How We Die: Reflections on Life's Final Chapter (review)

BOOK REVIEWS How We Die: Reflections on Life's Final Chapter. By Sherwin B. Nuland. New York: Knopf, 1993. Pp. 278. $24.00. Probably every reader of Perspectives in Biology and Medicine has heard of How We Die; most have probably read reviews, and many have read the book. There are many books on death and dying, written from clinical, psychological, economic , moral, religious, legal, and other perspectives; indeed, for some decades a small industry has developed around the subject. Surely the principal stimulant to much of the literature is the development of medical technology and its use. This becomes very clear when one compares Nancy Lee Beaty's book, The Craft ofDying: The Literary Tradition of the Ars Moriendi, published in England, with Robert M. Veatch's book, Death, Dying, and the Biological Revolution. Beatty's book interprets various humanistic and religious treatises designed to help persons die well, while Veatch's book is written by a leader in the contemporary medical ethics movement, and its agenda is set by the current standard clinical questions, such as the choice whether to prolong life. Nuland, in How We Die, intends to educate his readers in the dying process and is concerned with the conditions that make for a "good" death; he shares with Veatch and others the context of contemporary medical technology and care. But, following one of many "thick" descriptions of a patient's illness and Nuland's professional and personal relations to her (one hesitates to call his accounts "cases," since that term already suggests abstract and depersonalized accounts of the story), he points out that "ethicists and moralists run aground when they try to judge the actions of bedside doctors, because they cannot see the trenches from their own distant viewing point" (p.253). There are several lines of argument that run through Nuland's book. Argument , however, is not in its precise sense either the purpose or the style of the book. The general argument is suffused in richly descriptive and explanatory accounts of disease processes, or the experiences of patients and physicians and families, and in particularities of how persons die differently if they have heart conditions, suffer accidents, contract AIDS, or suffer from Alzheimer's. This general argument is incontrovertible, though its significance is not easily assimilated intellectually and affectively by physicians and other health care persons, or by patients and their families. It is that death "is simply an event in the sequence of nature's ongoing rhythms. Not death but disease is the real enemy" (p. 10). Dying of heart disease is a natural process "in which every tissue of the body partakes, each by its own means and at its own pace" (p.42). Aging and Permission to reprint a book review printed in this section may be obtained only from the author. Perspectives in Biology and Medicine, 39, 1 ¦ Autumn 1995 139 finally death are part of the total economy of nature and evolution; as with plants and animals, the renewal of the human species requires death so that "the weary may be replaced by the vigorous" (p.58). Dying is inexorably and simply part of living. This most general line of argument I heard made in a simple and pithy way when my five-year-old granddaughter asked her enzymologist father, "Daddy, why do people have to die?" He responded, "Because people are living things, and all living things have to die. Animals die, plants die because they're alive, but rocks don't die because they're not living." If the fact of mortality and a counsel to accept this indisputable fact is the main line of argument, it is enormously enriched by Nuland's accounts of the various conditions in which the natural event (or violent event in suicides and injuries) occurs. Nuland describes and explains, sometimes in considerable clinical detail, how death from stroke differs from death from cancer or heart disease or AIDS or Alzheimer's. These different accounts particularize dying; the medical diagnoses, care, use of technology, and engagement of family, medical staff, and general public differ significantly in different processes of dying. Thus there are important "arguments" implied in the main argument. That...