Atul Gawande offers light at the end of life's long tunnel

It is something of an understatement to say that Gawande is much in demand across the globe after writing what is surely the year's most reviewed book, which he only completed on a trip to Italy to mark his 20th wedding anniversary with his wife Kathleen.Being Mortal: Illness, Medicine and What Matters in the End is a thoughtful, humane, unsparing examination of the ageing process, our treatment of the elderly, and our attitude towards death and end-of-life care.

Brooklyn-born, Ohio-raised Gawande asks how do we balance quantity with quality of life in our over-medicalised world? And how do you make a good death in a world in which doctors have medicalised old age to such an extent that they no longer accept that life isn't curable?

So, here he is on a sunny November afternoon ensconced in an impressively lofty room in the Royal Society of Edinburgh preparing to deliver the third of his four Reith Lectures. The others have been recorded in Boston, London and Delhi.

The son of two doctors, Gawande -- a Rhodes scholar at Oxford where he read PPE, also worked for Bill Clinton in 1992 as his head of health and social policy -- still can't quite believe that he's a Reith lecturer. "It's amazing!" he exclaims. "The BBC throws around these numbers: 51m people will be in the listenership. I find that hard to fathom. But the great thing for me is that they wanted someone to talk about medicine and public health. They had so many people to choose from -- I got lucky to be tapped."

His lectures are based on his book, which was longlisted for the Samuel Johnson Prize 2014. It's beautifully written, although he insists that he finds writing difficult. Nonetheless, he's the author of three previous international bestsellers, has been a staff writer for The New Yorker since 1998, is a Harvard professor and a cancer surgeon at Brigham and Women's Hospital in Boston. He's won innumerable awards, including the Lewis Thomas Prize for Writing about Science and a lucrative MacArthur Fellowship.

Additionally, in his work for public health, he's director of Ariadne Labs, a centre that devises and tests medical innovations around the world. He's also chairman of Lifebox, a non-profit organisation making surgery safer globally -- NHS Scotland has adopted their procedures. Meanwhile, for Being Mortal he conducted more than 200 interviews with family, friends, patients and scores of specialists, making up a careful series of case studies, stories within stories.

Just listing his achievements and his astonishing workload makes me tired, I tell him. "I know! Although the most important thing for me is the writing because I try to take on unique things and tackle problems," he says, adding that he's reduced the number of operations he performs, from 350 a year to 125, despite the fact that he still loves being in the operating theatre.

Has being a physician made him a better writer? "No question! Every day I see really interesting dramatic things, such rich material. I also think it's made me a better doctor, because it means I get out of myself and it's made me a better listener, though I still talk 90% of the time! But writing means I sacrifice family time. As a dad I'm a B trying hard not to be a C."

And what about his own intimations of mortality?

"Of course writing Being Mortal has made me think about the future, although I'm healthy and have no worries," he replies. "In the book, though, I write about our lack of imagination about how a good life can still be possible under the constraints of frailty and old age." He writes about a nursing home that opened its doors to four cats, two dogs, 100 birds and children, and found that incidents of depression -- and even death rates in residents -- fell.

"That was a surprise to me," he explains. "As a doctor, I had no idea what a good life at the end of life could be. I was taught almost nothing about ageing and frailty during my medical training. You don't go to medical school to cope with dying. You're not there to deal with ageing and its problems except insofar as you can fix them. At medical school we never talked about the mortal process. We were gonna save people! You become a surgeon to become a hero.

"In the book, I describe meeting Lou Sanders -- 94-years-old, he has dementia. He still, though, manages to read two books a day and to connect to things that are really important to him, and he's happy and he's calm in the world. That was also a surprise. Suddenly, I wasn't afraid about coming to that place in my life.

"What is fascinating is that we now get to live so much of our lives -- around 70 years -- without ever fearing our mortality. In the 19th century and long before that mortality was all around. But we've come to ignore it, to hide it away -- 80% of deaths occur in institutions, most of all in hospitals. We are removed from death. When you enter this profession you suddenly see dead bodies for the first time, which gave me nightmares. I started to think about what it means to be good at helping people with problems that aren't getting better. So I spoke to a lot of palliative care doctors about what outcomes are unacceptable to you should your time become short."

Inevitably, he's discussed this with his wife, a former publisher and editor. "My view is if I am reduced to just a brain in a jar hooked up to some kinds of sensory devices that allow me to see and hear in the world and communicate and have a connection with people, that's good enough for me. I could live Stephen Hawking's life. If I were a body, though, and the brain were gone and I was not who I was and I couldn't interact, then let me go.

"My wife says that's stupid. She has a completely different view. In her view, even if she is not who she was, if she looks happy, keep her alive."

He met Kathleen Hobson at Stanford University, California, where he was an undergraduate. He was "interested" in her so he took the literature class she was taking. "I did not do well at it," he confesses. "I did rather better with her though." (They have one son, Walker (19) and two daughters, Hattie (18) and Hunter (15).) At college, he was in a rock band. Gawande wrote their gloomy songs. "They were influenced by The Smiths -- I wanted to be Morrissey. I wrote one love song for Kathleen about how Marxism was dying but not my love for her. Terrible!"

And, yes, he would have loved to have been a rock star rather than a surgeon. No rock musician, however, would receive letters such as those Gawande has been sent since his book came out. "I got a letter from a woman in a nursing home just yesterday," he says. "She wrote that 'Everybody has treated me as if I am crazy for finding my condition insufferable because I have no freedom in this home. I can't do anything that feels purposeful to me.' His book, she wrote, had made her feel that she was not alone. "That letter moved me tremendously. But I also hope that my book will be read by people who can do something about such intolerable situations."

Being Mortal ends with the agonising story of his own father's death. He was a urologist -- Gawande's mother worked in paediatrics -- who came to America from a rural village in India in 1963. "When my father, himself a surgeon, was diagnosed with a brain tumour just as I began researching the book, we found ourselves dealing with the same sets of issues that I had never had good answers to."

Gradually his father lost control of his body, while understanding exactly what was happening to him. Gawande writes of his family's ordeal and of his own particular helplessness as a doctor. His father died a relatively peaceful death in the arms of his family, because his son had asked him how much he was willing to go through just to have a chance of living longer. He decided enough was enough, but was happy so long as he could email. "He was Skypeing his grandchildren days before he died."

Being Mortal ends with him spreading his father's ashes into the Ganges. He writes: "We were lucky to get to hear him tell us his wishes and say his goodbyes. In having a chance to do so, he let us know he was at peace. That let us be at peace, too."

Being Mortal: Illness, Medicine and What Matters in the End by Atul Gawande (Profile Books and Wellcome Collection, £15.99). Atul Gawande's Reith Lectures examining The Future of Medicine begin on Radio Four on Tuesday, November 25.