Skip to main content

Doctor Considers The Pitfalls Of Extending Life And Prolonging Death

Humans have had to face death and mortality since since the beginning of time, but our experience of the dying process has changed dramatically in recent history.


Other segments from the episode on January 30, 2017

Fresh Air with Terry Gross, January 30, 2017: Interview with Haider Warraich; Review of Kevin Wilson's novel "Perfect Little World"


TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross. New medications and medical technologies have extended life. But for many people, these innovations have also prolonged the process of dying. Patients, loved ones and doctors are faced with decisions about how much to intervene and when to stop.

My guest, Dr. Haider Warraich, writes from a doctor's perspective about how medicine has changed the end of life. His new book is called "Modern Death." He's also written medical and op-ed pieces for The New York Times, The Wall Street Journal and The Atlantic.

He's a fellow in cardiology at Duke University Medical Center, did his residency in internal medicine at Harvard Medical School's Beth Israel Deaconess Medical Center. He graduated from medical school in Pakistan where he was born and grew up and where his parents continue to live. A little later, we'll talk about the visa issues that have made it difficult for them to see each other.

Haider Warraich, welcome to FRESH AIR. Why did you want to write a book about death?

HAIDER WARRAICH: Terry, thank you so much for having me on the show. It's such a great honor. And thank you for the introduction. I wanted to write a book about death for two main reasons. The first reason was that - you know, as a physician. You know, even though I'd been through med school, I'd learn so much about life, when it came to the end of life there were so many things that I didn't understand. I didn't understand how things had evolved to be the way they were. And I really wanted to find answers to some very, very basic questions like what are the implications of the sort of life extension that we've achieved? What is the role of religion, not only a patient's religion, but a physician's religion, when it comes to dealing with the end of life? You know, how is social media affecting how people experience the end of life?

I also wanted to write a book in which patients and their family members could learn about what the landscape of the end of life looks like with the advent of modern technology. So many times, I've found myself in the room where there are people who were so much more experienced in life than I was, yet knew so little about death and dying. And so I wanted to write a book so that people could go into those really, really difficult places and feel like they have - they're armed with information, that they - that this isn't a completely foreign territory for them and that in some way could help them navigate and deal with the sort of difficult situations that lay ahead for them.

GROSS: So you're still pretty young. Can I ask how old you are?

WARRAICH: Twenty-nine.

GROSS: OK, so this is something that a lot of young professionals go through. But I think might be particularly profound for a doctor who's dealing with life and death. So when family members or loved ones see you and the person they love is dying or they think they might be dying, or when you see a patient and the patient's life is in your hands, do they ever look at you and go, you're so young. You know, can I trust you? And who, like, who are you to tell me about life and death? Like, you're only in your 20s. Do you get that?

WARRAICH: So the one thing that protects me from that is probably my receding hairline...

GROSS: (Laughter).

WARRAICH: ...But I do get that and...

GROSS: Not the answer I was expecting.


WARRAICH: When I do - when patients do look at me and feel that I am young, I feel that in many ways it works out for both of us. You know, many physicians who are - when patients come to the hospital they're very scared. And doctors are very, very scary. I mean, we wear these white coats. We talk in jargon. We seem to know exactly what we're doing. There's an actual medical phenomenon called white coat hypertension in which patients have increase in blood pressure when they're in the hospital or surrounded by physicians.

When I do - when patients do look at me and feel that I am young, I feel that in many ways it works out for both of us. You know, many physicians who are - when patients come to the hospital they're very scared. And doctors are very, very scary. I mean, we wear these white coats. We talk in jargon. We seem to know exactly what we're doing. There's an actual medical phenomenon called white coat hypertension in which patients have increase in blood pressure when they're in the hospital or surrounded by physicians.

So when they see someone like me, who is younger, in some ways they can say things to me that they may not be able to say to other physicians. One thing I do in my practice is I never wear a white coat. And part of that is because I want the patient not to feel any type of otherness from me. So even though, at times, I think that can be a bit disconcerting to patients, it doesn't happen too often. In fact, I can't even think about the last time it happened to me directly.

