A Life Worth Living
Robert Martensen
Farrar, Straus and Giroux
240 pages

My best friend's grandmother is in the hospital again. Over the past few years, she has been plagued by a myriad of afflictions—chronic internal bleeding, a series of small strokes, heart problems, low blood pressure, and diabetes. Now in her early seventies, she is not terribly old by modern standards. When I had dinner and tossed horseshoes at her house last fall, she was physically active and mentally vibrant, even though the past few years had taken their toll on her.

About a week ago, her body stopped working. Seizures, a septic infection, and low-blood pressure were to blame. She fainted and was rushed to the hospital. In the ICU, she had to be intubated and heavily sedated. Complicating her treatment is the fact that because she spends six months out of every year in Florida, half of her medical treatments have taken place there and half have been in the Midwest. But she's not at her usual hospital. Instead, she's at another hospital nearby with a doctor who isn't familiar with her medical history. She's too sick to be transported the forty minutes to her regular hospital.

My friend's family must face the painful process of how far to push treatments. His grandmother would never have signed a DNR—a Do Not Resuscitate order—and she wants to live as long as she can. But her medical problems are complicated, so complicated it is difficult to disentangle the various factors that are causing her body to stop working. As her attending doctor pointed out, the hospital has a lot of equipment and can run a lot of treatments, but those treatments will not necessarily help. Her body is worn out. Even if they prolong her life—and how long they could indeed hold up is impossible to say—an aggressive regime of treatment will not be easy on the patient or her family. The treatments will also prove costly. Is it futile to treat her when more complications will invariably arise? For my friend's family, the issues are weighty and difficult to sort out, especially when emotionally preparing for the potential loss of a dear family member.

Recently published in paperback, Robert Martensen's book, A Life Worth Living, is meant to help sort out the weighty decisions that accompany coping with serious illness and death in a complex medical establishment. His argument is that the way Americans cope with serious illness and the way they die do not lend themselves to quality of life in illness or dignity in death. He points out that, "One has to struggle to even know how to struggle." Knowing how to struggle is difficult because of the broader culture, the doctors, the medical-industrial system, and also because of the strong notions embedded within us. Underlying the issues of treatment and death are ideological questions of ethics, biology, and policy. If it sounds complex, well, it is.

In the preface, Martensen says that he wrote the book "as a navigational aid for those crossing these treacherous waters themselves or facing questions of how to manage the serious illness of a loved one." Yet, Martensen's book is not a how-to book, a Dying for Dummies. He spent his undergraduate years studying design and writing short stories at Harvard. He went on from there to study medicine at Dartmouth and to spend a number of years practicing emergency medicine before he pursued a PhD in medical history. He currently works at the National Institutes of Health as the director of its Office of Health and Museum. His book exhibits the diversity of his training and interests; he describes it as "part memoir, part philosophy, and part guide." By and large, though, the book revolves not around life, as the title may suggest, but around death. As such, much of the book focuses on the place where most people die—the intensive care unit.

Relatively rare even in the 1960s, ICUs began to proliferate in the 1970s, when American medicine began to embrace new technologies and an aggressive treatment model. Medicine has seen a tremendous increase in its technological capabilities over the last few decades, particularly in diagnostic scanning and imaging. Surgeries which were once inconceivable are now performed on a routine basis. Doctors know more about illness and treatment than ever before. These are not the primary reasons that America's model of treatment has switched. Rather, Martensen says it is a matter of control—the doctor's desire to control illness, and even death, at all costs and the American individual's desire for personal autonomy, particularly in regards to one's health.

As Martensen paints the picture, the wealthy, post-WWII American society began to view life in terms of the ability to have; that is, the accumulation of possessions became the goal for a society whose members had unparalleled wealth. The most valuable possession of all became health. Americans ceased to see themselves as patients and instead saw themselves as "health care consumers." Doctors became "health care providers." Health became the commodity that Americans were most willing to spend extravagantly to attain.

The change in medical care was not just due to patients' mentality. In ages past, when a person was diagnosed with a terminal illness, the doctor's primarily responsibility was to provide an estimate of a timeline for the disease and tell patients what to expect so that they could make preparations for proper medical care and for dying. Martensen writes, "The idea that anyone could control desperate medical conditions has only arisen since World War II." Since the 60s and 70s, the "Achievement of control has taken on the status of a moral and aesthetic imperative." To not be able to control a patient's condition is to fail.

Health, however, resists commodification. Illness resists control. Martensen wants to say, "Maybe we need to rethink our approach to terminal illness and healthcare. Maybe we need to stop treating terminal illness like we can control it." When we aggressively treat terminal illness like we can control it, we in fact relinquish control of our final years to treatment and often die less humanely and more painfully than necessary.

Martensen's primary vehicle for making this point is stories from patients he has known or treated. The book is rife with devastating narratives, and as such, it relies a bit too much on inductive reasoning, a common problem for books dealing with complex problems but written for a general audience. But the stories are powerful, and they achieve their purpose.