One by one, vast numbers of people die every day and night. They do so in thousands of ways. As long as human life exists on earth so it has been and always will be. Death is nothing new, and neither are books about it. Because death takes so much from human beings—often in pain-filled if not untimely ways—it leaves not only a corpse behind but also senses of loss and grief so deep that nothing quite can fill them. Still, if words are never sufficient to meet the needs that death and dying create, they can help us to cope. So there is no lack of writing about death, most of it seeking to provide consolation.
How We Die: Reflections on Life’s Final Chapter breaks the mold. In more ways than one, this book about death and dying is new and different. What accounts for the book’s distinctiveness is the fact that its author, Sherwin B. Nuland, brings five different but related perspectives to this study. First, Nuland has had a long and distinguished career as a successful surgeon. He also teaches the skill of surgery at Yale University’s medical school. Thus, the most up-to-date medical knowledge informs his book.
Second, this surgeon is an accomplished scholar. In particular, Nuland’s teaching encompasses the history of medicine. His book draws on that history to restore death to its ancient place in human existence.
Third, this surgeon-scholar is also a caring and compassionate doctor who is dedicated to more than the life-saving techniques of surgery. His practice of medicine aims at keeping the whole person well. Therefore his book counsels healthy people as well as dying patients and their friends and families. Specifically, Nuland wants to equip all people to make informed choices that enhance life’s quality.
Fourth, Nuland is a gifted, eloquent, and even poetic writer. His book combines unsparing descriptive detail with unsentimental insight about how we die, much of it drawn poignantly from his own rich experience and the sensible skepticism it has produced about unlimited medical progress against death and dying. To cite just one example that keeps Nuland on guard against overoptimism, he reports that in the mid-1970’s some members of the public health establishment thought that the threat of bacterial and viral disease might become a thing of the past. Little more than a decade later, the AIDS epidemic arrived, and, says Nuland convincingly, “There has never been a disease as devastating as AIDS.” Nuland’s purpose in citing such examples is not to crush hope. Far from that, he turns realism and skepticism into common sense that helps humans understand what to expect as their bodies inevitably fail them.
Finally, Nuland’s book shows its author to be a wise and compassionate man who has suffered with family and friends whose lives could not be saved even by the latest medical techniques. His “reflections on life’s final chapter,” as the book’s subtitle calls them, reveal a philosophy about living and dying that contains wisdom we all should have.
The wisdom begins with an epigraph Nuland chose to govern the book’s themes. It comes from John Webster, a seventeenth century writer, who observed that “death hath ten thousand several doors/ For men to take their exits.” Nuland cannot operate on all the ways people die, neither in his medical practice nor in the pages of his book. Instead, he stresses that no sooner has a life begun than its dying is also under way. Good health, strength, vitality— all may grow and flourish for a time, even for a long time, but humans are physical creatures, and their bodies are not immune to the weakening that results in death.
Embodied selves that humans are, their bodies are besieged, not least of all by their own carelessness. Their frailty becomes apparent in Webster’s “ten thousand” ways. Nuland concentrates on the ones that most commonly kill humans. Among them are disease categories such as heart attack, stroke, cancer, Alzheimer’s disease, and AIDS. He also discusses clinically what happens when people die a violent death—criminally or accidentally—and how death can overtake people through an aging process in which vital body parts eventually lose their vitality.
Whatever the general category into which one’s death falls, whatever the details of one’s dying, Nuland shows that “the weapons of every horseman of death” involve “certain universal processes that we will all experience as we are dying.” Those processes include circulation stoppage, organ failure, and diminishing brain functions. What drives them all is the fact that human lives depend on oxygen. Lack of oxygen is at the bottom of how we die. One way or another, disease, trauma, or aging will find a way to rob us of the breath of life.
In his guise as a historian, Nuland notes that nothing fundamental has changed since the time of Hippocrates, the ancient and legendary Greek father of medicine, when it was known that man is an “obligate aerobe,” a creature, like all known terrestrial animals, whose life depends on air. Yet everything has changed as one medical advance after another has promoted better health and extended the time during which death is kept at bay. Nuland’s historical scholarship provides an important perspective by keeping before readers both the progress...
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