How We Die 
by Sherwin Nuland.
Chatto, 278 pp., £15.99, May 1994, 0 7011 6169 8
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‘He had never had a moment when death was not terrible to him,’ reports Boswell on the occasion of needling his famous friend with the news that the atheist philosopher David Hume had died well and without repentance. ‘The horror of death, which I had always observed in Dr Johnson, appeared strong tonight.’ Sherwin Nuland a surgeon from Yale, speaks to the Johnson in each of us, to our hunger for knowledge of our inevitable end: ‘Everyone wants to know the details of dying ... we are irresistibly attracted by the very anxieties we find most terrifying.’

Socrates tried to convince his students that it is irrational to fear death: ‘true philosophers make dying their profession.’ But his argument depends on a loathing of the body and on a belief that death is nothing but the soul’s separate existence under happier conditions in the next world. Neither position is likely to resonate favourably with many of us. As Socrates’ own students pointed out, this equanimity in the face of death was regarded by many as a sign of the philosopher’s madness.

Erasmus offers two suggestions, less eschatological, more psychologically and indeed physiologically informed than that of Socrates. ‘Is death as horrible a thing as it’s commonly asserted to be?’ asks Marcolphus the naive character, in one of the Colloquies. No, says Phaedrus, the voice of wisdom: ‘If a man dismisses from his thought the horror and imagination of death, he will have rid himself of a great part of the evil.’ And in any case, in the last stages, when the soul has already separated from the body, ‘nature dulls and stuns all areas of sensation.’

This is also the conclusion reached in one of the very few systematic studies we have of ‘the modes of death and the sensations of dying’: the survey conducted between 1900 and 1904 at Johns Hopkins University Hospital by Sir William Osler, one of the founders of modern clinical medicine and perhaps the most distinguished physician of his time. He found – based on reports by his colleagues and students – that while 90 out of about five hundred people experienced some sort of bodily distress, 11 ‘mental apprehension’, two ‘positive terror’, and one ‘spiritual ecstasy’, ‘the majority gave no sign one way or the other; like their birth, their death was “a sleep and a forgetting”.’

Dr Nuland sharply contests these reassuring assessments. He writes to ‘de-mythologise’ death; ‘to present it in its biological and clinical reality’; to stress the ‘physical deterioration’ of the body not its ‘emotional traumas’; to rescue death from culture. ‘Poets, essayists, chroniclers, wags and wise men often write about death but seldom see it,’ he declares in order to warrant passing the narrative torch to doctors. ‘Only within the pages of professional journals are to be found the descriptions of the actual processes’ by which we die.

This is fine, and others may have got it wrong, but in his grounds for denying the authority of experience to others Dr Nuland, too, is mistaken. Before our century there would have been no adult who had not seen – literally seen – some of his or her children, friends and, of course, parents die. Death behind institutional walls, death confined largely to those over the age of sixty, are phenomena of our century. Poets and essayists may not have had all the physiological details right but they, and more ordinary people as well, had seen their share of pain and suffering.

To be sure, lay voices are heard, insistently and often discordantly, throughout this book. There is the young Nuland who witnessed the death of his mother and his grandmother; there is the adult Nuland whose physician’s sang froid deserts him in the face of his beloved older brother’s death. The book may teem with quotations from Rilke, Tolstoy, Montaigne and other giants, but the voice of the doctor holds unquestioned narrative authority here. Stripped of myth, emotion and false hope, ‘death is simply an event in the sequence of nature’s ongoing rhythms.’ These rhythms are modulated by the processes of ageing and by the pathophysiology of particular diseases or injuries – heart disease, stroke, cancer, Aids, Alzheimer’s and traumas of various sorts – which Nuland describes in engrossing detail. In addition, we are taught how, at the molecular, cellular and gross anatomical and physiological levels, these diseases bring us low: that is, function as the ‘weapons of every horseman of death’, the universal processes we all experience as we are dying – stoppage of circulation, inadequate transport of oxygen to tissues, the failure of organs, the destruction of vital centres. Sometimes we are brought low by one, more often, as in old age, ‘by several of the seven horsemen’. (Bad as things are, there are not, despite Nuland’s insistence, seven horsemen: seven seals, seven candles and a seven-headed dragon – but only four horsemen of the Apocalypse.)

