What matters in the end also matters now

blog MarcWhat does a book about aging and dying and nursing homes and end of life choices—have to do with our every day choices in the workplace? Not much, I would have answered, before reading Atul Gawande’s extraordinary 2014 book, Being Mortal: Medicine and What Matters in the End. After letting Gawande’s argument sink in, however, I want to make the case that what matters in the end—let’s call it the skillful integration of technical mastery and compassion—also matters now, every day, in the world of business. Furthermore, I believe that Gawande’s insights can help us better understand how to align business practices with human values.

For those of you who haven’t read it yet, Being Mortal is a masterwork that is also intensely personal and moving; it is authoritative, while being a page-turner. Gawande was born in Ohio; his parents were born in India. He is a surgeon, a Harvard Medical School professor, a staff writer for the New Yorker, and a winner of the MacArthur Fellowship. In Being Mortal, he masterfully brings together multiple views on the question of how we die, including personal, historical, professional, and social science perspectives. He argues that we have over-medicalized the care of the frail and the infirm, and overlooked “what matters in the end.” He points to a number of “bright spots”—including the huge growth in recent decades of more client-centric independent and assisted living institutions, the expansion of hospice care, and success stories like La Crosse Wisconsin, where end-of-life costs are half the U.S. average and yet longevity and patient/family satisfaction are higher—due to a simple policy of requiring patients to consider, and talk about, their end-of-life choices. Before focusing on such bright spots, however, Gawande, calls it as he sees it:

The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet—and this is the painful paradox—we have decided that they should be the ones who largely define how we live in our waning days. For more than half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns. It’s been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs.  That experiment has failed. If safety and protection were all we sought in life, perhaps we could conclude differently. But because we seek a life of worth and purpose, and yet are routinely denied the conditions that might make it possible, there is no other way to see what modern society has done.  (p. 128)

Before I return to my opening question—what does this have to do with our everyday choices in the workplace?—I want to disclose my personal interest in Gawande’s topic. Before my mother passed away, in December 2014, she had a love-hate relationship with her modern medical establishment (in France). On the one hand she was deeply grateful for the highly competent professional care she received, which contributed to her outliving her initial prognosis by many years; on the other hand, as she approached the end of her life, she developed an aversion to the hospital environment, and a commitment to protecting the quality of her remaining days from “heroic” interventions aimed to prolong her life at any cost. Another dear friend of mine expressed a similar ambivalence when she referred to her “technical doctor” (who is a top researcher in her field) and her “human doctor” (who is empathetic and helps her relate meaningfully to her choices). These personal experiences had me nodding in recognition as I read Gawande’s description of the paradox we have created through the medicalization of end-of-life care.

As anyone knows who has confronted the blizzard of facts and options that blow when a major medical challenge arises, it can be hard to break through the shell of technical arguments to the “egg” of meaningful choices. (Likewise, business challenges can often “mascarade” as technical problems). And yet our choices are usually not purely technical. They require that we consider what matters to us and why, and to assign meaning to our options. So when we seek solace in a technical answer—“tell us, doctor, what is the next procedure?”—we may find ourselves searching fruitlessly for an elusive answer.

The genius of Gawande’s book is that he guides us not only through a personal and scientific inquiry, but also through a philosophical one: what DOES matter most in the end? To whom? Why? Without such questions, we would find ourselves skipping along on the purely technical (or anecdotal) outer shell of the topic. With such questions, we are able to discern a profoundly human story: a story of how, with good intentions and great talent, humans unwittingly created habits and institutions that undermine what we care about most. The value of this story is that it allows us now to objectify and disentangle ourselves from what seemed to be the impossible dilemma of modern medicine—safety and longevity vs. autonomy and meaning. By telling this story, Gawande helps us along in the process of managing, and resolving this dilemma more skillfully. After all, he suggests, why wouldn’t we evolve our medical training, institutions and habits—even if the learning curve is steep: “With this new way, in which we together try to figure out how to face mortality and preserve the fiber of a meaningful life…. we are plodding novices. We are going through a societal learning curve, one person at a time. And that would include me, whether as a doctor or simply as a human being.” (p. 193)

This, in short, is what Conscious Business—as a philosophy and a discipline of skillful leadership—endeavors to do with regards to the culture and institutions of modern business.  As I allowed the implications of Being Mortal to sink in, I saw that a very similar approach could be applied to business. For so many of us, the world of business poses a kind of Faustian dilemma: in order to succeed, it seems, we need to focus on what is profitable and productive—(and we have lots of technical answers to those questions). Yet the single-minded pursuit of profits keeps undermining the quality of our work experience and what matters most to us—a sense of connection with ourselves, with our communities and with meaningful accomplishments.

From a Conscious Business point of view, however, this dilemma, too, is a false one.  Inspired by one of our founding board members, philosopher Ken Wilbur, we take the “integral” position that exceptional, sustainable performance in any domain of human collaboration is characterized by three dimensions of success, which are too often collapsed into one. In any order (because they are interdependent and ultimately each as important as the next), these are the impersonal (or “IT”) dimension; the interpersonal (or “WE”) dimension, and the personal (or “I”) dimension. We recognize success in the IT dimension as High Performance, in the WE dimension as High Trust, and in the I dimension as High Engagement. When asked, our clients—senior managers in leading global companies—readily agree that their most successful initiatives involve performance in all three dimensions, and that each one supports the others. For example, trust, openness and mutual respect (performance in the WE dimension) make it easier for colleagues to learn from their mistakes, take risks, and engage creatively in their work (performance in the I dimension) which, in turn, increases innovation and speed to market (performance in the IT dimension).

