At the appointed hour, Atul Gawande answers the phone at his hotel room in Bengaluru, where he is on tour to promote his most recent book Being Mortal. He is polite and succinct to a fault.

Five weeks ago, this column dwelt on man’s quest for immortality. If an inquiry be conducted into the nature of man’s inevitable mortality, Gawande is the man to pick for it. He knows how to conduct such inquiries with the precision of a surgeon, the compassion of a writer and the outlook of a philosopher. Perhaps that is because he is a trained surgeon, award-winning writer and student of philosophy. That is also why his book comes across as a manifesto for medical practitioners who deal with the dying, a manual for the living on conversing with death, and a guide with pointers to the art of living.

Our conversation begins with some reflections on faultlines in contemporary medicine. For instance, the aggressive world view that argues ageing is a disease that ought to be fought and fended off. “The problem is,” Gawande says, “as doctors, we often experience pain, frailty and dying as failures of our skills—or ones where we feel our skills are irrelevant.” This, he points out, is because the human mind is such that it is pleased when it spots a problem that can be fixed or made substantially better.

The human body, on the other hand, has to deal with devastating ailments such as dementia or terminal illnesses, which cannot be wished away. While it is important that medicine learns to get more competent and helpful at dealing with these, it cannot until it lets go of the mentality that mortality is a disease. Instead, he argues gently, we ought to accept “death is not a failure. Death is normal. Death is part of life”.

What we ought to recognize instead is that we are gradually arriving at new ways of dying, not all of which are good. To put that into perspective, 50 years ago, Gawande points out, most people died at home. This was because healthcare didn’t have much to offer the dying. But as it evolved, at least in the West, over 80% of people now die in institutions and facilities surrounded by strangers.

While most people in the heart of India still die at home, prosperity has translated into a large number of people moving into institutions, hooked to life-extending machines and suffering pangs of separation from home. Add to this the trauma that accompanies pain and hopelessly limited access to narcotic medications like morphine. “It is a hard life. But this is the kind of dying that is happening,” says Gawande.

The question that arises then is, how do we live and die well?

Gawande’s father, Atmaram, he reminisces, is a good example of somebody who got the best of both worlds. Before death came calling (from cancer), he had the wisdom to ask of himself what his priorities were. Among things that topped the list was his social life. He had a dinner party every week. Having a circle of friends around was important to him as part of the meaning of life. “If you took that away, then it amounted to trying to extend his life by sacrificing his autonomy. It was clear he didn’t want to do that.”

But the structures imposed by modern medicine place safety for the elderly over autonomy. As this conflict plays itself out and medical treatment takes over, it also takes away the things important for existence. For instance, the ability to have an intact brain, or to be awake, or for some people, simply the ability to eat. In all of these cases, medicine demands you sacrifice all that you value for a little more time. So much so that it is now accepted wisdom. You can’t eat what you want to because it may cause pain and in the interest of safety, but this joy ought to be taken away.

What is often missed out is that people have priorities and values other than just surviving another day. Those differ from person to person. Because Gawande’s father had prioritized, he was clear he didn’t want to go through more surgery, radiation or chemotherapy. Instead, he wanted to go home. Even as the family supported him with pain control medications, Atmaram Gawande focused on what he wanted—a good life in the remaining time he had. It lasted all of four months. But he got the best of both worlds.

The reality is that giving people autonomy to make these decisions, in general, doesn’t shorten their life. On average for the population, if anything, it lengthens their life. Gawande argues that there is research to indicate that as people get older, they actually suffer lower rates of depression and anxiety than others in society. They are happier and content. But when they are put into institutions, their lives are no longer their own. They live under rules somebody else imposes, get depressed, witness severe decline and lose the will to live.

As ideas go, this is a difficult one to consume. For instance, what if you have somebody in the family who has dementia and doesn’t know where he is or who the caregiver is? Do you still keep this person at home? “You keep looking for what they want,” says Gawande, “because even in the worst of situations, people express themselves. And one of the joys is in simply eating.”

Eighty-five year old patients may be prohibited from having anything but puréed food because they may choke. Alzheimer’s patients may be stealing cookies and hoarding them. This may sound like morally ambiguous territory. But Gawande is clear. “You let them have the cookies. If their life is reduced to the point that the one joy they have is from eating, then you as a family member should have the ability to say, they should be allowed to have the cookies if they want to. If they choke, they choke.”

