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Title : A Book Worth Reading: An Emergency Physician's Ponders Medicine and Meanings
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A Book Worth Reading: An Emergency Physician's Ponders Medicine and Meanings

Robert Martensen, A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era (New York: Farrar, Straus & Giroux, 2008).
    In recent years, doubtless because of the anxious disquiet of so many who have witnessed experiences of their friends and families, books examining “end-of-life issues” have become so numerous as almost to constitute a little genre of their own. At first glance, Dr. Martensen’s book appears to fall neatly within this category. The emergency physician and medical historian recounts numerous memorable patient stories, discusses technology overuse at end of life and the ambiguities of "medical futility" when most doctors have seen the occasional almost-miraculous recovery, and says he wants the book to assist those with “difficult choices.” Martensen is perceptive and balanced about the terrors and disruptions of serious chronic illness, and its shifting, confusing territory, and I think the book is of real potential use – as he wishes – to those facing advanced illness.

    But though parts of A Life Worth Living are a worthwhile contribution to this sub-genre, the book as a whole – as its title indicates – is more: a broad reflection on what does make life worth living, and how both personal meanings, efforts, and decisions and societal conditions (including the medical system) can make an enormous difference to lives led in the shadow of illness and disability.

   Martensen does not confine his reflections to one end of life. He discusses "Baby-Doe" regulations and the difficult triangulation that takes place with families at both very young and very old ages. Martensen wonders whether we are wronging minors by allowing parents to make exclusive decisions on treating them, telling a haunting story of a girl who underwent many brutal procedures before her death from cancer, including amputations of her legs, hips and lower pelvis.

   Martensen is deeply disturbed by the commodification of and commercialization of medicine. It troubles him when he is pressed to introduce the topic of organ donation to grieving parents in light of how much his hospital stands to profit by the organ transplants.


Discussing the pretty good life of a man he knows with Downs' syndrome in favorable circumstances, Martensen understands that a limited life is not a non-life – and he is quietly outraged by the reality of how many somewhat impaired people, who could lead pretty good lives with a bit of support, instead have appallingly miserable existences.

When I decided to become a doctor in the 1970s, I never expected to practice in an America where the dire has become an everyday experience for so many…For the past thirty years, however, life has not gotten better for our most vulnerable. Through Democratic and Republican administrations alike, compassion has been scarce, despite political and commercial expressions to the contrary. Though our health care approaches squander billions on extravagant treatment regimes that end up accomplishing little, as a society we refuse to adopt the small, even tiny, adjustments that could easily reduce the clawing uncertainties that now degrade millions.

In another vivid passage:

A few years have passed. President Bill Clinton has almost finished his speeches about feeling our pain, and George W. has not yet gone national with his compassionate conservatism. Meanwhile, hundreds of formerly ‘nonprofit’ and public hospitals convert to ‘for-profit’ status or sell themselves to Wall Street corporations. Rules for Medicaid eligibility tighten significantly, and millions of workers move from full-time jobs with medical benefits to contract work arrangements that leave them on their own.

    Martensen talks about the jarring contrast of seeing a diabetic die in his emergency department as a result of having to scrimp on his expensive insulin, right before attending a luncheon where a university chancellor triumphantly announced the legislatively-permitted transformation of his hospital to an “entrepreneurial private-public partnership” that would expand to add new, lucrative, heart and stroke centers, while the hospital would be permitted to cease functioning as a public hospital and state funding for indigent care at the hospital would be phased out.

   Martensen, who at the time was serving as the hospital’s “chief ethics officer,” tartly reflects that ethics committees are never consulted about these critical big issues. If administrators actually cared about ethical issues and not just about window-dressing, he reflects, they would “include [an ethicist] to opine on large-scale change, just as they do a score of lawyers.”
 
   Martensen covers such wide territory that the book (like this review) can be a bit disjointed, even though everything truly relates to his title and central theme. But that's a minor flaw. This short, engaging, readable book packs an enormous punch, and I recommend it.

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