What Follows Is the Transcript of An

“In the presence of our families, colleagues, and communities, we take this oath in recognition of the honor and privilege of becoming a physician. We arrive at the threshold of our chosen profession, pledging to preserve our humility, integrity, and all the values which brought us to the practice of medicine. We will engage in honest self-reflection, striving for excellence but acknowledging our limitations, and caring for ourselves as we care for others. We will seek to heal the whole person, rather than merely treat disease, committing to a partnership with our patients that empowers them and demonstrates empathy and respect. We will cure sometimes, treat often, and comfort always.”

Dr. Gawande: That’s great.

Ms. Tippett: Isn’t that good?

Dr. Gawande: That last part, in particular.

Ms. Tippett: Isn’t that amazing? And I have to say, it was the day of — oh, there was all this drama going on in Congress about the health care bill and insurance. And it was so wonderful to be with them and see them and read this pledge they’ve taken that they wrote that’s so very different from what I think a doctor of my generation would have written and to see — well, this is the future of medicine. This is it, this care.

Dr. Gawande: I think the place we are coming to is, when you take that pledge seriously, it becomes a really interesting dialogue, because people often are not sure about their goals, or they have contradictory goals. I, for example, will badger my patients about quitting smoking and wearing a seatbelt, but their actions are telling me they want to not wear the seatbelt or want to keep smoking. They’re telling me what their priorities are. And so if I’m an effective counselor, I might argue with you about your goals. And that role, as a clinician of all kinds, not just doctors, but it’s nurses, psychologists, teachers, ministers — that is the deeper dialogue.

Ms. Tippett: Yeah, but that’s the kind of arguing we do with people we love. That’s also a form of care.

Dr. Gawande: That is when it is health care. [laughs]

Ms. Tippett: Right — [laughs] well, there you go. Did you know Sherwin Nuland, Shep Nuland? Did you know him personally?

Dr. Gawande: I did. I did. I got to — so Shep Nuland, surgeon at Yale, read his book, How We Die, which won — I think it was the 1980 or ’82 or something, National Book Award winner, and it just blew the top off my head. That was the book that started me thinking hard about dying and what it means. I read it later — I was in medical school in the ’90s, and I had no idea I would get to meet him and know him, then, but when I started writing for The New Yorker and then wrote my first book, Complications, during my surgical residency, he wrote the review in The New York Review of Books and then reached out to me.

And it was this great, very special relationship. We met only once, actually, face-to-face, but we weirdly enough, on Talk of the Nation, we ended up doing a regular thing [laughs] where he was the senior eminence, and I was but the junior pup doctor, and we would talk about a topic of the day, every few months. It was now and again, but it became this dialogue that carried on. And I just was such a huge admirer. And someone who was navigating his own difficult paths — he had written about his deep depression and the conflicts he’d had in his life. And so he had a tough life and things he had to struggle through. And so that was a very meaningful, influential relationship.

Ms. Tippett: I love thinking about that cross-generational conversation between the two of you. I interviewed him years and years and years ago, and the conversation I had with him was about some of the things he started thinking about later. We actually called the show “The Biology of the Spirit.” And he was thinking a lot about our brains and about what spirit is, and — what did he say — that the human spirit is an accomplishment of the human brain? Just with this awe of — because he went on, after he talked about how we die, about how — the miracle of how much works all the time. [laughs] How We Live; he wrote that follow-up.

Dr. Gawande: That was the follow-up book, yeah, which, of course, [laughs] less people are interested in how we live. [laughs]

Ms. Tippett: Yeah, less people were interested. And it was just full of wonder. I’m just thinking of that because I want to ask you about this, and I offered that as a way into this idea of spirit, whatever that is, if it is an accomplishment of our biology. But one of the things that I ended up talking with these medical students about was, I really do think, and I want your response, that 50 years from now, people will look back at the way we used to use this phrase, “mind, body, spirit” and think how primitive that was, because so much of what we’re learning is about the distinction between these things — again, however you want to define “spirit,” we know what we’re talking about — but that what we call emotion and spirit are as physical as they are mental, and that the brain lays physical pathways and takes bodily direction, and that trauma and joy are in our bodies, as much as they’re emotional.

I just wonder if you think about that, because it seems to me that even though I don’t know that I see you using that language very often, that this runs through your reflection: the wholeness of us, the mysterious fullness of us.

Dr. Gawande: Yeah, there’s many ways in which I find the word “spirit” so difficult to understand. I use it all the time; for example, one of the ways I use it is just simply to ask people, after we’re done talking about “How are you doing?” And people then tell me about their aches and their pains and what their temperature has been doing, and so on. And then I’ll say, “How are your spirits?” Or “How is your spirit?”

And that’s one level, but then there’s this interconnected level, the sense of spirit at a kind of — starts to become “spiritual,” the ways in which there’s some sense of something transcendent, at least across all of people, if not beyond that. And I grapple with it a little bit towards the end of the book…

Ms. Tippett: Yes, you do.

