Authors: Sherwin B Nuland
How We Die
Acclaim for
Sherwin B. Nuland
Sherwin B. Nuland
“The story comes from a sensitive observer . . . who has seen much, taken much thought, and written it all down with a superior gift for descriptive narrative. . . . Nuland’s meditations . . . reflect a pragmatic, measured skepticism permeated by an intensely human compassion.”
—
Washington Post Book World
Washington Post Book World
“Powerfully eloquent . . . a relentlessly frank and graphic description of the ways human life achieves its terminus.”
—
The New York Times
The New York Times
“As powerful and sensitive, and unsparing and unsentimental as anything I have ever read.”
—Oliver Sacks
“Nuland proposes what almost anyone who has been touched by death will recognize as common sense. . . . [He] never shies away from the cultural implications of his profession. . . . You cannot read
How We Die
without becoming aware of your body, if only . . . to ask it impermissible questions. You put the book down merely to pick it up again.”
How We Die
without becoming aware of your body, if only . . . to ask it impermissible questions. You put the book down merely to pick it up again.”
—
The New Yorker
The New Yorker
“Stunningly frank . . . strips away the fantasy about what happens when the body stops.”
—
Newsweek
Newsweek
“Any reader who is not still convinced of his own mortality . . . is bound to be altered in some profound way by this book. . . . This is knowledge we all should have.”
—
USA Today
USA Today
“Nuland combines the clinical eye of a trained physician with . . . emotional and philosophical reflectiveness.”
—
Newsday
Newsday
About the Author
Sherwin B. Nuland, M.D., is the author of
Doctors: The Biography of Medicine
. He teaches surgery and the history of medicine at Yale, and is also Literary Editor of
Connecticut Medicine
and Chairman of the Board of Managers of the
Journal of the History of Medicine and Allied Sciences
. In addition to his numerous articles for medical publications, he has written for
The New Yorker, The New Republic
, and
Discover
magazine. His book
The Origins of Anesthesia
is a volume in the Classics of Medicine Library. Dr. Nuland and his family live in Hamden, Connecticut.
Also by
Sherwin B. Nuland
Sherwin B. Nuland
The Origins of Anesthesia
Doctors: The Biography of Medicine
Medicines: The Art of Healing
The Face of Mercy
This eBook is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the publishers, as allowed under the terms and conditions under which it was purchased or as strictly permitted by applicable copyright law. Any unauthorised distribution or use of this text may be a direct infringement of the author’s and publisher’s rights and those responsible may be liable in law accordingly.
Epub ISBN: 9781407074689
Version 1.0
FIRST VINTAGE BOOKS EDITION, JANUARY
1995
1995
Copyright
© 1993
by Sherwin B. Nuland
© 1993
by Sherwin B. Nuland
All rights reserved under International and Pan-American Copyright Conventions. Published in the United States by Vintage Books, a division of Random House, Inc., New York, and simultaneously in Canada by Random House of Canada Limited, Toronto Originally published in hardcover by Alfred A. Knopf, Inc.,
New York, in 1994.
The Library of Congress has cataloged the Knopf edition as follows:
Nuland, Sherwin B.
How we die / Sherwin B. Nuland.
p. cm.
Includes index.
ISBN: 0-679-41461-4
1. Death. I. Title.
BD444.N85 1994
616.07’8—dc20 93-24590
CIP
Vintage ISBN: 0-679-74244-1
7 9 C 8 6
To my brothers
,
,
Harvey Nuland and Vittorio Ferrero
. . . death hath ten thousand several doors
For men to take their exits
.
.
—John Webster,
The Duchess of Malfi
, 1612
Contents
Acknowledgments
The eighteenth-century novelist Laurence Sterne once remarked that writing “is but a different name for conversation.” The content and tone of a book or essay are determined by the author’s perception of the reader’s anticipated response to each sentence as it is given form on the page—the reader is always present. The book you are about to read was conceived with no other plan in mind than that of conversing with people who want to know what it is like to die. I have tried to hear how a reader might reply to what is being said. By listening well, I hoped to be able to address every response as immediately and clearly as possible.
The dialogue in these chapters, however, is only the culmination of other conversations I have been having most of my life—with my family, my friends, my colleagues, and above all my patients—with those who have been closest to me and whose wisdom I have sought in order to come to an understanding of what our lives, and our deaths, are about. To seek wisdom in another’s words is much less difficult than to find it in another’s experience. I have looked for it everywhere I thought it could be discovered. Even when I had no idea I was learning from one or another of the vast number of men and women whose lives have entered mine, they were nevertheless teaching me, usually with equal unawareness of the gift they were bestowing.
