very younger), Caesar, and a raft of miscreants and plotters.

My passage through translating Cicero’s great speeches from Latin into English fifty years ago did seem to me more vivid than what I encounter here, but I’m not sure there’s much a modern author can do about this. A single Ciceronian sentence can go on for ten or fifteen lines of text. That doesn’t make for good novelizing. But at the same time, Cicero would pack so much into his long sentences that finding an end to them brought a fantastic sense of relief and understanding. He possessed a rhetorical mind equal to any. Think of Churchill because Churchill thought of Cicero; think of many another great Western orator, because they, too, thought of Cicero.

One aspect of life in Cicero’s Rome that comes through Conspirata with disturbing clarity is how dangerous and fickle it was. Cicero defended governance by the upper class, not a popular stance today, but one can see how tense and ready to burst Rome was as its wealth and decadence grew. Pompey the Great brought fantastic riches to an empire that still thought of itself as a kind of city. Caesar capitalized on the instability this wealth engendered. Then he was killed. Finally, Augustus established order, but the beloved Roman Republic was dead.

One of Cicero’s greatest legacies was bringing Greek philosophy into the Latin language and amplifying Latin to accommodate it. He was, as Harris portrays him, a thoughtful man of public affairs. Today we can look around and find few public leaders with a broad intellectual horizon. Though he does not flaunt it, Obama has such an horizon. Churchill had it and so did Woodrow Wilson. Sometimes this is a weakness, perhaps more often than not, but it’s a fascinating characteristic and introduces a kind of melancholy into learned leadership. Such figures know the outer limits of what philosophers can dream, and they know the limits of what politicians can accomplish. All too often the ultimate agent of change is war, and no one who is widely read can be an enthusiast of violence rather than reason.

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The Meditations of Marcus Aurelius

The Meditations of Marcus Aurelius, which are perhaps best read in the Modern Library translation by Gregory Hays, are a sequence of thoughts, or self-talk, Rome’s best known philosopher emperor did not mean as a book. The most extraordinary thing that can be said about them, and this should be said quickly, is that what Marcus Aurelius thought in his maturity (165-175 A.D.) prefigures some of the best thinking current today. His version of Stoicism in many ways is virtually identical to what goes by the name of cognitive behavioral therapy. In fact, the Meditations are representative of the best of many traditions, East and West. Their core concern is right thinking, stripping away illusions and misconceptions, identifying reason with the wisdom of nature, and using the fact of constant flux, whereby life implies death and vice versa, as an antidote to anxiety and depression.
Because this is a short work, its repetitiveness is tolerable. But it evidently is repetitive because the emperor needed to jot these insights down over and over again to make them stick not only in his mind but in his life.
One of the shallowest formulas one has heard in recent decades goes something like, “Perception is everything.” I heard a lecture earlier this week to which I objected because part of its thesis was that Ronald Reagan was a “great” president because he “performed the presidency” brilliantly. This is the mental masturbation of the twentieth century’s marketing mentality and feeds right into the primacy of money, associating value with transient grandeur, showiness, and the divinity of things in general–the more you have, the more godly you are.
Perception is critical to Marcus Aurelius, emperor of Rome, in an entirely different sense. For him the key is to perceive the truth of things, their littleness (his own included) in the scheme of eternity, and as a consequence to attain peace of mind, not be troubled by gossip, jealousy, the fact that ultimately Alexander the Great, Augustus, and everyone else will die and be transmuted by nature into something else.
Here we see the connection to cognitive behavioral therapy, which emphasizes using reason to dissect troubling distortions in one’s thinking, imagining one has failed, or is disliked, or always comes up short, or is bound to fall short when, in fact, each of these distortions can be shown to be unreasonable.
The existential element in Marcus Aurelius’s approach is clear and explicit: if you have in fact fallen short to this point, take a different path from here on; don’t permit yourself to dwell on the irrecoverable past since it can’t be changed; let it go; face the fact that everyone fails without generalizing that into total self-condemnation.
But at the same time, realize that your desires, your lusts, your anger, your obsessions will not alter the fact that your time as a human being is limited. So don’t get too down on yourself, but don’t get too full of yourself . . . again, even if you are an emperor.
There is no doubt that Marcus Aurelius remains one of the more unique ruler/leaders in history. I can’t think of a comparable political figure, so penetrating and severe with himself, so learned, and so articulate. The Meditations remind me in many ways of Tolstoy’s notebooks for eloquence, self-criticism, and erudition. The difference of course is that initially Tolstoy lived the life of a famous literary figure; then he became a religious leader. But Tolstoy never had to bear the responsibility of governance. He was more free to think as his spirit moved him. Marcus Aurelius had to steal moments from his public existence to anchor himself in these private reflections. That’s not easy for anyone to do. As Kissinger said once, you assume office and from that point forward you draw on what you learned beforehand; it isn’t possible to develop new insights and act at the same time. The profundity of the Meditations suggests that Marcus Aurelius was an exception to this rule, always striving for new formulations of eternal truths in order to perform his official functions justly and effectively.