GROSS: Patients often get CPR toward the end of life - cardiopulmonary resuscitation. We see this performed on TV a lot and in movies. What's it like in real life? My impression from your book - because I haven't ever seen it actually performed - my impression from your book is that it's a much more severe kind of shocking - it's...

WARRAICH: It's very visceral.

GROSS: Yeah, yeah - then it appears from most TV shows. So what is the procedure and what do you witness when you give a patient CPR?

WARRAICH: So, Terry, it's interesting that you ask about CPR. I was actually working in the hospital last night. And it was about 3 in the morning. And I was called by one of my other colleagues, who's another cardiology fellow. He asked me, Haider, I need your help. I have a patient that we are doing CPR on. And he wanted some help from me. So I walked over to the intensive care unit. And the patient was in her 60s. Again, I'm changing some of the details to maintain her anonymity. And when patients are in the 60s we considered them very young. And that's just - is one indication of, you know, how much things have changed. And she was - there was an entire team in the room doing chest compressions on this woman. And they had been doing it for an hour and a half at that point - much, much, much longer than most CPR's last.

And the - my colleague who called me is one of the, you know, one of the brightest people I know. He was basically thinking about - is there anything I have missed? Is there anything more I can do for this woman? Is there anything that you can think of that you can help me? And I could see the amount of empathy and care that he had. And I could see that in the entire team. In some ways, despite knowing that at this point more was probably not going to change the outcome. One of the things about CPR, Terry, is that almost everyone in medicine knows how to start CPR, when to start CPR, really what to do in CPR under - even complex situations. But the one thing that almost no one really teaches us and there are no guidelines for is when to stop CPR. And I think in some ways that is one of the biggest challenges that we in medicine face all the time.

Doing things has become very easy - ordering a CT scan, ordering some treatment. All these things can be done very easily just with the click of a button on a computer. But knowing when to stop is so much harder.

And at the same time, while this CPR was ongoing, the patient's family member - her daughter was outside the room. And she was crying. And I felt that she was so alone at that time because even though we could give her all the information we needed that wasn't, perhaps, what she was looking for. Because what we were asking her to think about or to do was one of the hardest things anyone has to ever bear, which was, do you want us to stop CPR?

GROSS: So what's the downside of continuing to do it?

WARRAICH: CPR in some ways is almost the anti-hero of medicine. The cases in which CPR works - it's almost - there's almost nothing like it because what you do is you revive someone whose heart is at standstill, and you bring it back to life. And that can - that is - there's nothing more dramatic in medicine - in life really - which can cause such a turnaround. The problem with CPR, especially when it is done in sicker patients, when it's done over a longer period of time is that even if you get the heart to start beating again, by that time the brain has received so much damage, it has incurred so much damage, it has not seen blood flow to it for X amount of time, that the brain may not be able to recover function.

In fact, there is this one study that showed that patients who have multiple chronic diseases, which is now the majority of elderly Americans, only 2 percent of them are able to go home after six months if they get CPR. And the rest of those patients all have some amount of neurologic dysfunction. So CPR sometimes if CPR works, you can get the heart to come back to life so to speak, but the patient's brain, perhaps the most vital organ, may have already suffered incurable and irreversible damage. And that's hard to predict. And the longer you do CPR, the more the chance that the brain will not recover function.

GROSS: So what was the outcome in this story? Did the daughter who was crying outside of the room where you were performing CPR, did she give you the order to stop performing it?

WARRAICH: Eventually, she asked us that we should not do any more chest compressions. But the fact is after I came out of the room, and I put my hand on her shoulder, I brought her a glass of water. And she was crying, and she was telling me that this was the most difficult decision I've had to make. And I told her that this was not a decision either of us made.

It was a decision that was made outside her control, and even though I felt that, you know, this is something that's going to last, you know, in her memory forever, there is in fact data that shows that family members who witness their loved ones getting CPR actually have less depression and post-traumatic stress disorder if they've witnessed CPR being performed.

