Book Review Assignment
Freedman, Ethan
Professor Katrina Balovlenkov
Columbia University School for Social Work, New York
Submitted in partial fulfillment as a Book Review Assignment within the requirements for Columbia's School for Social Work program and Prof. Katrina Balovlenkov Health Care Systems course.
Acknowledgements:
I would like to acknowledge Prof. Katrina Balovlenkov and her class in Health Care Systems (SOCWT6910) for introducing me to pivotal social work, health care, and LME principles. Moreover, my Health Care Systems course peers with whom I worked closely in discussion and were very influential in developing thoughts related to this paper. I appreciate everyone in the class for the ideas they have assisted in generating. With these acknowledgements, I present the following work of my own.
Atul Gawande's Being Mortal (2014) offers a personal reckoning and systemic critique of American medicine, positioning towards a health care system that reminds mortality is a collective experience. When Gawande became a doctor, they "crossed over to the other side of the hospital doors," reflecting a professional transformation and a shift from empathic social experiences of death to a medical framework of curative control (p.7). The United States health care system placed alongside Gawande's experience positions the incentives of a medical industrial complex that privileges treatment over prevention and prolonging life through providing meaning and purpose (Sherman, 2021). Bodenheimer and Grumbach (2024) observed that "only 2.5% of the $3.5 trillion spent on health care in 2017 went to prevention," while Cox et al., (2024) notes the U.S. overspends in health, but is profusely laggard in health outcomes. These realities reveal a cultural and economic logic that Gawande's stories make uniquely visible. His narrative reflects medicine's limits, while masking ethical and policy critiques that demand systemic and moral reform.
While Gawande's Being Mortal reveals how the U.S. health care system is structured by medicalization, inequity, and moral dilemmas that fail to honor the experience of aging and dying, his narrative case studies, paired with policy reflection and personal testimony, expose a system that privileges prolonging life over preserving meaning. Genuine reform is rooted in empathy, informed by patient agency, and scaffolded by morals of care.
Medicalization of Mortality: Dying as Something to Fix
The United States health system perpetuates the notion of death as an individual and technical medical failure leading to a system that prospers under the denial of mortality. Gawande's account of Joseph Lazaroff represents this curative pathology as "he was pursuing little more than a fantasy at the risk of prolonged and terrible death" through pervasive and invasive treatments that offered a glimmer of hope (Being Mortal, 2014, p. 174). Gawande humanizes the institutional pressures alongside Lazaroff's story to highlight the forces pushing patients and clinicians towards futile interventions. The hospital becomes a site where there is an illusion of control that is sustained through policy to overshadow agency and dignity of those proximal to death. This is noticeable in Medicare's reimbursement structure that "rewards acute procedures but not conversations about what patients value," while the "rising health care costs contribute to many people facing difficulties affording care, even among those insured" (Cubanski et al., 2024; sec 3, sec 4). The medical system in the U.S. is bolstered by legislation that cages how all parties involved think about and react to health and dying.
Gawande's rhetorical tone shifts from detached to mournful when describing Lazaroff's final days among machines and tools developed to aid recovery and create the facade of healing completely. This parallels a moral transition in the novel where systems designed for survival struggle to recognize when surviving no longer serves the agent – because it will always financially serve the medical systems to treat. Gawande critiques the culture of medicine that equates quantity of life with success, and Lazaroff's case functions as a disguised policy argument illustrating the affective and ethical costs of medicine that statistics struggle to portray.
Institutional Aging: Safety Without Autonomy
If hospitals and doctors offices illustrate medicine's denial of death, nursing homes posit medical denials of life. Gawande writes, "the nursing home staff treated her like a patient, not a person" when describing the confinement of Alice in a facility governed by safety checklists instead of community (Being Mortal, 2014, p 112). The sterile hallways and constant surveillance evoke feelings of containment disguised as comfort. This mirrors the structural conditions in the United States, as "Medicaid finances the majority of long-term care, but low reimbursement rates lead to inadequate staffing and poor quality" (Bodenheimer & Grumbach, 2024, p. 270). "Families often must spend down assets to qualify for Medicaid coverage" for assistance, supporting Gawande's narrative of monetizing dependency as one approaches death Bodenheimer & Grumbach, 2024).
In contrast, Lou Sanders' assisted living facility is built around resident choice, gesturing towards what agency and autonomy could look like within care settings of the aging. Lou "wanted to make his own choices, even bad ones," succinctly noting gentle defiance that encapsulates some of the moral stakes of aging policy (Being Mortal, 2014, p.133). For those dealing with aging populations, and all those aging, to find freedom and meaning in life might necessitate resisting medical pressures that mitigate risk or indulgence. This freedom is not evenly distributed, as "socioeconomic status and race / ethnicity are important determinants of the health of a population" (Bodenheimer & Grumbach, 2024, p. 67), and "Black and American Indian/Alaska Native populations experience higher institutionalization and lower-quality facilities (Ndugga et al., 2024, para. 8). Gawande's characters, primarily those who are white, middle class, and have means for care assistance, occupy spaces that policy makes inequitable.
