[ JBEM Index / Volume 8 / Number 3 ]

Book Review

How We Die,

Alfred A. Knopf, 1994, 278 pp., $24.00

All patients eventually die. The denial of that unpleasant fact is the source of much bitter disappointment and many unfulfilled expectations in modem medicine. In the introduction to his book, Sherwin Nuland, surgeon and professor at Yale University, observes: “We have erected the method of modem dying. Modem dying takes place in the modem hospital, where it can be hidden, cleansed of its organic blight, and finally packaged for modem burial. We can now deny the power not only of death, but of nature itself. We hide our faces from its face, but still we spread our fingers just a bit, because there is something in us that cannot resist a peek.”

In the pages that follow, readers get far more than a peek. The ugly reality of death, graphically depicted in descriptions of the six major avenues by which the end of this life will come for eighty-five percent of us, is held harrowingly before our eyes. Nuland’s aim is to “demythologize the process of dying” so that we can be prepared for it and “rid ourselves of the fear of the terra incognita of death that leads to self-deception and disillusions.”

Those who affirm the truth of Scripture will realize immediately that this is an unattainable aim. The fear of death comes not from our lack of knowledge about the physiological and biological details of terminal disease processes, but from the cause of death, sin (Romans 6:23), and the effect, judgment (Hebrews 9:27), when we are called to give an account of our lives to God. Therefore, only Christians are delivered from the fear of death since Christ shared in our human nature “so that by his death he might destroy him who holds the power of death – that is, the devil – and free those who all their lives were held in slavery by their fear of death.” (Hebrews 2:14-15).

While Nuland does not succeed in ridding us of the fear of death, How We Die powerfully confronts our death-denying culture with the repulsive and inexorable necessity of death. Along the way, Nuland chides and challenges his colleagues in medicine who “are trained to think only about life and the diseases that threaten it.” (p. 61) and therefore ignore the fact that “there is plenty of evidence that life does have its natural, inherent limits. When these limits are reached, the taper of life, even in the absence of any specific disease or accident, simply sputters out” (p. 70). Heresy though it may be to the moderm mind, we die of old age because “we have been worn and tom and programmed to cave in. The very old do not succumb to disease – they implode their way into eternity” (p. 83).

The value of this book lies in its plea for an understanding of the limitations, as well as the potentials of modem medicine. The implications from the standpoint of bioethics are profound and practical. Wise physicians and patients will heed Nuland’s exhortations and place every decision about treatment options in the context of the aging process. Too often in my own care of critically ill patients, I have observed the propensity of some physicians to recommend highly invasive and burdensome interventions which yield exceedingly small benefits (or have no realistic expectation of success) and merely serve to imprison elderly patients in intensive care beds for the last days of their lives. To Nuland, this symbolizes “the purest form of our society’s denial of the naturalness, and even the necessity of death.” (p. 254). These patients are deprived of any final comfort, of sharing life’s last moments with loved ones, of opportunities to affirm their faith and often of an awareness that they are dying.

Nuland also takes aim at physicians (he calls them “biomedical problem-solvers”) who unwittingly abandon their patients by emotionally, if not physically, disappearing when it becomes obvious that the biomedical problems refuse to yield to their best efforts. Without a problem to solve, and with death drawing near, the physician loses interest: ‘To stay and oversee the triumph of unrestrained nature is to acquiesce to his own impotence,” writes Nuland. “Every time a patient dies, his doctor is reminded that his own and mankind’s control over natural forces is limited and will always remain so” (p. 259).

Nuland’s Jewish faith shines only dimly in his work. He quotes from the Old Testament a few times (pp. 73, 84-85, 167) and affirms that we are God’s creatures (p. 56) but in the end strikes an agnostic pose: “If there is a God, He is present as much in the creation of each of us as He was at the creation of the earth.” (p. 263).

The candid criticisms of the medical profession by one of its own and the critique of our death-denying culture make this book worth reading. It is most valuable as an spoken plea for the resurrection of the family doctor” (p. 266) and as a poignant cry for compassion to be married to competence, so that physicians will be more than highly skilled technocrats.

“For as in Adam all die” wrote the inspired Apsotle Paul, “so in Christ all will be made alive” ( I Corinthians 15:22). How We Die gets it half right. By hammering readers relentlessly with the certainty of the last enemy’s grip on the hu-. man race, Nuland inadvertently, but convincingly, demonstrates the first half of that verse.

[ JBEM Index / Volume 8 / Number 3 ]