GROSS: Why is that?

WARRAICH: I think what happens is that when family members see CPR being performed, the one thing they know is that the medical team went above and beyond whatever expectation they had of CPR in their minds to try and resuscitate their loved one. And I think that feeling of knowing that everything, quote, unquote, "was tried" is something that is reassuring because even today, no one wants to feel like there's something missing.

GROSS: If you're just joining us, my guest is Haider Warraich, and he's the author of the new book "Modern Death: How Medicine Changed The End Of Life." He's now a fellow in cardiology Duke University Medical Center. We're going to take a short break, and then we're going to talk more about what he's faced as a doctor dealing with death. We'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR, and if you're just joining us, my guest is Haider Warraich. He's the author of the new book "Modern Death: How Medicine Changed The End Of Life." He's now a fellow in cardiology at Duke University Medical Center. Before that, he was at Harvard Med School. One of the ways that life is extended now is through feeding tubes in hospitals and nursing homes. That's also a really tough decision for loved ones to make. Sometimes the patient himself or herself can be in on the decision, but sometimes they have dementia or some other problem that's preventing them from really participating in the decision-making.

So you had an op-ed that was headlined "Force Feeding Cruel At Gitmo But Ok For Our Parents." And the implication of that to me reading it was like, wow, if you approve a feeding tube for your parents, it's like force feeding them like at Gitmo or something. It's like a really torturous, horrible thing to do. So, like, how bad is feeding through a tube? How invasive a procedure is that?

WARRAICH: The headline was not my choice, but, specifically, the piece that I wanted to address was the use of tube feedings in patients who have dementia. So tube feedings have a role in certain settings. For example, if you have a stroke and you are unable to swallow, and you need nutrition of some sort, tube feeding is probably the best option for nutrition at that point. It is better than nutrition through an IV. It is better than feeding you solid food that you may aspirate and which could cause pneumonia. And there are some other settings in which tube feedings certainly have a role.

But one of the biggest groups in the United States and other developed countries who get tube feeds are patients who have dementia. And why that is problematic is that study after study has shown that patients with dementia who have feeding tubes actually do not do any better. If anything, they do worse than patients who do not have tube feeding. A patient there is - studies that show that patients who have - who are getting tube feeds are more likely to have pressure ulcers. And some studies have shown that there's even no nutritional benefit.

And the reason some have surmised or have hypothesized is that the lack of nutrition or the lack of eating is, in fact, a symptom of a very terminal disease that we just cannot overcome by pushing pureed tube feeds through a tube that goes either down the nose or through the stomach.

GROSS: You describe a case where a patient - I'm sorry. I'm forgetting exactly what the interventions were. But they were about to get I think a respirator. It was a respirator or a feeding tube. It was some kind of tube. And the patient opened his eyes and said to you, kill me. Would you tell us the story of that patient? And how do you respond when a patient says that to you?

When - what can you do? I mean, is that a directive - is that officially a directive from a patient to stop interventions or is that something that you ignore because you might think, oh, the patient's not in their right mind now, they can't make a really rational decision? ***

WARRAICH: This is one of the one stories, one encounters that I had in residency that I have been unable to shake from my memory. This was a patient who had dementia. In fact, this patient barely spoke any English, even when he didn't have dementia, and in fact hadn't spoken for weeks or even months according to the family. And the patient was very, very sick, and the family had requested that we place a feeding tube to help him eat so to speak. And, reluctantly, but respecting the family's wishes, we proceeded with placing the feeding tube through the nose.

Now, I will say that even though it sounds innocuous, placing a feeding tube through the nose that goes down to the stomach is one of the most uncomfortable procedures that many patients will undergo. In any case, I was the resident supervising the intern, and the intern was one of the best interns that I've ever worked with. She was extremely proficient, very humane, very empathetic, and she was going through the steps of the placing the feeding tube just perfectly, but as she started to swivel the feeding tube which is a long, rubber tube up the patient's nostril, the patient who had been almost still, almost unresponsive before that, came to life in a very strong and powerful way. His eyes were wide open, and he was looking right at us. And he started to scream.

