How We Die: Reflections on Life's Final Chapter. By Sherwin B. Nuland. Knopf. 278 pp. $24. Reviewed by Francis Canavan
A professor of constitutional law and a doctor write about dying and death from their respective points of view. Melvin Urofsky is on the faculty of Virginia Commonwealth University; Sherwin Nuland teaches surgery and the history of medicine at Yale University. Each of them, however, addresses the same problem: What should the individual do, and society permit, when the phenomenal advances in the medical profession's ability to sustain life reach the point where efforts to prolong it become, in Dr. Nuland's words, "well-meant exercises in futility" and cause continued suffering rather than relief and cure?
Each book is a readable survey of its field because it is enlivened by numerous stories of real cases in law and medicine, and discusses the issues they raise in relation to real people. Urofsky gives us the current state of the law in regard to "the right to die," suicide and assisted suicide, mercy killings, the right of condemned criminals to be executed if that is what they want, letting deformed babies die by refusal of care, and "living wills."
Like everyone else, of course, he writes from a particular point of view. A dust-jacket blurb written by the president of the American Civil Liberties Union puts it well: "While Urofsky objectively describes competing moral concerns and legal arguments, his humane concept of the 'right to life' comes shining through: a concept that respects the autonomy and dignity of competent adults, and accordingly embraces their right to determine if and when their lives are no longer worth living."
That he honestly tries to be objective and accurate is certainly true, and to a large extent he succeeds. But sometimes he is in over his depth. Thus, he quotes Daniel Maguire as declaring that "the morality of terminating life, innocent or not, is an open question although it is widely treated as a closed one." But Professor Maguire is hardly an authoritative voice in Catholic moral theology, and the question is not open merely because he says so. Nor does Urofsky really know what he is talking about in saying: "When medicine could not alleviate pain, Catholic moral theologians termed pain a means by which God purified man of sin." The Crucifixion as the supreme atonement for mankind's sins is central to the Christian religion, but not because the authors of the New Testament didn't foresee the wonders that modern medicine would achieve.
Nonetheless, allowances made for the biases and gaps in knowledge that afflict us all, Urofsky's book is well worth reading as an account of what the law is at this time in regard to letting go of life. He summarizes it in these terms: "First, it is now well established that both the common law and the Constitution support a right to die, that is, a right to terminate medical treatment, including the cessation of nutrition and hydration." Once it is established that a patient is competent and has voluntarily chosen the cessation of a treatment, the doctor and the hospital must obey. If the patient is not incompetent, "the law recognizes the right of a surrogate to make the necessary decisions."
Dr. Nuland's title, How We Die, aptly describes the content of his book. In language that the medical layman can easily understand, he unflinchingly, unsparingly, and in detail describes the process by which diseases such as heart failure, Alzheimer's, and cancer will eventually kill us all, and, if they do not, old age surely will. Not all of us die of disease, however; murder, accidents, suicide, and euthanasia are alternative ways of dying, and he describes how and why they, too, bring about death.
It is not a pleasant book to read but it is a fascinating one. It can be recommended to all who want to see life steadily and see it whole, including its inevitable end in death. Others may feel like the schoolgirl who was assigned to write a review of a book on penguins, and did it in one sentence: "This book tells me more about penguins than I really wanted to know." I myself could have lived comfortably without knowing quite so much as Dr. Nuland has told me about the process of aging that is inexorably moving what I had thought was my healthy body toward its final disintegration.
Still, ignorance is not always bliss. As Dr. Nuland says, "Good health is a guarantee of nothing." Even the healthiest body must eventually wear out and die, not often at a time that we can predict. Nuland tells us this, not to shock or dismay us, but to enable us better to accept reality.
I have written this book as much for myself as for everyone who reads it. By trooping some of the army of the horsemen of death across the field of our vision, I hope to recall the things I have seen, and make them familiar to everyone else. . . . If they become just a bit more familiar, perhaps these horsemen will also become less frightening, and perhaps those decisions that must be made can be sought out in an atmosphere less charged with half- knowledge, anxiety, and unjustified expectations.Unjustified expectations are the main object of Nuland's criticism. He directs it chiefly at medical specialists who look upon disease and death as enemies to be conquered and who carry attempts to overcome them to the point of giving the patient false hopes of recovery, disregarding his suffering in futile efforts to score a medical triumph. How fair this is to the medical specialists is not for me to say. But one can sympathize with Nuland when he says of himself, "The conditions of my illness may not permit me to 'die well' or with any of the dignity we so optimistically seek, but within the limits of my ability to control, I will not die later than I should for the senseless reason that a highly skilled technological physician does not understand who I am."
