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A doctor’s examination and diagnosis of a taboo
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by B ob R oehr
eath, like sex, is always on our minds.
“It may not be on our conscious minds,
but it takes nothing to bring it out. We
hide our eyes,” says Dr. Sherwin
Nuland, putting a hand to his face and
peering through splayed fingers. “But we really
want to see it.”
The surgeon and teacher at Yale University set
out to write How We Die: Reflections on Life’s
Final Chapter “to demythologize the process of
D
oo/cs
dying by presenting its biological and clinical
realities.” He did that in a manner one reviewer
described as “almost sadistic in [its] candor.” And
there was something more. As with all works of
genius, the book asserted its own persona.
Stories began to bubble forth— enveloping,
breathing life into cold data. Stories of Nuland as
a medical student grasping a still-twitching heart,
“a wet, jellylike bagful of hyperactive worms,” in
a futile attempt to countermand a heart attack. Of
the decline and passing of his Bubbeh, his beloved
grandmother. Of HIV’s relentless assault on
Ishmael Garcia’s organs.
“What I ended up doing was opening up this
enormous rich vein that
was waiting to be cracked.
I hadn’t been aware of it,
except in retrospect.”
Public response to his
book has been overwhelm-
ing: 400,000 copies in
hardback, rave reviews ev
erywhere, the prestigious
National Book Award for
nonfiction—all within the
first year. The paperback
edition, just out with an
initial 100,000 copies, hit
the New York Tim es
bestseller list even before
its official release date.
“We are on the verge
of wanting an open dis
cussion about death,” says
Nuland, explaining a re
ception he had not antici
pated. He compares it to
the landmark Kinsey Re
port of 1948, which unleashed a national discus
sion of sex. “This book in essence gave them
permission to talk about death.”
AIDS was key. Up until the early 1980s medi
cal schools “were teaching our students that in
fectious disease, within 15 years, would be a thing
of the past. It would be eradicated.” AIDS de
stroyed “that entire gestalt, our entire approach to
medicine.”
Nuland says, “All of a sudden this generation
which assumed that nobody died until they were
in their 70s was forced to recognize it.”
Death reasserted itself. Death which had been
removed from the bedrooms and parlors of our
grandparents and locked inside sterilized hospital
walls. “Death with dignity,” that myth which had
flourished in isolation and ignorance, now came
tumbling down. Death, like sex or homosexuality,
which acquires much of its power to intimidate
through our silence, our fear to speak the word.
“Death is, to use the cliché, part of life,” says
Nuland. AIDS has brought a large measure of this
recognition to the gay community. Natural and
created families have formed “to do something
that has been lost in society, which is to accom-
pany a loved one to death.” He laments that the
experience, captured so brilliantly in poetry and
prose by writers such as Paul Monette, has not
been embraced much beyond the gay community,
“because humanity needs it.”
“When people are very close to a dying per
son, they come to a sense of resignation about the
death, an understanding of the power of nature,
and the inevitability of this conclusion.
“Every person that I have taken care of who
was dying knew they were dying, even if they
didn’t talk about it,” says Nuland with absolute
certainty. “The worst thing it seems to me, the
worst, is holding cards so close to the vest that
nobody sees it. That communion at the end, that
expression of what my life means to you or your
life means to me never happens.”
And changes are due in the traditional charac
ter of the role of the physician. ‘The kind of hope
we tend to give a dying person is a false hope. We
are going to find a treatment that will keep you
alive for another six months. We can really cure
this thing. That is terrible. The real thing that
makes sense is the communion with the people
who are dying, the serenity, the not being forced
to try a last-chance treatment when the chance of
its working is tiny, tiny, tiny. When you devastate
the last weeks.”
Nuland says, “We give a lot of lip service to
families or patients them
selves, but the fact is,
families and patients al
ways do what doctors
want. I used to point out
to people, with pride, that
in 30 years of clinical
practice I have never had
a patient refuse my rec
ommendation. And after
I wrote this book I said to
m yself, ‘Jesus Christ,
what have 1 been doing.
I’ve been brow-beating
people, like all doctors
do.’
“[A doctor] can be au
thoritarian in the sense of
having better knowledge,
but that doesn’t mean that
all of the aspects of judg
ment come from knowl
edge alone. They come
from knowing the other
guy’s values, they come from knowing what
makes sense at this time in his life for him.”
In his manuscript the author lauded “the whole
AIDS community— the people who have it, the
people who treat it, the support groups— for their
thoughtful, humanistic care.” But his editor said it
was too much and excised a page and a half of
homage.
“Death belongs to the dying and to those who
love them,” Nuland says. “Though it may be
sullied by the incursive havoc of disease, it must
not be permitted to be further disrupted by well-
meaning exercises in futility.
“The greatest dignity to be found in death is
the dignity of the life that preceded it.... Hope
resides in the meaning of what our lives have
been.”
He adds, “By writing this book, I so familiar
ized myself with death that it is in no way the terra
incognita it once was. Instead of me belonging to
death, death now belongs to me.”
How We Die: Reflections on Life’s Final
Chapter by Sherwin B. Nuland. Vintage Books,
¡995; $13.00, paperback