He started to scream to us kill me. And he kept saying that again and again, and I didn't know what to make of it. The patient obviously had dementia. The patient was very, very sick, and yet that story still stays with me. The patient's family was all standing there right next to us. And it was very clear what they wanted, and it was very clear that the patient had no capacity to be able to make medical decisions for himself. How does one resolve that story? How do I erase that memory from the intern who was doing that procedure in the most appropriate way possible? I don't know, and I think if you ask any physician, any nurse, any paramedic, they'll have many such stories to tell you.

GROSS: So what did you do?

WARRAICH: We ended up completing the procedure as we had been instructed by the patient's family. You know, there was - it was clear to us that the patient did not have capacity to make medical decisions. He had - he did have pretty end stage dementia. He could barely swallow. He hadn't spoken in months, and even afterwards, he didn't speak much at all. So we ended up doing exactly what had been requested of us by the family.

GROSS: But you suspect that when he said kill me, that really came from his very essence, that he really meant it, but you had to overrule it?

WARRAICH: I don't know if it came from his essence, but it did affect mine. It did affect mine. It did give me a lot to think about. It was actually the reason why I ended up writing that op-ed was because I still don't know the answer. I just don't.

GROSS: My guest is Dr. Haider Warraich, author of the new book "Modern Death: How Medicine Changed The End Of Life." Warraich grew up in Pakistan where his parents live. After a break, he'll tell us about the visa problems that have prevented him and his parents from traveling see each other. And Maureen Corrigan will review a new book about a utopian community's attempt to find an ideal approach to raising children. I'm Terry Gross, and this is FRESH AIR.


GROSS: This is FRESH AIR. I'm Terry Gross back with Haider Warraich. His new book "Modern Death" is about how modern medicine has changed the end of life and presented new complicated, emotionally difficult decisions for patients, their loved ones and their doctors. Warraich is a fellow of cardiology at Duke University Medical Center. A lot of people now have directives, living wills, do not resuscitate orders. So from your position as the doctor who sees a lot of patients for whom those kinds of should we continue heroic efforts, decisions have to be made - are those living wills and directives helpful? Are there times that they add more ambiguity as opposed to making the situation more clear-cut?

WARRAICH: I think for the vast, vast, vast majority of cases having an advance directive, having a living will, having a designated health care proxy, those are some of the best thing, I think, patients can do for themselves, and also for their family members. If a patient makes a decision themselves - when they're healthy, when they're not in the intensive care unit, when they're not having to face these awful situations - that they do not want any type of, quote, unquote, "heroic measures" such as intubation, breathing with a machine or CPR, it tells me many different things. It tells me one, and most importantly, that the patient and/or their family members have thought about this and talked about it because in some ways, that is the biggest barrier.

One of the biggest problems that we face in, not only modern society, but in societies of olden times as well, is that people have always been very afraid to talk about death. In many cultures, it is considered bad luck to talk about death. And it is thought to be a bad omen. And I think to some extent that extends to this very day. But when I see that a patient has filled out a living will or an advanced directive, at some level, even if they have not fully done so, they have faced their mortality. They have faced a situation - and they might need something that is as drastic as needing a breathing machine or CPR.

GROSS: What should be in our directives?

WARRAICH: That's a great question because I think in a lot of situations people may say whether you want CPR, whether you want dialysis, whether you want tube feeding. But I think increasingly, I think what should be in our directives - whether they are formal directives or whether they are informal, things that we have told our family members or our health care proxies - is what do we want our lives to be like? How do we define a good life? How do we define a good death? And for some people it may mean something else, and it may mean something very different to another person.

GROSS: So you're suggesting that in a directive, instead of having no feeding tubes or no respirator or ventilator, you should just say this is the kind of quality of life I want. If I can't get that, let me go.