As a society, we have created business cultures and institutions that pit profits, productivity, and short-term gain against what matters most in our lives. We find ourselves acting as if the only way to succeed in business were to sell our souls, sometimes at a discount! And yet we are learning that this dilemma was of our own making; that while we may be plodding novices, we can manage and even resolve it. Indeed, we can see that the most high performing companies—the ones that are best able to attract and retain talent, and that move dynamically to keep adapting and innovating—are the ones that have cracked the code of sustainable exceptional performance: they have learned to be NOT ONLY High Performance (IT), BUT ALSO to be High Trust (WE) and High Engagement (I) workplaces.


My colleague Richi likes to say “we can do better than the golden rule; let’s apply the Platinum Rule: ‘treat others not so much as you would like to be treated yourself, but rather as they would like to be treated.’”  The Platinum Rule is not an easy rule of thumb; it can take ten fingers or more to figure out how to practice it when we see someone being biased or self-interested, or when we have a different idea of what they “really” need; but the Platinum Rule has the virtue of pointing out that we are not, at any given point in our lives, the standard-bearers for what is important or true for someone else, given where they are in their lives. It tells us that perspective matters.

Gawande, cites a simple but powerful example of how perspective matters. It turns out, Stanford professor Laura Carstensen has shown, that the amount of time we perceive we have ahead of us in life, strongly influences our priorities about how we want to spend our time. In one experiment, Carstensen’s team studied a group of adult men:

Some of the men [ages 23-66] were healthy. But some were terminally ill with HIV/AIDS. The subjects were given a deck of cards with descriptions of people they might know, ranging in emotional closeness from family members to the author of a book they’d read, and they were asked to sort the cards according to how they would feel about spending half an hour with them. In general, the younger the subjects were, the less they valued time with people they were emotionally close to and the more they valued time with people who were potential sources of information or new friendship. However, among the ill, the age differences disappeared. The preferences of a young person with AIDS were the same as those of an old person.

In another experiment, she and her team studied a group of healthy people ages 8-93. When they were asked how they would like to spend half an hour of time, the age differences in their preferences were again clear. But when asked simply to imagine they were about to move far away, the age differences again disappeared. The young chose as the old did. Next, the researchers asked them to imagine that a medical breakthrough had been made that would add twenty years to their life. Again, the age differences disappeared—but this time the old chose as the young did. (p.98)

Carstensen’s research provides a wonderful opportunity to practice perspective-taking, and a welcome antidote to our oh-so-human habit of generalizing our own needs and perspectives as if they were THE TRUTH that applies to everyone.

As people in business know well, differences in priorities and perception about what matters most can lead to misunderstanding, polarization and politics.  A marketing executive can swear up and down (in all sincerity) that “obviously” the company needs to increase its marketing budget in order to compete for a new customer segment, while her rival in the finance department can advocate, with equal certainty, that the company needs to finally bring “unproven spending” under control. So long as each believes she is holding “the truth”, the likelihood of a productive negotiation is slim, and the temptation to personalize and politicize the conflict is high.

In the case of our system for caring for the frail and infirm, such differences in perspective have had massive and systemic implications. Referring to the role of adult children, who are often the elder-care decision makers, one expert in the field put it this way: “We want autonomy for ourselves and safety for those we love… Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.” (p. 106)

To help us think about these implications, Gawande offers an iconic image from Tolstoy’s classic novella, The Death of Ivan Ilyich:

As Ivan Ilyich’s health fades and he realizes that his time is limited, his ambition and vanity disappear. He simply wants comfort and companionship. But almost no one understands—not his family, his friends, or the stream of eminent physicians whom his wife pays to examine him.

Conscious Business is an invitation to let vanity disappear long before we reach the end of our lives, and to let “what matters in the end” inform how we do business today. It is an invitation to build not only technical mastery but also a willingness to ask “for the sake of what?” and to care not only about our own answers, but also about other people’s answers. In the end, our experience suggests, values-based business is possible. Through the skillful integration of technical mastery and compassion, we can generate value through values.

One thought on “What matters in the end also matters now

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  1. Andrew, Many years ago it was my late colleague who wrote:

    “Substitute personal greed with compassion, and the balance sheets will still work out just fine. Profit/loss statements take on a whole new dimension and meaning. Greed and capitalism are not one and the same thing. “Social” capitalism, social enterprise, is perfectly doable. This is the most effective sustainable strategy available for alleviating widespread human suffering stemming from poverty and all that comes with it — up to and including terrorism.”

    Around 2008 we’d become partners in the Charter for Compassion which is based on the Golden rule of reciprocity. Our focus at the time was children who had been left to die in institutions and to whom my colleague was referring when he wrote:

    “Allowing that some people do not matter, as things are turning out, allows that other people do not matter and those cracks are widening to swallow up more and more people. Social enterprise is the first concerted effort in the Information Age to at least attempt to rectify that problem, if only because letting it get worse and worse threatens more and more of us. Growing numbers of people are coming to understand that “them” might equal “me.” Call it compassion, or call it enlightened and increasingly impassioned self-interest. Either way, we are all in this together, and we will each have to decide for ourselves what it means to ignore someone to death, or not.”

    it was Dr Martin Luther King jr. who once said ” Our lives begin to end the day we become silent about things that matter”. What mattered to him as is does most people was that children were being abused and neglected in the name of profit maximisation. This was no less than organised crime. He took a stand for what matters.


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