"Decisions that must be made" and "ability to control" are the key terms that state the basic issue in these two books. The decisions concern what Urofsky calls passive euthanasia, meaning "the withdrawal of 'heroic' or other measures that keep a moribund person alive." He distinguishes it from active euthanasia, where "one takes a positive action that leads directly to the death of another person." Active euthanasia, he adds, "is considered murder in most legal and religious systems." Therefore, while we may expect it to become more and more a political issue, it is not yet the issue in most cases that come before courts. The "ability to control" is the measure of freedom to make these decisions that the law or their own moral beliefs allow to individuals or to their surrogates (who are usually their family members).
Such decisions do indeed have to be made, and the progress of medicine has made them all the more urgent. Neither of these writers pleads for total freedom to make those decisions. Urofsky explicitly recognizes the state's power as parens patriae "to protect the interests and well-being of its citizens and to intervene on their behalf when necessary." But for fully thirty years now it has been clear, to this reviewer at least, that as euthanasia became a live political issue, the pragmatic, problem-solving American mind would see no significant moral difference between killing and letting die, since in either case the patient is just as dead and free from pain.
Urofsky seems to lean that way when he says, "In both instances, a decision is made to take or cease certain procedures in the expectation that death will result." He acknowledges that questions about the morality of suicide "are far more complex than the often heard 'Whose life is it anyway?'" But it is fair to say that, on the ground of personal autonomy, he is not unsympathetic to suicide and "assisted suicide" in what he regards as hard cases.
Nuland believes that "taking one's own life is almost always the wrong thing to do." But he approves of it in the case of a physician who "knowingly facilitated" the suicide of a patient whom he had treated for a long time, knew well, and who had convinced him early on that she preferred to die rather than go through a long and losing battle with cancer. One understands Nuland's feelings in the matter. But we live in a country where half the marriages break up, nearly a third of pregnancies are aborted, a plague of AIDS that Nuland calls pandemic is spread mainly by homosexual intercourse and the use of infected drug needles, and the rate of out-of-wedlock births steadily rises. These and similar facts do not inspire confidence in the ability of Americans to resort to suicide only in rare and compelling cases, if it should become accepted as morally and legally permissible. Better to stick to the belief that the Everlasting hath indeed fixed His canon against self- slaughter, but does not oblige us to use any and every way of prolonging life no matter how burdensome the means or how slight the hope of recovery.
Nuland calls himself "a confirmed skeptic," but says of God: "Nothing would please me more than proof of His existence, and of a blissful afterlife, too." He does not explain why he insists on proof, but it may be the result of having gone to college and medical school, where he learned that the scientific method is the only road to truth. However that may be, the Judaism in which he was raised still has an obvious influence on his mind and heart. He is familiar with its Bible, knows its prayers, and has often recited the Kaddish since his mother's death. "If there is a God," he says, "He is present as much in the creation of each of us as He was at the creation of the earth"-and Dr. Nuland acts as if he truly believed that.
He is a dedicated physician who genuinely cares for his patients. He will help them to get well if he can, and he thinks that on their part they should try: "Few people faced with a diagnosis of potentially remediable malignant disease should be willing to give up the struggle if there is any reasonable chance that some promising form of treatment is available to lessen the ravages of the disease or cure it. To do anything less is not stoicism, but folly."
But he maintains that "our own choices should be allowed, insofar as possible, to be the decisive factor in the manner of our going," i.e., not the doctor's or the hospital's. If patients are dying and are beyond reasonable hope of recovery, he believes that they should be told so, and not be deceived and tormented with desperate and probably useless medical procedures. He regards the current ideal of "death with dignity" as largely a myth: "I have not often seen much dignity in the process by which we die." Yet death comes to all of us, and we do better "by knowing the truth and being prepared for it."