The fascination of this book lies not primarily in its biology lessons for the layman but in the stories it tells of the mysterious places where we die: the insides of our bodies. A layman might watch Lillian Hellman’s Little Foxes and see the death of Horace Giddens being made more miserable by his wife’s shrewishness. But Nuland tells us what he imagines going on behind Giddens’s breastbone: an enlarged, flabby heart no longer able to beat with anything resembling vigour; scars; an SA node struggling to maintain its declining authority; ischaemia. All this explains why the patient’s nostrils flare, why his gait is shuffling, why he is in pain, why his oxygen-starved heart muscle stops in an agonising cramp. Or, we learn how an Aids virus does its work, how sepsis comes to be the terminal event in a cancer patient’s life and why she is so thin, why Dr Livingstone being attacked by a lion probably felt no pain (endorphins). And in being made privy to the lives of those in whose bodies these universal forces do their work we are made privy, too, to the life and complex sensibilities of Dr Nuland.

This book, however, is much more than a collection of medical tales. Nuland makes three large claims based on the authority of the clinic and the universal truths of science. The first appears to be an empirical generalisation. If we expect an easy or painless death we are in for a big disappointment. Dying for the great majority of us, he insists, is a ‘messy business’. Contrary to what Sir William Osler or Dr Lewis Thomas might lead us to believe, death is ‘glutted with mental suffering and physical distress’. There was, he claims, ‘a nice Victorian reticence in denying the probability of a miserable prelude to mortality’ and he will disabuse us of our forbears’ illusions. Here, however, as in most of his historical pronouncements, Nuland is mistaken. If anything, the glory of the Victorian deathbed scene is fortitude precisely in the face of suffering. A good death depended on the possibility of its opposite, of the soon to be departed faltering in the face of adversity. In the most famous of 19th-century evangelical children’s books, The History of the Fairchild Family, for example, the last and most perfect death begins with young Charles Trueman telling of the pain ‘around the heart’ and the hope that he will bear it with patience. He does. And then ‘after a while, his eyes half shut, he fell into the agonies of death.’

Nuland’s second claim is more explicitly a cultural deduction from the supposed facts of nature. The hope of death with dignity is a cruel illusion because ‘the quest for true dignity fails when our body fails.’ The daughter of one of his patients regrets that ‘there was no dignity in my mother’s death’ – and none to be expected, he explains. The belief in what has traditionally been called a good death is merely our effort to deal with what is in fact an irredeemably miserable reality: ‘a series of destructive events that involve by their very nature the disintegration of the dying person’s humanity. I have not seen much dignity in the process by which we die.’ Dying badly is not ‘a judgment upon the many that are fated to die badly, simply the nature of the thing that kills them’. Here one hears the voice of the 18th-century philosophe, leading us from spiritually benighted immaturity into Enlightenment: the sooner we accept what nature teaches us, and give up the childish hope of death with dignity, the happier – or the less disappointed – we will be.

Finally, Nuland offers the hope of wisdom and resignation in return for acknowledging the painful truth about how we die. ‘Real control’ comes from our having full disclosure: ‘a realistic expectation is the surest path to tranquillity.’ In short, by understanding that our deaths are as ‘much a part of the ecosystem as is any other zoologic or biologic form’, we will gain the wisdom to know when to struggle and when to resign ourselves.

I will take up the last point first because there is ultimately no evidence that can be deduced for or against it. Some may find reassurance in the reminder that, like all of nature, we must die and do so according to well-understood principles; but I doubt whether we gain wisdom from the kinds of learning Nuland offers. In the first place, I think Hume had it right: we cannot deduce laws for living from nature. Second, none of the deaths Nuland describes does in fact constitute a natural history. They are all deeply imbricated in our – Western, technological, materialist – medical culture and therefore the question of whether dignity in death is possible cannot be answered by recourse to a medical journal or pathology textbook. Most important, as the most deeply felt of Nuland’s stories illustrate, human dignity is not dependent on the vagaries of biology.

Of course, in a metaphysical sense mortality is an indignity ‘All Flesh is grass and all its beauty is like the flower of the field. The grass withereth, the flower fades.’ It must be enormously difficult under any circumstances to hold onto the pleasures of life as one becomes really old: ‘Remember also your Creator in the days of your youth, before the evil days come.’ We do not need a scientist to tell us this. By definition, human worth, merit, estimation, honour, all the components of dignity, are extinguished – one might say mocked – by death.

If by dignity we mean, as Nuland seems to mean, taking full autonomy with us to the grave, there is little question that we lose it as we age and die. But this is a dubious standard for dignity and certainly not one predicated on nature. To ensure that there is dignity in death means treating the ageing, sick or dying person ethically, as a member of the human community. It is, profoundly, a cultural not a biological imperative.

