Commentary Magazine

How We Die, by Sherwin B. Nuland

A Messy Business

How We Die: Reflections on Life’s Final Chapter.
by Sherwin B. Nuland.
Knopf. 278 pp. $24.00.

On beginning to read this book, I found myself thinking almost obsessively of not very funny doctor jokes, of the good news/bad news variety. Doctor: “I have bad news and good news.” Patient: “Tell me the bad news first.” Doctor: “You have terminal cancer.” Patient: “What’s the good news?” Doctor: “See that nurse down the hall? I’m making it with her.”

Shortly thereafter, the book disappeared. I searched for it frantically, to no avail. Then quite as suddenly it reappeared. It had been in plain sight and I had not seen it. (Interestingly enough, at the time of its disappearance I was reading the chapter on Alzheimer’s.) It was only then that I recognized what now seems obvious, that the book had evoked some characteristic defenses, first that manic streak which makes light of the dark, and when that failed, stark simple denial.

This book can do that to you. As its author, a professor of surgery at Yale, tells us, “dying is a messy business.” Even fairly sudden deaths will seem messy when described graphically enough. In the first chapter, Nuland writes of his own rite of passage as a third-year medical student, when “it was my unsettling luck to encounter death and my very first patient at the same hour.”

The patient was a fifty-two-year-old executive, hard-driving and high-living, who had had an infarction which was seemingly stabilized. Young Nuland was asked to help out at a busy time at the hospital with a simple admissions workup. He was eager to do so. He entered the room, introduced himself, and then the following event took place:

As I sat down at his bedside he suddenly threw his head back and bellowed out a wordless roar that seemed to rise up out of his throat from somewhere deep within his stricken heart. He hit his balled fists with startling force up against the front of his chest in a single synchronous thump, just as his face and neck, in the flash of an instant, turned swollen and purple. His eyes seemed to have pushed themselves forward in one bulging thrust, as though they were trying to leap out of his head. He took one immensely long, gurgling breath, and died.

Many of the descriptions of death and dying presented here have the same shocking clarity, whether the demise is sudden, as in this case, or painfully drawn out over many years.

Nuland’s intention is not to frighten us or to appeal to a sort of mortuary prurience. He feels, rather, that the contemporary attitude to death is compounded of illusions, denials, and deceptions, so much so that we are unable to deal with it effectively. And so we are to take the book’s title seriously. Nuland tells us, lucidly and precisely, just how we die, the mechanics and the dynamics. In particular, he takes us through the more common paths to death: heart disease; stroke; Alzheimer’s; the traumas of homicide, suicide, and accidents; AIDS; the cancers. He chooses these because they are common but also because

they are representative of certain universal processes that we will all experience as we are dying. The stoppage of circulation, the inadequate transport of oxygen to tissues, the flickering out of brain function, the failure of organs. . . .



The point of view of How We Die takes some getting used to. When we pick up a book on modern medicine addressed to the general reader, we expect to read about breakthroughs and miraculous discoveries, medical triumphalism. Nuland does not quite ignore these: we learn, for example, about the steady advances in the last half-century in the survival rates for cancer. But the emphasis is on limits, when and where and how and why our most zealous efforts are defeated by the inexorable powers of death.

This is an unusual book in other ways as well. Nuland is one of those rare physicians who knows a great deal about a great deal, not only medicine but also its history and, beyond that, literature and the humanities. The very first person mentioned is the 18th-century English novelist Laurence Sterne, followed soon thereafter by the Jacobean dramatist John Webster and the 20th-century German poet Rainer Maria Rilke. In a single page in the chapter on old age we learn about Chi Po’s The Yellow Emperor’s Classic of Internal Medicine, the oldest extant medical book, written 3,500 years ago; then the biblical book of Ecclesiastes; then Homer; and then the correspondence between Thomas Jefferson and John Adams at the end of their lives. It is not a gratuitous display of erudition. Nuland discusses these and other writers in the course of a fascinating analysis of the mechanisms of aging, where we find (as elsewhere) a deep opposition between an environmental theory, wherein extrinsic events within and without the organism wear it down, and a genetic theory holding that aging and death are essentially preordained from the beginning, as in the unrolling of a tape.

What I have not conveyed is Nuland’s gift for keeping us close to his own experience, in what he tells us of family, friends, and patients who became friends. It is autobiography of a strange and special kind. He was raised in the South Bronx, during the Great Depression, in a working-class Jewish family, three generations living in a small four-bedroom flat—a widowed grandmother, his parents, a maiden aunt, and two sons. His father and aunt worked in Manhattan’s garment district. His mother died of colon cancer, an event which shaped the rest of his life. His grandmother was seventy-eight when he was born, and after his mother’s death, “without realizing it, I spent my first eighteen years watching her descent into death.” The book movingly and unflinchingly describes that descent.



The most affecting family narrative concerns Nuland’s older brother, Harvey, who died at sixty-two from the same form of cancer that had earlier taken their mother. Nuland was aware almost immediately that the malignancy was too advanced to be treated successfully. It is his strong conviction that, in such circumstances, the patient should be dealt with honestly. Many a physician, however, will not or cannot do so:

Rather than seeking ways to help his patients face the reality that life must soon come to an end, he indulges a very sick person and himself in a form of medical “do something” to deny the hovering presence of death. This is one of the ways in which his profession manifests the entire society’s current refusal to admit the existence of death’s power, and perhaps even death itself.

Yet even Nuland, faced with his brother’s dying, did exactly what he had warned others against. To tell the truth, he writes, would have been to “‘take away his only hope.’” He and Harvey entered into a minuet of mutual deception and self-deception:

In trying to do the right thing for Harvey, I became what he wanted me to be, and in so doing fulfilled both his fantasy of me and my own: the smart kid brother who had gone to medical school and grown up to be the all-knowing and quite omnipotent medical seer. . . . I would marshal the forces of cutting-edge medicine and rescue him from the brink of death. . . . Had I been wiser, . . . I might have understood that my way of giving Harvey the hope he asked for was not only a deception but, given what we knew about the toxicity of the experimental drugs, an almost certain source of added anguish for all of us.

It was in fact to become a horror. Harvey Nuland underwent several desperate efforts at miracle cures which caused immense suffering, with little apparent gain in longevity. In these grim pages we learn some bitter truths. Even being the brother of an eminent physician may not protect you from the indignities that can attend dying in the modern era—from understaffed hospitals and assembly-line treatment, and even more from specialist physicians whose interest is in the disease rather than the patient, often a coded number in a research protocol. And when the doctor’s magic does not work, his narcissism and sense of control may be so damaged that, unwittingly, he may withdraw, psychologically and even physically, leaving the patient marooned.

At the end of this book, Nuland turns from the clinical to the moral and spiritual. Much as we may hope otherwise, few of us will die painlessly or in serenity. In some respects contemporary medicine has, paradoxically, made matters worse. In becoming the art of saving life, it has lost the art of managing death. But as Nuland writes, and as earlier generations understood, death is in any case not the proper province of medicine: “Death belongs to the dying and those who love them.”



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