This ambiguous territory gets even more muddled when you are witness to a loved one going through suffering or misery so great, you think they’re better off dead. But at times like these, do you pull life support? Do you proactively assist their dying when there is no hope of doing anything better?

“So if you have somebody who has cancer, like my father who had it in his brain and his spine, the pain from the tumour in his spine was so severe that he was immobilized and incapacitated and made him miserable. Then you could say, well, you should get him assisted dying.”

That said, Gawande files a caveat. “It alarms me, if what we do is provide a method of assisted death rather than first making sure people have access to basic pain medications. We have to get those systems in place as a first step and then find ways to provide possibilities for people who choose to end their own lives.”

The cheapest and most effective drug to alleviate pain is morphine. The problem, though, is a complete misunderstanding of what the drug can possibly do. There are laws in place that regulate how it is used. But many doctors and nursing homes shy away from the drug because it is seen as a horribly addictive narcotic substance. What makes it worse still is that on the rare occasions morphine is prescribed, people in pain and their families give up hope because it is perceived as a palliative—something that is administered when all hope is lost.

But hope is a relative term. Gawande says people who live well are the ones who have come to terms with the fact that their times are limited. And almost always, it is because they have had time to think about it in advance.

Having accepted that, it is then possible to live the good life. But it is for an individual to define what constitutes the good life. When probed on that, Gawande says “I was really struck by the philosopher Josiah Royce, who argued people have an intrinsic need to search for themselves bigger than the self.”

Royce argued that the thing an individual is willing to sacrifice his life for is what is bigger than the self. It could be loyalty to friends, love for your children, commitment to your country, the urge to serve a community, an ideal you worship or a god you believe in.

To illustrate that point, Gawande asks a rhetorical question. “Imagine you are told one hour after you die, the entire world will be destroyed, including everybody you know. Do you care?” All of the many thousands of people he asked the question said they care. The next question that emerges is: Why do you care if you’re gone? Because your life has no meaning if the rest of the world is destroyed. Implicit to that answer is that you live for something bigger than yourself. “Just because you end up in a wheelchair does not mean you cannot have a purpose, loyalties or contributions to things most meaningful to you.”

By way of example, Gawande talks of a woman he met who was found abandoned on the streets, infected with maggots. After being treated, bathed and fed, the volunteers who got her to the nursing home put her to work. She chose to work in the kitchen. She liked it. She had a purpose. She had a role. Having that role made her happy and made it the place she wanted to be in.

The medicalized version of mortality, though, insists that you get into a wheelchair when you are in a hospital. “That is when people feel empty because there is no respect or purpose left in that phase of life.”

“For me,” Gawande says, “purpose is being able to continue to converse and have dialogues with people and to keep on writing and contributing in some way. Maybe I will change my mind as time goes on. But it’s the dialogue and mental preparation that matters. Death is out of our control. It is not dignified. It is never pretty. But it is okay. The key is giving whatever hand you are dealt with that chance to have something still worth living for.”

But modern medicine is such that it makes dying a prolonged event. It allows illnesses to be diagnosed early and then live with it for months, if not years. What it cannot take away is the inevitable feeling that you are in decline. As much as it provides an opportunity to explore whether your life can be extended and made better, efforts ought to be made to articulate what you want to be alive for and what you will not sacrifice.

And in that understanding lies the art of living. People who are able to navigate that road are those who have had crucial conversations with people they care about. Unfortunately, death is not something most people like have conversations around. But Gawande insists it must be had—both with the self, and the immediate family—at a time when an individual is in full control of all faculties.

A few of those questions open the door to asking somebody their fears, worries, hopes and priorities if time is short. “I think these are normal conversations we need to have instead of treating them as extraordinary ones with our friends, family and not just doctors.”

But even that done, the answers won’t come easy. Because as Gawande writes in his book, “Even more daunting is the courage to act on the truth we find. The problem is that the wise course is so frequently unclear. For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most.”

This article was first published in Mint on December 19, 2014. All copyrights vest with the newspaper and this cannot be reproduced without permission from the publishers