Gawande is also at tension with their recognition of institutional innovation and frustration with bureaucratic processes, writing that "having a place that genuinely feels like home can seem essential to a person as water to a fish" (p. 134). Attempting to expand toward a structure of care that assists in belonging, the notion that belonging is also a privilege correlates with Medicaid eligibility. Bureaucratic logic that values safety and control over connection turns care into custody battles between medical systems and agents seeking assistance, something around which Gawande is quietly issuing a profound call for reform that aligns autonomy and agency with equity.
Unequal Dying: Structural Inequities and Privileges in Proximity to Death
While Being Mortal (2016) can suffer from a generalized tone, structural inequities reveal that not all Americans experience dignity in dying. Gawande's absence of explicit racial analysis reflects medicine's broader lack of acknowledgement for the structural inequalities of health care that often mask privilege. Lou Sanders' access to assisted living assumes the presence of wealth and family support many marginalized elders lack as "we've created institutions that shelter the frail but separate them from the world they helped build" (p. 142). When reading through a health equity lens, the uninsured and underinsured are far more likely to delay or forgo care due to cost (Tolbert et al., 2024), and structural racism compounds these disparities leading to "conditions that unfairly disadvantage certain groups, resulting in poorer outcomes" (Ndugga et al., 2024, para. 6).
From a social work perspective, such inequities reveal why "professionals must bridge communities and systems to align values, resources, and action" (Browne et al., 2017, p. 11). Gawande's narratives of choice, independence, and meaning acquire new moral weight in these contexts, as these rights are not available to everyone, but disproportionately disseminated along racial and class lines. Silence becomes Gawande's message for the invisibility of inequity that is adjacent to the invisibility of those most affected by it. Reflectively, Gawande's narrative functions as a limitation and an invitation. Asking the reader to imagine who is missing from the pages and why, integrating a racial and socioeconomic lens deepens Gawande's critique and transforms it from an individual ethics of dying well to a systemic ethics of dying justly. Health equity extends Gawande's moral vision for policy that embeds empathy, cultural humility, and structural reform into scaffolding for care systems.
Through his father's illness, Gawande discovers that medicine's ultimate purpose is not to resist death, but to sustain an agent's meaning for life through its approach. When seeing a doctor about critical health issues, Gawande's father "decided what risks were worth taking, and that made all the difference" (Being Mortal, p. 221). The narrative shifts back professional detachment to empathy, mirroring the transformation he advocates for through the medical profession. His fathers insistence on exercising agency and choosing when to opt in or out of procedures becomes a microcosmic example for medicine that centers what patients' cares and concerns over the systems agenda for a facade of curative processes.
Reconstructing Medical Morals and the Purpose of Medicine
Policies can learn from the personal ethic fluidly provided in Gawande's recount with medical systems of care and dying, as "universal coverage represents a moral commitment to shared risk and collective dignity (Bodenheimer & Grumbach, 2024, p. 330.) While Walter et al. (2016) note that "health equity cannot be achieved without structural policy reform that redistributes opportunity" (p.17), Browne et al. (2017) expand on this logic to emphasize that "integrated care connects physical, behavioral, and social support to address the full range of patient needs (p. 9). Gawande's father's care team practices this integration intuitively when they ask, "What are your fears? What are your goals if time becomes short?" (p. 230). While simple, these questions encapsulate person centered care and how the ideal policies are relational and human centered.
When discussing his fathers medical situation, Gawande's tone generates a bridge between analysis and reflection. After being admitted for surgery and learning from the doctor that there was a complication with his fathers surgery, Gawande exercises the opportunity to turn theory into practice at a very challenging moment in his family's life. Interpreting his father's agency as a revelation, Gawande synthesizes that medicine's task is not to defeat death, but to help people live fully until they die. His father's story models the moral reconstruction required of the system itself, one that privileges meaning, relationship, and equity over metrics and profit.
Conclusion: The Meaning in Mortality Can Be Shared Humanity
Gawande closes with a redefinition of medicine's mission when he says, "we've been wrong about what our job is in medicine. It's not just to ensure health and survival, but to enable wellbeing" (Being Mortal, p. 259). This recognition reframes care as an ethical partnership, rather than a technical service provided to someone and received by another in need. It aligns with equity research showing that "eliminating racial and ethnic disparities requires addressing underlying social and structural inequalities" (Ndugga et al., 2024, para. 19), and that wellbeing is best enabled by professionals with potential energy to cultivate cross-disciplinary fluency and compassion" (p. 15).
Transcending a traditional biography, the peaceful death of Gawande's father becomes symbolic of shared humanity. As an image of intergenerational collectivity rather than individual triumph, professional care's "ultimate goal is not a good death, but a good life to the very end" (p. 260). To face mortality consciously affirms belonging – to family, to community, and to the lineage of those who lived and died before us. Thus, aging and death become connective rather than isolating. In the end, policy reform is not merely administrative, but moral. It must reorient the system toward empathy and justice by integrating reformed values into law, training, and institutional systems to inch closer to a health care system and society that remembers why we care in the first place.
Bibliography:
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