Failure and the aging of society

But fear of making mistakes can itself become a huge mistake, one that prevents you from living, for life is risky and anything less is already a loss.

Rebecca Solnit, A Field Guide to Getting Lost

American surgeon, academic, and writer Atul Gawande was the recent BBC Reith Lecturer.^1,2 In the course of 4 lectures, given in settings as diverse as the John F. Kennedy Presidential Library and Museum in Boston, Mass, and the India International Centre in New Delhi, Dr Gawande considered the future of medicine. Beginning with a meditation on the kinds of failures that afflict medicine and ending with a consideration of the challenges that aging and death present to medicine and society as a whole, he weaved together the themes of much of his writing in works like Complications,³ The Checklist Manifesto,⁴ and, more recently, Being Mortal.⁵

Gawande credits an essay he read early in his career by philosophers Samuel Gorovitz and Alasdair MacIntyre with influencing his thinking ever since. Gorovitz and MacIntyre described 3 kinds of errors that make humans so fallible.⁶ The first is caused by ignorance. The second is caused by ineptitude—the failure of individuals or groups to apply knowledge that already exists. The third kind of error is caused by necessary fallibility, and they used the example of how a hurricane will behave when it makes landfall to explain the concept—and suggest we are asking of science more than it can do when we ask it to predict the outcome.

Worldwide, the number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050.⁷ In high-, low-, and middle-income countries, the global future of medicine will be mostly about the aged and the enormous challenges they present—medical challenges that include complex, chronic illness and frailty; the social challenges of dispersed, nuclear family structures; and the fact that 80% of the elderly die in medical institutions.⁸

So, what are the fallibilities that blight our current care of the elderly and that will make getting old in the future even more bleak?

The first is ignorance—our lack of knowledge. Dr Gawande argues in his Reith Lectures that in the 20th century medicine largely solved the ignorance problem and that the challenge of the 21st century is medical complexity and our ineptitude in dealing with it, but when it comes to care of the elderly, knowledge remains a considerable problem. For example, most drugs are evaluated for safety and efficacy in younger patients, but they are widely prescribed for the old. Further, polypharmacy is commonplace, and serious adverse drug reactions are prevalent. As Lee and colleagues address in their clinical review article (page 227), frailty is thought to be an accurate, but potentially modifiable, predictor of mortality in the old. Yet it remains an elusive concept that is not well applied in primary care.⁹

The second is ineptitude—the failure to apply the things we know. In persons with complex, chronic illnesses taking multiple medications, in whom both the medications and the diseases themselves might interact, a checklist approach to care, as described by Marshall and colleagues (page e129), can improve outcomes and satisfaction.¹⁰

Pioneering American geriatrician Robert Butler called aging “the neglected stepchild of the human lifecycle” and in the 1960s coined the term ageism.¹¹ Perhaps the greatest fallibility of medicine when it comes to care of the elderly is one not described by Gorovitz and MacIntyre, but the one described by Dr Butler, which afflicts physicians and society alike. In this issue, Lam and colleagues describe (page e135) an educational program that they developed for busy practising family physicians aimed not only at imparting knowledge but also at changing attitudes.¹²

In his latest book, Being Mortal, Dr Gawande parses one of the fundamental generational conflicts affecting the lives of old people.⁵ The desire of adult children to protect aging parents from harm by institutionalizing them often trumps what matters most to the elderly themselves—having something to live for and the freedom to pursue that desire. Perhaps that is where necessary fallibility enters the picture. By allowing the elderly to live their finals days on their own terms we cannot predict how they might die, but perhaps we can save them from the unnecessary medical interventions that attend the deaths of so many.