Although most learning is thus subtle and unrecognized as such by either its recipients or its providers, a great deal of it does grow out of the more usual kind of conversation: direct verbal interchange between two people. In my own case, the most extensive of those dialogues have gone on intermittently for years or even decades, while a few have taken place only during the writing of the book. If “conference [maketh] the ready man” as Francis Bacon claimed, then I have been made ready for
How We Die
by countless hours in the company of extraordinary people.
How We Die
by countless hours in the company of extraordinary people.
Several of my fellow members of the Bioethics Committee at the Yale–New Haven Hospital have again and again sharpened my comprehension of critical issues faced not only by patients and health professionals but at one time or another by all of us. I am particularly indebted to Constance Donovan, Thomas Duffy, Margaret Farley, Robert Levine, Virginia Roddy, and Howard Zonanna. Together and individually, they have shown me an image of medical ethics that is as humane (and even spiritual) as it is intellectually disciplined.
Thanks go also to another member of the committee, Alan Mermann, a pediatrician who found renewed vigor as a Congregationalist minister and the chaplain of our medical school. He has been generous in helping me understand what it is like for medical students and dying patients to befriend each other and share one another’s fears and hopes.
Ferenc Gyorgyey has made available the vast resources of the historical collections at Yale’s Cushing/Whitney Library, but his even greater gift during these many years has been the equally vast resources of his friendship and his wide-ranging intellect. Jay Katz, both in our conversations and in his writings, has taught me a sensitivity to medical decision-making that transcends the mere clinical facts of a patient’s illness and even the conscious motivations that would seem to determine choice of treatment options. My wife, Sarah Peterson, teaches me yet another kind of sensitivity, which is sometimes called charity and sometimes called love. In charity or love there is an understanding of another’s perceptions and there is also unquenchable faith. In Sarah’s tradition: “Though I speak with the tongues of men and of angels and have not love, I become as a sounding brass or a tinkling cymbal.” Therein lies a great lesson not only for individuals but for nations and professions—especially my own profession of medicine.
For the past decade, I have benefited from the friendship of Robert Massey. As a practicing internist, a medical school dean, and a historian of medicine as well as a commentator on its present and future, Bob Massey has transmitted to several generations of his physician colleagues a dimension of understanding and a sense of medical obligation that surpass the ephemeral concerns of the moment and the parochial concerns of the guild. I have taken advantage of his friendship by making him my sounding board, my oracle, and even my authority for classical allusions, not to mention Latin grammar. There is almost nothing in this book that he and I have not discussed. His confidence in the value of this undertaking has been a source of quiet energy for me over these many months of work.
Each chapter of
How We Die
has been reviewed by one or more authorities on its content. In every case, important suggestions have resulted from the readings which contributed in significant ways to my ability to clarify the material. The cardiac chapters were critiqued by Mark Applefeld, Deborah Barbour, and Steven Wolfson; the sections on aging and Alzheimer’s disease by Leo Cooney; the trauma and suicide section by Daniel Lowe; the AIDS chapters by Gerald Friedland and Peter Selwyn; the clinical and biological aspects of cancer by Alan Sartorelli and Edwin Cadman; the discussion of the doctor-patient relationship by Jay Katz. Specialists in these areas will easily recognize the names of each of my consultants—I honor myself by recording them here. They have been generous beyond my expectation.
How We Die
has been reviewed by one or more authorities on its content. In every case, important suggestions have resulted from the readings which contributed in significant ways to my ability to clarify the material. The cardiac chapters were critiqued by Mark Applefeld, Deborah Barbour, and Steven Wolfson; the sections on aging and Alzheimer’s disease by Leo Cooney; the trauma and suicide section by Daniel Lowe; the AIDS chapters by Gerald Friedland and Peter Selwyn; the clinical and biological aspects of cancer by Alan Sartorelli and Edwin Cadman; the discussion of the doctor-patient relationship by Jay Katz. Specialists in these areas will easily recognize the names of each of my consultants—I honor myself by recording them here. They have been generous beyond my expectation.
A number of people have helped me answer specific queries and track down sources: Wayne Carver, Benjamin Farkas, Janis Glover, James M. L. N. Horgan, Ali Khodadoust, Laurie Patton, Johannes van Straalen, Mary Weigand, Morris Wessel, Ann Williams, Yan Zhangshou, and my great-hearted secretary, Rafaella Grimaldi. G. J. Walker Smith reviewed an autopsy series with me and helped to put its findings into the context of the degenerative processes of aging. A morning spent with Alvin Novick opened my eyes to political and intensely personal aspects of AIDS that I had only guessed at—it could not have been easy for Al to expose to a virtual stranger the pain in his still-grieving heart, but somehow he found the strength to do it, and I will not forget what he taught me. Irma Pollock, whom I have admired since childhood, spoke to me through the anguish of recalling the tragedy of Alzheimer’s disease, because she wanted to help others. Her story has strengthened my faith in the power of selfless love.
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