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Last Updated on May 5, 2015, by eNotes Editorial. Word Count: 2177

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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 of medical expertise and the recognition that the history of medicine shows that nothing human can stop death indefinitely. In fact, not even the ugliness and anguish of dying can be prevented completely by any medical advance. The dying that awaits us all involves deterioration, destruction, and decay. Just as we start dying from the moment we are born, the inexorable processes of the body’s demise may be checked, arrested, even in some ways reversed for a time, but only for a time because they are the ways that nature takes with us.

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Repeatedly Nuland reminds readers that they are not destined to live forever. To the contrary, whatever brought each one to life, the truth remains that humans are perishable creatures whose living is also a process of dying. Nuland reminds his readers of this fact because the amazing medical advances that have occurred as generation after generation of physicians and researchers have battled disease so often dispose people to keep life going at any price in the hope that death does not have to arrive—at least not yet.

As a doctor who cares for patients living and dying, Nuland counsels that such refusal to accept what is inevitably coming, understandable though that is, ultimately proves as unwise as it is futile. The emphasis, he believes, should be on the quality, not the sheer duration, of one’s life. Where it can cure disease, Nuland insists that treatment should definitely be used. Where medical intervention can truly enable one to live better, it ought to be employed. But as far as life’s quality is concerned, unavoidably times come when the “cure” will be worse than the disease and the dying it brings. As much as possible, Nuland believes, physicians, patients, and their families should work together to discern the differences in these situations, to understand the available options, and to take the realistic decisions that have the best chances to make people’s dying days as meaningful, good, and full of joy as they can be.

In his professional capacity as a doctor, Nuland cares passionately about life. He truly wants it to be as good as possible for all. Like doctors everywhere, however, he has seen much more death than most people have, and he has seen it up close. Understating what his experience has taught him, Nuland writes that he has “not often seen much dignity in the process by which we die.” That observation becomes a key point of departure for the work of Nuland the writer.

Nuland has not produced what might have been, in his words, “a horror-filled sequence of painful and disgusting degradations,” but neither does How We Die mince words. Readers learn more than they might like to know about the physical details of dying, especially now that hospitals and the intensive care that modern medicine provides have done so much—wrongly, Nuland insists—to isolate the dying person and to insulate family and friends from the processes that result in death. There is nothing beautiful, not even much that is tranquil, about the dying that Nuland describes. Human bodies do not give up life easily. Even when the battle is a lost cause, the lingering is not completely passive. As far as our bodies are concerned, the poet Dylan Thomas need not have worried. As long as it can, the body keeps raging “against the dying of the light” with the result that few of us go gently into the night. The idea of death with dignity, much in vogue at the time of Nuland’s writing, is much more an imagined possibility than anything that happens as death approaches.

Nuland says that he wrote to “demythologize the process of dying.” To do so, he takes his readers to meet the persons and to visit the places where he has seen people die—sometimes virtually alone—from diseases that have ravaged them and their loved ones. Nuland’s detailed accounts of the physical, mental, and spiritual deterioration that various diseases bring creates a reading experience that is often disconcerting and even frightening.

Death, as Nuland says, conveys the idea of “a permanent unconsciousness . . . in which there is simply nothing. It seems so different from the nothing that preceded life.” Thus, impulses to put this book down, to wonder why one is reading it, are likely to be felt. Yet readers do not have to fight these impulses in order to keep on with the reading. Once the reading starts, this book is not one that many readers are likely to set aside. There is even a reluctance to have it end. Nuland’s narratives are gripping as little else could be; in addition, one soon senses that their goal must not be missed. Nuland does not miss his mark, and the reader’s apprehension is changed into awareness that the author’s demythologizing realism, including its skepticism about unending medical progress, contains reassurance.

As surgeon, scholar, doctor, and writer, Nuland becomes a wise friend who guides readers through what Psalm 23 calls “the valley of the shadow of death.” His is a counseling guidance based on a philosophy of living and dying that makes sense. The key to the sense that Nuland makes about how we die is found in a line of poetry that he cites at the beginning and again at the ending of his book. It serves as a counterpoint to the book’s seventeenth century epigraph. John Webster spoke of the “ten thousand several doors” through which death may take us. Yet Nuland also loves the thought of the great poet Rainer Maria Rilke, who once wrote simple words that ask, “Oh Lord, give each of us his own death.”

Nuland loves this line not because he expects Rilke’s prayer will be answered in any way that we can—or even God will—control. What Nuland knows, however, is that each of us will have our own death, and because that is true, he wants each of us to know how we die. To the extent that we have this knowledge and share it with one another in care and compassion, not only our dying but also our living will be less anxious, less driven by unjustified expectations, and thus more honestly and intensely human.

“We die,” says Nuland, “so that the world may continue to live.” Each of us has a gift of life. Nuland wants us to make the most of it. To do so we cannot live forever, at least not on this earth. We have to do what we can in the time we have and then take leave so that others can have their turn. Before the breath of life is taken from us, Nuland wisely stresses, we ought to live so that no one is left to die alone, so that no one is left to die in needless pain, and so that others, especially those we love and care about the most, will have good and worthy reasons to appreciate what we have been. If those things are true of us, then the right words in response to our death can rightly include the profound benediction that comes from Nuland’s Jewish tradition: “May his memory be for a blessing.”

JAMA: The Journal of the American Medical Association. CCLXXI, June 22, 1994, p. 1966.

Los Angeles Times Book Review. March 6, 1994, p. 6.

Nature. CCCLXX, August 4, 1994, p. 340.

The New York Review of Books. XLI, March 24, 1994, p. 14.

The New York Times Book Review. XCIX, January 30, 1994, p. 11.

The New Yorker. LXX, February 28, 1994, p. 92.

Publishers Weekly. CCXLI, January 3, 1994, p. 64.

Time. CXLIII, February 21, 1994, p. 66.

The Times Literary Supplement. May 27, 1994, p. 7.

The Washington Post Book World. XXIV, February 27, 1994, p. 1.

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