WARRAICH: I think that's certainly a component that needs to be present at some level because the medical interventions can come - can be presented in many different contexts. They can represent many different things. But those values are some things that are much more easy for the patient themselves to imagine. And they can inform us in ways that just having, you know, basic facts may not be enough.

For example, you know, I had a patient in the intensive care unit when I was in residency. And she was very, very sick. And when I asked her, do you want CPR or do you want to breathe with a breathing machine? She didn't answer that question. But she gave me another very important piece of information. She said that I wanted - I want to make it to my daughter's wedding. And what that meant to me was that that was the single most important thing for her, more so than even the quality of her life, more so than even the length of her life, more so than whether she got CPR or dialysis or feeding tubes, etc., etc. The fact that she wanted to be there for her daughter's wedding was the single most important thing for her. And once I had that piece of information - once our entire team had that piece of information, we could tailor the medical therapies around it to make her achieve that end.

And in that wonderful story, what ended up happening was that the patient's daughter's fiance actually decided that he wanted to get married in the intensive care unit. And so that became our goal as a team. Our goal was not to make sure that her kidney function reached this level or it wasn't that, you know, her pulmonary embolism was treated in such and such manner. Our goal was to make sure that she was able to achieve what she wanted most. And that was to be there for that wedding.

And I think having that type of information whether in a written form or whether in the form of a conversation that you have with a loved one is perhaps the most important thing because that is the one thing we don't know as physicians.

GROSS: So was the wedding performed in the patient's room?

WARRAICH: As soon as we found out that this was something that was very important to our patient and that the patient's daughter's fiance and the daughter were both willing to have it performed, that became our goal. So we set about to do everything that we could do. We wrote a letter to have the marriage certificate expedited. The cafeteria baked a cake. We made decorations with some of the things that we had in the hospital, such as, you know, our hospital drapes and whatnot. And we had a pastor over. We had a harp player over. And we had, what I would consider, one of the most beautiful weddings I've seen because it was so heartfelt, right there in the intensive care unit.

GROSS: If you just joining us my guest is Haider Warraich. He's a fellow in cardiology at Duke University Medical Center and author of the new book "Modern Death: How Medicine Changed The End Of Life." We're going to take a short break. Then, we'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Dr. Haider Warraich, author of the new book "Modern Death: How Modern Medicine Changed The End Of Life." He first came to America from Pakistan to study internal medicine at Harvard Medical School and do his residency at the Harvard teaching hospital Beth Israel Deaconess Medical Center. He's now a fellow in cardiology at Duke University Medical Center.

His parents continue to live in Pakistan. We recorded this interview Thursday before President Trump issued his executive order restricting immigration from seven Muslim-majority countries. Pakistan is not one of those countries.

Do you have concerns now in the President Donald Trump-era about your ability to travel back and forth to Pakistan to see your family that's still there or your family's ability to come here to visit you and then return home?

WARRAICH: Well, you know, I will say that - you know, I came to the United States in 2010 and have only lived in an America in which Barack Obama was the president. I think, in some ways, Trump's victory has, you know, really shaken me because of how invested I was in the idea that America is this special place. It's a truly multicultural society. And I'm still trying to understand, I think like so many others, just exactly what happened, you know, especially as a writer.

And as a physician, I try to separate myself from my identity as a Muslim, you know. I would rather be known as a physician, scientist, writer who, you know, happens to be Pakistani, rather than a young Pakistani Muslim immigrant who happens to be a doctor and a writer. But I don't know. You know, given how things are changing, I'm not even sure if I am - I will be able to set that narrative for myself. And that's a scary thought - to live an identity that is so politicized, even when you wish for it to not be.

GROSS: You know, you described - I forget whether this was in your book or in an article - that on the day of the Boston Marathon bombing, as the bombs were exploding, you were basically, like, across the street at a food court in the Prudential Center on Boylston Street. And, you know, everybody was just, like, shocked and not sure what to do. You were there with your wife and some friends. And at that point, you felt both like a victim and a suspect. What were you worried about?

