One has to decide whether one’s fears or one’s hopes are what should matter most. - Atul Gawande

As different as Emily Dickinson’s parents’ life in America seems from that of Sitaram Gawande’s in India, both relied on systems that shared the advantage of easily resolving the question of care for the elderly. There was no need to save up for a spot in a nursing home or arrange for meals-on-wheels. It was understood that parents would just keep living in their home, assisted by one or more of the children they’d raised. In contemporary societies, by contrast, old age and infirmity have gone from being a shared, multigenerational responsibility to a more or less private state — something experienced largely alone or with the aid of doctors and institutions. How did this happen? How did we go from Sitaram Gawande’s life to Alice Hobson’s?

I felt a sense of shame like a burning ulcer. This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong.

Consider the case of La Crosse, Wisconsin. Its elderly residents have unusually low end-of-life hospital costs. During their last six months, according to Medicare data, they spend half as many days in the hospital as the national average, and there’s no sign that doctors or patients are halting care prematurely. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year.