Jason Byassee: The confession manifesto

Atul Gawande’s terrifically readable new book not only convinces me of the utility of checklists. It provides a secular example of St. Augustine’s greatest teaching: confession.

Others at Call & Response have already written about Atul Gawande’s new book “The Checklist Manifesto: How to Get Things Right,” but having just finished it myself I couldn’t resist weighing back in. Gawande is selling something strikingly unsexy. He has reams of data that checklists save lives, both in surgery and in finance. If he was peddling an expensive new drug or some angle on the next company about to go big, you can bet hospitals and investors would be buying. But a checklist?!

My favorite moment in the book is when Gawande reflects on why we don’t use checklists in situations in which they have been proven to save lives and fortunes:

It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us -- those we aspire to be -- handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.

It’s an Augustinian point Gawande makes here, though I doubt he would describe it that way. For Augustine, the most dangerous sin is pride. Pride doesn’t just put us in the place of God, running the cosmos, judging who is righteous and who wicked. Even worse, it’s false imitation of God.

We are creatures meant to imitate God -- the right way. We are meant to imitate God’s humility. God’s life among humans is that of a fleshed human being, one of God’s chosen people, the Jews. We religious types tiptoe on high to catch a glimpse of the majestic God unsusceptible to the vicissitudes of time, knowledge or power. But stretching up, we trip over the crucified slave at our feet. All humanity imitates God in one way or another. The church means to by imitating his humility. The proud imitate his grandeur. This latter option does not go well.

In the book’s final chapter, titled “The Save,” Gawande shows the sort of humility Augustine would be proud of. Sure, Gawande has run around the world the last few years, trying to convince hospitals from the wealthiest to the poorest (one US hospital he mentions has a budget twice the size of the whole nation of Tanzania) that checklists save lives in surgery. But did he really need one himself, Dr. Atul Gawande?


Until he did. He’d never had trouble removing tumors from endocrine glands until one day when he, oh, severed a patient’s vena cava. You need this blood vessel -- it returns all the blood to your heart. The patient’s blood loss was “terrifying.” I found what Gawande did more terrifying still: He slashed open the man’s chest and belly and began squeezing his now-stopped heart to pump blood to his brain.

You know how this story is going to end: The checklist saved the man’s life. Going over it beforehand, Gawande mentioned that the tumor was close to the vena cava so the surgical team should have sufficient blood reserves nearby. The nurse checked. They didn’t. So she got them. When they needed the blood, it was there. Good thing. The man lost three times as much blood as he had in his body.

The result wasn’t good for the patient -- he lost vision in one eye, a wound he will bear his whole life. Nevertheless he agreed to let Gawande tell the story. He knew he is one of the lucky ones. One saved by a checklist. I imagine there will be others, saved not only by this manifesto, but by one surgeon-cum-writer’s willingness to tell others about one of his most terrible failures as a physician. His confession of this failure as a professional may prove to be one of his finest acts as a human being.

Augustine would approve.