The best and most sensitively observed death in the book is that of the author’s ‘bubbeh’ or grandmother. As she aged, her walk became more of a shuffle; her vision slowly faded; she was up more often at night to relieve herself. She lost her last teeth when the future Dr Nuland was in early adolescence, but somehow ate until either her appetite or ability to chew faltered. The young Nuland escorted his ageing ‘bubbeh’ to schule for the high holy days: ‘Bubbeh would hold tightly onto my arm, sometimes gripping the cloth of my sleeve as I guided her with agonising slowness through the streets.’ Five years before her death she ceased being able to walk to prayers and so prayed at home from memory: she stopped praying when she had stopped doing almost everything else. (There follow several pages on the pathophysiology of ageing.)

One day, as Nuland and his bubbeh ‘were doing ordinary things’, he reading the sports pages, she wiping the table, this old woman suffered a stroke. He called her name and when she did not respond gathered her up and carried her into her room. The doctor came and did nothing. Bubbeh lived, but within forty-eight hours contracted pneumonia. She survived that as well, recovered much of her speech and what functions she had had, and died in the bosom of her family of a second stroke some months later.

Dr Nuland’s bubbeh died with dignity but not, as he would have it in much of his book, because she was one of the lucky few spared the pain of ageing and multiple system failure. It was culture, not nature, that smiled on her. She died with dignity because her grandson and not an insensitive ambulance driver carried her to her bed because her nephew Harvey and not an uncaring stranger or a machine sucked mucus out of her throat, because she was the object of ‘the tears and prayers’ of a family that loved her. Others in this book were less fortunate: those whose physicians and carers had taken leave psychically when their cases became hopeless but before they actually died; those who, like Nuland’s brother, faced death on a gurney in the hall because there was no room at the hospital and because the physician who might have intervened was away for the weekend; those who were called by their first names by total strangers; those abandoned by relatives; those who were lied to or ignored.

The last death Nuland recounts falls almost at the opposite end of the spectrum of dignity but again, not as a consequence of the supposed natural history of death. The tone of acceptance and tranquillity Nuland affects in the earlier story – perhaps one that echoes from deep in his consciousness, from more innocent days before he became a surgeon – is gone here. As he is writing his final chapter, he tells us, there lies beside him the chart of a 92-year-old woman: Miss Hazel Welch. Before the episode which brought Miss Welch under Dr Nuland’s care she was suffering from arthritis and obstructions of the arteries of her leg. These resulted in her being unable to walk unassisted and were causing the gangrenous rotting of her toes; she was also in remission from leukaemia. In short, her body was well on the road to wearing out even though her mind remained sharp.

Miss Welch collapsed and was rushed unconscious to the emergency room. Her blood volume was restored, tests were performed and she was diagnosed as having a perforated digestive tract. She was apparently in no pain and refused surgery because she felt that 92 years was quite long enough, especially as she had no one in particular to live for. It was time. And had she been left alone, I am told by medical colleagues, she would have had her wish. She would have died, peacefully and painlessly, from hypovolemic shock, from exsanguinating into her abdominal cavity, from ischaemia.

Dr Nuland, however, would not leave it at that. When Miss Welch refused treatment he sought to change her mind. She would die for sure if she persisted, but with surgery she had a one-in-three chance of recovery. The problem is not that Dr Nuland tried to convince his patient that she had made the wrong decision – a duty, if he believed her to be mistaken. It is rather that he withheld information, as he subsequently admits, on the miseries of post-operative recovery – which might have influenced her to come to a decision of which he did not approve. Still she refused. Nuland left her alone and returned fifteen minutes later. By then, she was prepared, reluctantly, to assent.

As Nuland knew might happen, but Miss Welch did not, recovery was slow. Her mind, which had been clear when she entered surgery, became clouded and remained so for a week; the breathing tube had to stay in longer than expected so that she could not talk, although she could and did look reproachfully at her surgeon. Two weeks after she was transferred back to where she had been living she suffered a massive stroke and died within a day.

Nuland is fully aware that his paternalist, ‘doctor knows best’ attitude is out of place at a time when informed consent and respect for the autonomous choice of a perfectly rational patient might have led him to act with more respect for Miss Welch’s clear and explicit wishes. But he is unrepentant: ‘I imply ... I would have acted differently, although I know I would have done exactly the same thing again, or risk the scorn of my peers.’ And the reason is that his was the correct ‘clinical decision’. ‘Leave moralising to preachers.’ his colleagues would have told him had he acted differently. Moralists and, by implication, the laity ‘run aground when they try to judge the actions of bedside doctors’, because ‘they cannot see the trenches from their own distant viewpoints.’