Dr. Gawande: When I take my dad’s ashes to the Ganges, because again, I’m the apostate Hindu, the ultra scientist, and “What’s the data?” But for him and my mother, it was that you bring your ashes to the Ganges in order to allow yourself to be released from the cycle of birth and rebirth and enter the state of nirvana, where it’s kind of like a heaven, is the way I think about it.

But there was, for me, a sense of the spiritual connected to going there on the Ganges in one of those little boats and undergoing a ritual that has been going on for hundreds of years, more than a millennia, at least, probably a couple thousand years, and people coming and bringing the ashes of family members and chanting these same chants and being connected to this whole chain of generations, where there are things that my father completed that came from the generations before him, there are things that he was passing onto me and my sister that we are responsible for carrying on, and that there is something much larger than us that matters.

I end up calling it “loyalty” in the book. I wrote about Royce, a philosopher who was at Harvard in the late 19th century and into the — and wrote a book at the very beginning of the 20th century, called The Philosophy of Loyalty. And what it meant was that we all have a — he was arguing, we all have a deep need to live for something larger than ourselves, and he went through a series of thought experiments to demonstrate it. And one of them that really stuck with me was asking, “If I told you, half an hour after you die the world would blow up with everybody you know in it, would that matter to you?” And for the vast majority of people, it would matter. And the reason why it matters to people is that it feels like it takes away — that the meaning of your life would be gone; that we’re not all, at core, totally self-interested creatures, that we have things we live for that are larger.

Now, that’s not the only piece of evidence. There’s lots of others that he goes through and then others you can think about, along the way. But that, for me, is part of that idea. It’s the closest thing I come to, to being able to recognize that idea of spirituality and connection and meaning that rises above your own life.

[music: “You’re So Very Far Away” by Clem Leek]

Ms. Tippett: I’m Krista Tippett, and this is On Being. Today, with physician and writer Atul Gawande, the author of Being Mortal.

[music: “You’re So Very Far Away” by Clem Leek]

Ms. Tippett: Here’s some very beautiful language in your book. You wrote — I don’t know if this was in the book. Anyway, you said this or wrote this somewhere, [laughs] that “We are a link in a chain in making a contribution that goes well beyond our own life. And that’s part of what makes dying tolerable. That’s what makes being a mortal creature tolerable.”

Dr. Gawande: Yes, the — a weird thought came to mind. [laughs] So I just finished, recently, this three-book series by a Chinese science fiction writer named Liu Cixin. It begins with a book called The Three-Body Problem.

Ms. Tippett: I tried to read those books, and I couldn’t get into them. Did you love them?

Dr. Gawande: Did you really? You know what I’m talking about. Oh, my God — I totally fell into them. [laughs]

Ms. Tippett: I love the title, The Three-Body Problem. I was really drawn to that. [laughs]

Dr. Gawande: Right. The characters are unbelievably cardboard. They have no depth whatsoever. But part of what was — it has this extraordinary scale of time, partly because, yes, the three-body problem is this other planetary system, which has three suns, and the planet revolves around — is captured by the gravity of each of those suns, and so every day, you’re never sure when the sun is gonna come up, what the temperature is gonna be, whether it’s gonna be 300 degrees or minus-300 degrees and how long the day will last, all those things, and will it be a habitable climate or not. And the creatures will dehydrate when it becomes terrible, and then, when water appears again, they rehydrate and then continue civilization. And it pushes the questions, because what he’s imagining is the extinction of human beings, but the continuance of other forms of life, and how wide our imaginations go towards bringing those in and making them feel that they are part of our chain of being. And can we have a chain of being that goes on 15 billion years, that go beyond — Earth is extinguished, and humanity is extinguished, but we still feel there is spirit, in some way?

I don’t know, it made me think of that, and I kind of believe in that. I found it really beautiful that it managed to expand my mind, to make me feel that I’m part of life and that even after human beings are gone, that there is meaning in our little contributions.

Ms. Tippett: Sometimes, you are called — I don’t know if you refer to yourself this way — a “public health journalist,” in addition to being a physician, obviously. I’m starting to think of you — I like this language of “citizen scientist.” I kind of feel like “citizen physician” would be a good thing to call you. Do you like that?

Dr. Gawande: The word that I really liked, you used, was “citizen.” And what I’m partly trying to do is open the portal both ways, that the world of what happens to you, in the course of our average, currently 80-plus-year existence, is one where the people that are part of that relationship on the clinical side are also people themselves who are journeying through that pathway. And — I’m fumbling for this a little bit, but the sense that the portal that I hope I open is that I’m speaking not only as a physician to the outside world, but I’m also opening the outside world to us as physicians and nurses and others, to think of ourselves as just citizens and to break down that inside/outside and to make it all kind of seamless. And it’s a sensibility, more than anything I’m trying to make happen.

Ms. Tippett: Yeah, it’s a porousness, though, too, and it’s a conversation that you’re curating, making possible.

