The Inevitable Hour: A History of Caring for Dying Patients in America by Emily K. Abel (review)

Beginning in the late 1950s, Western attitudes toward mortality became the subject of growing scholarly interest. A series of groundbreaking studies were published over the next few decades, including monumental works by historians Michel Vovelle and Philippe Ariès. For various reasons, academic interest in death studies proved short-lived, however, and it is only recently that new scholarship has begun to scrutinize various taken-for-granted assumptions about the history of death and dying. Using a rich array of archival materials, Emily Abel explores the relationship between changing values and Americans’ efforts to deal with, and make sense of, fatal illness. Her lively and engaging book The Inevitable Hour: A History of Caring for Dying Patients in America clearly demonstrates that the progressive institutionalization of dying patients in the twentieth century was not primarily driven by loved ones’ perceptions that their presence at home was unwelcome or unwanted.

The first chapters draw upon the diaries of ordinary Americans, supplemented by observations of physicians and a Methodist hospital chaplain, to explore nineteenth-century attitudes toward mortality. One comes away convinced that premature death during this period was commonplace, that most Americans died at home, that physicians’ and other health care workers’ role at the end of life was limited, and that most Americans’ efforts at understanding their travails were informed by traditional religious convictions. The rest of the book explores the evolution in each of these domains over the course of the twentieth century.

Abel insists that the advent of modern scientific medicine was marked by a decisive shift wherein the care of acutely ill, salvageable, patients became paramount. In an age of growing therapeutic optimism and the massive expansion of the hospital system, certain prominent twentieth-century physicians such as Ernest Boas insisted that no chronic disorder should be dismissed as incurable. Yet Abel claims that, paradoxically, medicine’s rising prestige and ambition encouraged physicians to increasingly devalue patients for whom there was “nothing more to be done.” Actively excluded by most American hospitals, terminally ill patients in the twentieth century had nowhere to turn other than a few substandard public institutions or a smattering of privately endowed “homes for incurables.”

As the century advanced, a small but growing number gained access to research facilities that sought to find a cure for devastating diseases, particularly cancer. Unfortunately, dying patients were (another) vulnerable population whose rights and interests were given short shift in the pursuit of scientific progress. The creation of two satellite institutions by America’s leading cancer hospital, Memorial Sloan Kettering, was particularly revealing in that they expressly sought to recruit charity cases willing to be subjected to unproven treatments. The uneven burden of medical research is one facet of a compelling claim that permeates the book: poverty has consistently and decisively shaped Americans’ end-of-life experiences. Serious illness and death are unpleasant, even in a private room at the best hospital. That being said, Abel clearly demonstrates that the system did little to assuage the personal and economic distress of dying urban dwellers whose poverty constrained their choices. On the one hand, they could be cared for at home under trying circumstances. Alternately, they could throw themselves upon the mercy of public charity and risk being ignored, at times even sufficiently mistreated to be the subject of a muckraking story in the New York Times.

The fact that death and dying are historically elusive experiences had important consequences for this work. Several of the chapters are short and the contents largely driven by the availability of source materials. Furthermore, nineteenth-century rural Americans may have been paragons of social cohesion, neighborliness, and spiritual yearning in the face of devastating illness. It is not clear that the care provided in America’s largest urban centers in the twentieth century can be dismissed as...