I do not want to make light of the responsibility of bedside doctors. Nuland might be applauded for regarding every life as worth saving; our judgment of his actions would have been very different had he succeeded. And the body does have remarkable recuperative capacities: ‘People can be so mighty bad and get better,’ a character remarks in Dorothy Richardson’s story ‘Death’. But that said, there can be little dignity in the death of someone whose body is described as a ‘trench’.

In fact, very early in his book, Nuland abandons his expressed view that death is an event in the sequence of nature’s ongoing rhythms in favour of the much more bellicose position that ‘no action of nature is more hostile.’ He makes occasional criticisms to the effect that ‘even a temporary victory’ for modern medicine ‘justifies the laying waste of the fields in which a dying man has cultivated his life.’ But Nuland’s prose is redolent with images of war. Not surprisingly, there is little human dignity to be salvaged from the carnage he describes.

In the late 18th century, in his Physiological Researches on Life and Death, Xavier Bichat defined life as ‘the sum of forces by which death is resisted’. Nuland develops this Enlightenment tradition in the language of militarism. The purpose of the book is to ‘troop ... some of the army of the horsemen of death across the field of vision’. Disease is a ‘malign force that requires confrontation’. His bubbeh was confronted with a ‘blitzkrieg of microbes’; ‘a swarming horde of secondary invaders’ confronts the Aids patient. Nowhere are the rhetorical excesses of this martial spirit more evident than in his description of cancer, a disease surgeons call ‘the Enemy’. Here, it is ‘berserk with maliciousness of killing’, or on ‘a barn-burning expedition of destructiveness’. Cancer cells are alternately ‘members of the barbarian horde with but one purpose: to plunder everything within reach’, or ‘bastard offspring of hyperactive (albeit asexual) fornicating’ – well, at least it’s not sexual. Little wonder that oncologists are aggressive. In Nuland’s words, ‘anything we do to arrest’ cancer cells, ‘remove them from our midst, or induce their demise – anything which achieves one of these aims – is praiseworthy.’

The battle is joined: scientist v. cell, with a human being as battleground. It is difficult under these circumstances to step back and consider the landscape. Neither the cityscape of Hiroshima or Dresden nor the fields of the Somme enjoyed much dignity either. Dr Nuland’s brother and his patient Robert De-Matteis managed to salvage some of their humanity despite their front-line positions – the brother managed a farewell kiss, DeMatteis a wonderful family Christmas – but this was because of the resilience of their souls in the face of battle. Dignity, we should note, was threatened not by nature’s cruelties, berserk cells, and such like, but by lies, false hopes and chemical warfare.

This brings us finally to the question of pain. Is Nuland right that for the great majority of us there is no easy death, but only one ‘glutted with mental suffering and physical distress’? At one level this is an empirical question, although a complex one. Between 20 and 25 per cent of us die a sudden death which leaves us little time for dignity but equally little for suffering. That leaves the other 75-80 per cent of us. Nuland admits that Osler may well be right that 80 per cent of us are peaceful at our end, but he then goes on to redefine the question so as to include the weeks and months preceding death. Even if we go along with this temporal extension of dying, empirical problems remain. Cancer, for example, accounts for 20 per cent of deaths in the United States. Only 25-30 per cent of patients with advanced disease report very severe pain; 40-50 per cent have moderate to severe pain; and 25 per cent, presumably, are relatively pain-free. So if we add the percentage of those who die a sudden death to those who do not suffer severe pain from cancer, as many as 40 per cent of us might hope for not such a bad, i.e. physically painful, end.

Even those who do suffer pain are not, however, condemned to do so by nature. A recent clinical practice guide published by the United States Department of Health and Human Services, Management of Cancer Pain, finds that in 90 per cent of patients ‘cancer pain can be managed effectively,’ but that for a variety of reasons, cultural and clinical, it isn’t. Because the course of diseases is no longer natural, neither is the course of pain. Chemotherapy often causes more discomfort than the cancer – worth it if the patient survives, gratuitous suffering if she does not. The Aids patient whom Nuland describes dying of a fungal infection of the brain would have died peacefully if his first pneumocystic pneumonia had not been treated. He would have gone more gently had he been sedated, and not treated, during his last illness. I do not advocate this course; I only note that the ensuing misery cannot be laid at nature’s door.