Dr. Gawande: Yeah, and the sense of — I like getting down into the microscopic of the real stories of what happens when human beings care for one another and enter into these kinds of relationships, and you see everything that flows through there, money and jealousy and politics and misunderstanding and conversation and et cetera. And then, furthermore, we’re this interplay of knowledge and technology and trying to make — trying to function in a world where none of us have a full handle on it all. And we’re inside a system, and we have to have some agency in that system, and how do we not be powerless? And how do we shape that thing we’re part of? And so I’m interested in not only the sense of inside and outside; I’m also interested in the sense of the microscopic to the telescopic and starting to arrive at a way that we feel connected, and we know the meaning and the feelings, as well as the data, about what’s happening.

Ms. Tippett: Yes, and as you write about, this is a sphere of some of the most cathartic, existential, and potentially meaningful moments of being human, of our whole lives, take place in the context of health care. That’s huge.

Dr. Gawande: That’s why I feel like I have the unfair advantage of my fellow writers [laughs] at The New Yorker. I live inside this material that is extraordinary every day, and I get to think about all these really confusing, interesting, sometimes distressing things, like, do we have a right to this stuff [laughs] called health care? Why are the costs so high? Or, why do we itch? [laughs] And what the heck is going on there?

Ms. Tippett: And how does investigating itching lead us to the question of consciousness itself? [laughs] It’s what you do.

Dr. Gawande: Right. [laughs] Yeah, right.

Ms. Tippett: I want to say too, the question of what it means to be human, a big, ancient question, it actually runs — it’s not just being mortal, but being human that runs all the way through your work. Here’s some beautiful language from the epilogue of Being Mortal: “Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone.” The fact that we are limited is something that you come back to. I think you say, “To be human is to be limited.”

That has informed the way you have grappled with the definition and practice of medicine. I’m curious about how this fact, this reality that to be human is to be limited, which is also so hard for us to take in, how that spills over into other aspects of the way you move through the world, how you move through the world as a human being.

Dr. Gawande: The first way that I think about it is, number one — well, two things jump to mind. Number one, in my public health work, it’s about the idea that we’re all so incredibly limited, and yet there are ways that we string together and are almost unlimited, as groups of people. And it’s the kind of magic of when that happens, when you all start pulling together, and then you eradicate polio from the world, which we’re almost on the verge of doing. It’s just fricking amazing when you see that happen and how these limited, flawed — and to me, that was the amazement of surgery. We’re these smart, great people, but we’re all limited, and yet, can pull off these incredible, risky, complicated operations and forms of care that give people back their lives and give them many years of better life. So that’s one, that’s the first one that I went to.

And then, the second direction — it’s quite the opposite, which is that as I walk through the world, I’m constantly combating the fact that I feel the sense of coping with that limitation and being constantly aware of those limitations. One of my favorite New Yorker cartoons, which in many ways encapsulates me, is a gravestone that reads, “He kept his options open.” [laughs] And my way of navigating through limitation is trying, as much as possible, to keep my options open, try to navigate with as minimal risk as possible, which means you don’t accomplish anything. So I’m always fighting that sense of needing to take the leap, despite the reality of imperfection, of mistakes, and push forward, make your bets. I have to make my bet without 100 percent of the information and certainty.

And that’s, in many ways, to come full circle, the attraction to me about going into a field like surgery was very similar to the ones that drew me into the world of politics, which is that the best people I saw in surgery were like the best leaders, politicians I saw, who recognized that we’re limited, that you don’t have all the knowledge, that your abilities are imperfect, the information is incomplete, and yet, there are times when acting is the better choice than not to act. And then you live with the consequences and learn from them, take ownership and responsibility, and move on. And that sense of enacting that in our lives feels really important for me to aspire to.

[music: “Awakening” by Random Forest]

Ms. Tippett: Atul Gawande practices general and endocrine surgery at Brigham and Women’s Hospital in Boston. He’s also Professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and he’s Samuel O. Thier Professor of Surgery at Harvard Medical School. He’s been a staff writer for The New Yorker magazine since 1998 and is the author of four books, including The Checklist Manifesto and Being Mortal: Medicine and What Matters in the End.

[music: “My Only Swerving” by El Ten Eleven]

Staff: On Being is: Trent Gilliss, Chris Heagle, Lily Percy, Mariah Helgeson, Maia Tarrell, Marie Sambilay, Bethanie Mann, Selena Carlson, Malka Fenyvesi, Erinn Farrell, Jill Gnos, and Gisell Calderón.

Ms. Tippett: Our lovely theme music is provided and composed by Zoë Keating. And the last voice you hear, singing our final credits in each show, is hip-hop artist Lizzo.

On Being was created at American Public Media. Our funding partners include:

The John Templeton Foundation, supporting academic research and civil dialogue on the deepest and most perplexing questions facing humankind: Who are we? Why are we here? And where are we going? To learn more, visit templeton.org.

The Fetzer Institute, helping to build the spiritual foundation for a loving world. Find them at fetzer.org.

Kalliopeia Foundation, working to create a future where universal spiritual values form the foundation of how we care for our common home.

The Henry Luce Foundation, in support of Public Theology Reimagined.

The Osprey Foundation, a catalyst for empowered, healthy, and fulfilled lives.

And the Lilly Endowment, an Indianapolis-based, private family foundation dedicated to its founders’ interests in religion, community development, and education.