WARRAICH: You know, growing up in Pakistan, terrorism was never a very foreign concept to us. I had sometimes, at times, found myself in similar situations in which I could hear bombs going off or something else awful was happening in my vicinity. I was having lunch with my wife and our friends right across from where the marathon bombing happened. And initially, we all ran. There was a stampede.

And that was, in some ways, as awful as it sounds, an experience that I was, in some weird way, that I was comfortable with - being on the run and not knowing what's going to happen. But it was the other experience of feeling like - that I could actually be a suspect, that people could actually look at me and feel like maybe this guy had something to do with what happened. And that was a feeling that was very foreign to me.

And, you know, I remember that day, we - it was one of the most horrifying days we've ever had. And that fear that I could be a suspect was not just my imagination. There was in fact, we learned later that day, that there was a Saudi kid whose house was raided because people suspected that he was involved in the bombing.

It shook me to such a level because I felt like, you know, having come to the United States, I wouldn't have to have the feeling of being surrounded by terror. But I realized that not only could I be surrounded by terror, I could also be a suspect. And that's something that I think haunts me to this day. But again, knowing how things are changing, all I can do is kind of sit back and watch as our stories are written for us.

GROSS: So getting back to the question about whether you're concerned that you'll have trouble traveling back and forth to Pakistan to visit family or that family will have trouble visiting you, are you worried about that?

WARRAICH: Well, Terry, the interesting thing is that even before Trump's election, my mother was denied entry into the United States. And my father has never been able to get a visa. The surprising thing about this is, you know, my parents are both based in Pakistan. All three of us are based here in the United States. My sister is a pediatrician in training in UT Southwestern in Dallas. My brother is in St. Cloud. Both me and my brother have green cards.

And we are about as - we're the type of immigrant success story most people, you know, think about when they think about people coming to the United States. And yet, despite all their children being here, my dad has never been able to get a visa. And my mother, who actually studied at UCLA and trained in Germany and has traveled the world, was denied entry into the United States despite having a visa. So in some ways, that restriction on traveling has been a very, very real part of my life, even before Trump came to power - even in Barack Obama's America.

So I don't know what Trump's America will look like for me. But it does fill me with a great deal of trepidation.

GROSS: When your parents were denied visas, were they giving reasons for that?

WARRAICH: None. My father and my mother - my father was never able to get a visa, and his application is still pending. It's been, I think, years. And my mother was - had a visa, and she'd actually traveled and visited me in Boston the year before. And she was actually traveling on Christmas Eve to see her granddaughter - her first granddaughter, my daughter - when she went up to the ticket terminal with her visa, with her flight ticket and with a boarding pass - when she was just summarily told that she was not allowed to board the plane. She was given no reason for it.

She was asked to reapply for a visa. She replied for a visa, and the visa was denied. And no reason was given. And to this day, she doesn't have a visa. So that's the reality that I have lived with and I've had to live with silently, even as I enjoy a wonderful, beautiful life here in the United States surrounded by people who are so generous, so loving and in a country which has offered me every opportunity that you can ever imagine. And yet, that is a part of my life as well. And that, I think, represents the dual type of experience that many Muslims and immigrants experience in the United States.

GROSS: Is it hard for you to not be able to see your parents?

WARRAICH: Terry, so last year, I was here, and I told a few people that my dad had a heart attack. And - he was at home. He started having chest pain. And my mother, who was there, put him in the back of the car seat and drove her to the hospital. And she called me afterwards. And, you know, just this thought that she had to drive my dad, who was potentially dying in the back seat, to the hospital while I was here without being able to be there is something that, you know, can never leave me. So yes, it is hard.

GROSS: Yeah.

WARRAICH: Sorry, can we - once second - I...

GROSS: Sure. No, no it's fine.

WARRAICH: (Sighing) OK.