But the more important point about pain is not empirical. One of Osler’s colleagues remarks tersely on the protocol recording the death of a 24-year-old German woman: ‘extreme bodily pain, but no apparent apprehension of consequences’; ‘Mental distress: apparently none.’ Physical pain does not always translate into misery. Our forbears, who believed in an art of dying more than in the arts of healing, understood that, like the pain of childbirth, or martyrdom, or sacrifice, the pain of death could be redeemed, or anyway rendered less horrible. We do not know how Osler’s patient managed. We do know that the whole point of the great deathbed scenes of the past was not the absence of pain, but rather the triumph of culture, of art, of human community until the very last moment. Hume, for example, suffered from ‘an habitual diarrhoea of more than a year’s standing’, his friend Adam Smith tells us. Every evening he was weaker than he was when he arose in the morning, and eventually he became so weak that the visits of friends fatigued this most sociable of men. Not terribly dignified by Nuland’s standards. But in the face of what he knew to be mortal decline, Hume read and discussed with his colleagues Lucian’s Dialogues of the Dead. It was this stoic insouciance which so delighted Smith and outraged Johnson.

The glory of Montaigne’s account of his friend La Boétie’s death, too, is predicated on the dying man’s suffering. He began suffering a violent dysentery, with great weakness, followed by intermittent lucidity and great pain. ‘He called to me very piteously ... “have you no compassion for all the torments I suffer? Don’t you see that from now on all the help you give me serves only to prolong my pain?”’ Soon after, he fainted. But throughout these agonies the two men kept up the drama of death as the vindication of their philosophical inquiries. ‘An vivere tanti est?’ ‘Is it so great to be alive?’ La Boétie said to one friend. His tongue was beginning stubbornly to refuse to do its work. Heavy sighs. ‘I am going off to sleep. Good night, my wife, go now’ were his last words to her. ‘My brother, stay close to me,’ he murmured to Montaigne.

It is not given to most mortals to have such artful deaths, nor indeed such artful lives. But the question of whether we might not have some art of dying for the modern age remains unanswered in this book. Even if the minor indignities of hospital death were eliminated, one still wonders whether the suffering of debility and death might not he sweetened by words, touches, humanity. Nuland does not make the case that biology precludes such hopes. He is suspicious of the voice that Henry James reported hearing as he sank to the ground from the first of the three strokes that were to kill him – ‘So here it is at last, the distinguished thing!’ – because he is so suspicious of the Jamesian notion that ‘art makes life, makes interest, makes importance.’

Nuland’s book is wonderfully illuminating on ‘how we die’ as biological systems. But he has very little ultimately to say about the possibilities of dignity in death or how we bear suffering. We do not learn much about how human beings decline and die. The question remains open, and exigent.

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Vol. 16 No. 18 · 22 September 1994

In his interesting review of Sherwin Nuland’s How We Die (LRB, 18 August), Thomas Laqueur doubts that greater clinical knowledge of the process of dying will help us approach death with more equanimity. This issue figured in many Renaissance debates about the desirability of learning an ars moriendi, one of the most acute responses being that of Francesco Guicciardini in his Ricordi (1530), suggesting that nature has in fact programmed us to ignore death:

It is certainly a remarkable thing that we all know we have to die, and we all live as though we were sure of living for ever. I do not think the reason for this is that we are moved more by what we have before our eyes and impresses our sense, than by distant things which cannot be seen. For death is close at hand and one can say that our daily experience shows it to us at every hour. I think it arises from the fact that nature wishes us to live according to the course or order of this world. Not wishing it to remain as if dead and without feeling, nature has given us the power to ignore death – if we thought about that, the world would be full of indolence and torpor.

The art of dying may be naturally unlearnable.

Brian Vickers
Swiss Federal Institute of Technology,

Thomas Laqueur asserts that our alienation from the experience of death began at the start of this century. This does not seem true of Ireland. I attended university in Ireland, starting in 1948, and in the six following years I was privileged to share the deaths of many friends’ parents, siblings, children etc. In every instance, the body was laid out in the home, where mourners of all ages came to light a candle and pray for the deceased. It astonished me, a stupid Yank, to see death so thoroughly domesticated and, especially, to observe that not even the smallest child was numbed or terrified by the experience. I was all the more impressed because only several years before I had been seeing, and making, lots of dead soldiers in Europe.

The memory of that ancient war experience raises a perhaps more serious reservation about How We Die. These days we die in many ways unmentioned by Dr Nuland, a lot of them much less desirable than even an agonisingly painful lingering illness.

Robert Ostermann
Albuquerque, New Mexico

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