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I, Claudius by Robert Graves

Robert Graves published his novel, I, Claudius, in 1934. Seventy years later it remains a distinctive book, rich with erudition about the Rome of Augustus, Tiberius and Caligula, and somewhat contrarian in that it “tells” more than it “shows.” Some critics and publishers consider this a no-no, but it works. Claudius, who succeeded Caligula, was an historian, and so his account of Rome at its peak and Rome at a nadir, is a history, not a drama.
And yet there is plenty of drama here, buttressed by Claudius’s sharp wit, knack for moving the tale along, and ability to make characters real. After you read it, you’ll feel you know Augustus for his cautious, equivocations, Livia, his wife, for her cunning and ruthlessness, Tiberius for his balky, perverse arrogance, and Caligula, possibly the best portrait in the gallery although it’s the shortest, for his vicious madness.
With rulers like these, all of them carelessly bloodthirsty and self-interested, it’s a wonder that Rome retains even today a certain luster. Its empire was extensive, to be sure, but the number of minor and unnamed figures thoughtlessly beheaded and tortured in I, Claudius might run into the thousands.
Claudius pauses at one point in the narrative to note that he is focusing on a small ruling class which isn’t representative of the millions who lived under Rome’s rule, but it was that capricious, violent ruling class that we think of, perversely, when we think of Augustus as the wisest of the Caesars and Livia, his consort, as the most able and insightful of the general nobility that, by marriage found its way into near divinity.
The reason Claudius can tell all these tales is twofold: First, Graves, his puppeteer, possessed exceptional knowledge of the ancient world. He knew Rome’s customs, its landscape, its families, and its wars in Germany, France, the Balkans, and North Africa. Second, Claudius the character in the novel is happy to cede the stage to relatives who are not cursed by lameness and stuttering from infancy on. This gives Claudius perspective, and when he surprisingly finds himself named emperor after Caligula is murdered, he has the trained eye of the library researcher to rely upon now that he possesses access to Rome’s most secret archives.
Rome’s decay actually began earlier than many might think. At one and the same time, Augustus was the steadiest of emperors and the beginning of the end. He wasn’t personally corrupted by power to the extent that Tiberius and Caligula were; it didn’t lodge itself in his sexual organs or take over his brain, but Livia did a lot of dirty work so that Augustus didn’t have to, and therein lies the problem: she was determined to see her son by a first marriage, Tiberius, succeed Augustus, and that was at best a mixed blessing. Tiberius himself knew it would be better for Rome to return to being a republic; he said as much; but he played along, ever more remote, ever more decadent.
In fact it was hundreds of years of institutional structure building that saw Rome through its imperial phase to the end. First and foremost, Rome had great military institutions. Second, it had mastered engineering and shipbuilding. Third, it had a corrupt but effective way of exacting taxes and grain from its imperial subordinates. Fourth, the Romans learned how to think and write from the Greeks, and this helped them develop a great literary tradition, including Virgil, Catullus, Cicero, Horace, Livy and Tacitus. One might ask, “What’s so important about a literary tradition?” I suppose I would say that in the case of Rome it was essential to its sense of identity and it also was essential, from time to time, in generating self-criticism that was, to use a Latin-based word, salubrious.
Through Claudius, Graves gives us all this and relates how a fantastically complex society managed and abused itself. The shock to today’s reader is that the Romans can be seen as a template for terrorist organizations like ISIL. The challenge implicit in Graves’ novel is for us to recognize the dangers of responding to terror with terror and creating a governmental structure that rots from the top down out of fear that it will not be privy to every secret, every threat, every real or imagined assault on its secure grasp of power. The lands over which the West and ISIL, Hamas, Hezbollah, and others struggle are exactly the lands where Rome suffered some of its cruelest defeats and learned lessons in applying unbridled power that it would have been better off not learning.
But enough of the political comparisons. It’s a solid novel written with authority and wit. In a way it has to tell the tale it tells because the facts it presents are better than most fictions.

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