GROSS: Yeah. No, I mean I understand when you find out a parent is sick. Your first reaction - let me drive there. Let me book a ticket. Let me get there. Let me be there - and that's something that was denied to you.

WARRAICH: That's something that, you know, I think many people live with here. These are choices that, you know, you wish no one has to ever make.

GROSS: But could you get back in if you went to Pakistan? Are you afraid you wouldn't be able to?

WARRAICH: So at that point, I wouldn't have been able to because I was on a visa, and there was no guarantee that I would be reissued a visa if I had traveled back. So at that point, I had no chance of being able to go back and also knowing that I could come back and actually be able to continue my medical training. Now I have a green card and potentially if something bad happens - and I hope it doesn't - I could go. But again, you know, reading the news, it does give you some pause.

GROSS: Is your father OK?

WARRAICH: My father is good. He's taking his medications. I check up on him regularly, and he's doing a good job. He quit smoking. I'm very proud of him.

GROSS: Good.

While we're talking about changes in America, I'm interested in your thoughts about the ACA, Obamacare - how it's affected you as a doctor and what your thoughts are about the possibility of either repeal and replace or repeal and not knowing what the replacement is going to be maybe for, you know, a year or two.

WARRAICH: Well, Terry, you know, if anything, when I moved to the United States and I moved to Boston, which is in Massachusetts, where they had already instituted what was called Romneycare back then. And yet, whenever a patient without insurance came up, it was such a tragic thing. It happened very rarely in Massachusetts because the insurance rate was so high. But when it did happen, we almost felt like our hands were tied in so many ways. Because even though we could do whatever we could in the hospital, we could not insure that the patient would be able to take care of them or afford their medications when they left the hospital.

So it is very unfortunate that health is so politicized in this country because it doesn't have to be. Health and wellness aren't red or blue, and they shouldn't be. But unfortunately, that is where we are. And I hope that when policies are being enacted in D.C., patients' voices - those who've benefited from the ACA, those who have gained insurance - those voices are not lost in the midst of all of this political activity.

GROSS: Haider Warraich, thank you so much for talking with us. Thank you for being so reflective.

WARRAICH: Thank you so much, Terry. And thank you for having me on the show - what a great honor - and thank you.

GROSS: Dr. Haider Warraich is the author of the new book "Modern Death: How Medicine Changed The End Of Life." We recorded our interview Thursday.

After we take a short break, Maureen Corrigan will review Kevin Wilson's new novel about a utopian experiment in communal child rearing. This is FRESH AIR.

TERRY GROSS, HOST: This is FRESH AIR. Are there better ways to raise children? That's the subject of countless advice books and also the question that Kevin Wilson's latest novel "Perfect Little World" tries to answer. Our book critic Maureen Corrigan has a review.

MAUREEN CORRIGAN, BYLINE: Utopian communities don't fare much better in fiction than they do in real life. As the plot usually unfolds, a brave new world loses its luster fast when the failings of its founder are exposed, or when the community itself begins to morph into a cult. Think of Lauren Groff's "Arcadia" or Carolyn Parkhurst's "Harmony," two recent novels that have imagined alternative communities and their inevitable crack-up. How could it be otherwise in fiction? As the Talking Heads told us, heaven is a place where nothing ever happens. A novel about heaven, about a successful utopia without sin or tension, would be pretty dull, indeed.

Fortunately, for us readers, the experimental ideal community that Kevin Wilson brings to life in his second novel, "Perfect Little World," has the delicious makings of a mess from its very inception. Wilson broke out with his 2011 debut novel, "The Family Fang," about a married couple, avant-garde artists, who deploy their two children as props in their performance pieces. That novel was ingenious, a whirlwind of screwball comedy, art and sad realizations about the limitations of family. Wilson is still thinking hard about the idea of family in "Perfect Little World." This is, in some ways, a calmer, less quirky novel. But what "Perfect Little World" loses in eccentricity it gains in emotional depth.

Wilson's story focuses on Isabel - Izzy - Poole, a smart, self-contained high school senior in Tennessee who falls in love with her depressed art teacher and becomes pregnant. Izzy's mom is dead. Her alcoholic dad is just barely scraping by. And her teacher-lover is too entangled with his own demons to be of any use. Izzy, who's a quietly compelling character, has decided to keep her baby. She comes to the attention of something called the Infinite Family Project cooked up by a child psychologist named Dr. Grind and funded by a billionaire who cherishes happy memories of being raised in a caring orphanage. The project aims to place 10 infants and their parents in a state-of-the-art commune for 10 years. The children will be raised by all the adults. And for a long stretch, they won't know who their biological parents are.

The aim is to see if both adults and children are happier and healthier when the pressures of child rearing are widely distributed. Young as she is, Izzy knows this mega-blended family is probably doomed. But single motherhood isn't looking like a walk in the park either. Here's her rationale for taking a chance on the project. (Reading) Izzy thought, for the millionth time, of her future as it lay before her without the aid of this project - working two jobs to make ends meet, her son in the cheapest daycare she could find, so tired at the end of the day that her baby felt like an unbreakable curse, failing each and every day until the bottom fell out of the world.

Wilson richly imagines the mundane details of life in the futuristic compound, as well as the bumpy personalities of the other parents all of whom, except Izzy, are coupled. A year in, a research assistant to Dr. Grind declares, the kids are going to be great. The parents are the unstable element. That's partly because the adults have trouble figuring out what they are to one another - brothers and sisters, second cousins? One night, as Izzy and some of the other parents are sitting around drinking whiskey smashes, another mom suggests that they're all like the cast of "Gilligan's Island." One of the fathers points out there was a lot of sexual tension on that show. The snake has been let into this nursery-land Eden, which is soon rocked by illicit hookups, the likes of which Ginger, the Professor and Mary Ann dared not even dream of.

Wilson is such an inventive and witty writer, that it was only after I'd finished "Perfect Little World" and no longer caught up in the story, that I realized how many ideas he raises here, how many kinds of family arrangements he scrutinizes among them - biological, chosen, nuclear, communal, broken and bandaged. The utopian Infinite Family Project may be flawed from the get-go, but Wilson's "Perfect Little World" of a novel pretty much lives up to its title.

GROSS: Maureen Corrigan teaches literature at Georgetown University. She reviewed "Perfect Little World" by Kevin Wilson.

Tomorrow, my guest will be screenwriter and director Jim Jarmusch. His new film "Paterson" stars Adam Driver as a poet and bus driver named Paterson, who lives in Paterson, N.J., and is inspired by William Carlos Williams' epic poem "Paterson." Jarmusch also made a recent documentary about Iggy Pop. I hope you'll join us.

FRESH AIR's executive producer is Danny Miller. Our technical director and engineer is Audrey Bentham. Our associate producer for online media is Molly Seavy-Nesper. John Sheehan directed today's show. I'm Terry Gross.

Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

You May Also like

Did you know you can create a shareable playlist?


Recently on Fresh Air Available to Play on NPR


Daughter of Warhol star looks back on a bohemian childhood in the Chelsea Hotel

Alexandra Auder's mother, Viva, was one of Andy Warhol's muses. Growing up in Warhol's orbit meant Auder's childhood was an unusual one. For several years, Viva, Auder and Auder's younger half-sister, Gaby Hoffmann, lived in the Chelsea Hotel in Manhattan. It was was famous for having been home to Leonard Cohen, Dylan Thomas, Virgil Thomson, and Bob Dylan, among others.


This fake 'Jury Duty' really put James Marsden's improv chops on trial

In the series Jury Duty, a solar contractor named Ronald Gladden has agreed to participate in what he believes is a documentary about the experience of being a juror--but what Ronald doesn't know is that the whole thing is fake.

There are more than 22,000 Fresh Air segments.

Let us help you find exactly what you want to hear.
Just play me something
Your Queue

Would you like to make a playlist based on your queue?

Generate & Share View/Edit Your Queue