At a moment when medicine has brought us blessings beyond our grandparents’ dreams, a sour aroma of disappointment surrounds the healing arts. Indeed, the medical and political professions are now akin: the more omniprovident government is, the lower it sinks in public esteem, and the more impatient, demanding and irritable its beneficiaries become. Roy Porter, medical historian, says medicine is suffering a malaise that is partly “the price of progress and its attendant unrealistic expectations.”
Medicine has become a prisoner of its success. As the Western world becomes healthier, it craves more medicine until, Porter says, medicine’s mandate becomes muddled. “Medical maximization” becomes a patient’s right and a doctor’s duty. “Anxieties and interventions spiral upwards in a double helix” as “medicine-mongering” leads to “gung-ho, ‘can-do, must-do’ technological perfectionism: everyone has something wrong with them, everyone can be cured.” But there is a law of diminishing returns in medicine, pointing to an ignominious destiny-medicine bestowing meager increments of unenjoyed life, the result of disproportionate investments of resources, comparable to athletes taking steroids to shave milliseconds from sprint records.
The subject of medicine is deeply, even metaphysically, disturbing because it reminds us that death is coming and could come with the next tick of the clock. Furthermore, progress regarding medicine’s timeless aspirations-longer life, better health-has whetted appetites toy unlimited progress toward retarding senescence and preserving youthfulness. Concerning such yearnings, Sherwin B. Nuland says, briskly: Too bad. Medicine has a job to do, but nature does too, and will do it, medicine be damned. Nature’s job is to send us packing so that subsequent generations can flourish. And medicine that does not respect limits set by nature can make death unnecessarily unpleasant, and can distort life too.
Nuland is a surgeon and a surgical writer-precise, incisive, unsentimental. In his harrowing new book, “How We Die: Reflections on Life’s Final Chapter,” be says that life’s final flickerings are, more often than not, messy and agonizing and devoid of dignity. Life is dappled with periods of pain, but in dying there often is only the affliction. And medicine-or, more exactly, the wrong kind of doctoring-can make matters worse.
Eighty-five percent of the aging population will succumb to one of seven ailments-atherosclerosis, hypertension, adult-onset diabetes, obesity, Alzheimer’s and other dementias, cancer and decreased resistance to infections. Nuland’s purpose in “trooping some of the army of the horsemen of death across the field of our vision” is to “demythologize the process of dying.” He does. Do not pick up his book at bedtime. Its unsparing detail about the incremental debilitation of our tissues and organs is almost assaultive. Did you know-do you want to know-that in every decade after age 50 your brain loses 2 percent of its weight? Nuland’s explanation of a heart attack is enough to cause one, but his description of one is less searing than what he has to say about AIDS.
He pummels his readers with their mortality in order to get them to face the skull beneath the skin of life. In the Western world in less than 100 years the life expectancy of a child at birth has more than doubled. This has incited the hope that there is no species-determined limit to lifespan. But Nuland believes there are “natural, inherent limits. When those limits are reached, the taper of life, even in the absence of specific disease or accident, simply sputters out.” And a good thing that is, says Nuland, noting that, in medicine and elsewhere, two world views are in tension. One view recognizes nature’s inexorable tides. The other believes that science’s task is to throw all available resources into resisting those tides, even though those tides, by constantly renewing the species, stabilize our social environment and make possible civilization’s progress.
Every doctor who understands, as Nuland does, that medicine is an art as well as a science is apt also to be a moralist who understands that medicine’s fight against illness can be fierce without being disproportionate. An obsession with longevity distracts us from our duty to live well. Acceptance of death is a prerequisite for rising above concern for mere bodily continuance. Biology confirms what philosophy teaches: We are social creatures whose lives point beyond themselves, toward children. Children, says Leon Kass, another philosophical doctor, are “life’s answer to mortality, and their presence in one’s home is a constant reminder that one no longer belongs to the frontier generation.”
Mortality gives life symmetry, and an urgency about getting on with good works. But accepting limits goes against the grain of medicine, which Nuland calls the “most egocentric of professions” and “the one most likely to attract people with high personal anxieties about dying.” Medicine is especially susceptible to modern science’s “fantasy of controlling nature.” Medicine, he says, has lost the humility proper in the presence of nature’s power. That fact is related to this one: Today 80 percent of Americans die in hospitals, too often tangled in webs of wires and tubes in intensive care units which are, Nuland says, “the purest form of our society’s denial of the naturalness, and even the necessity, of death.”
“Between the lines of this book,” he says in his epilogue, “lies an unspoken plea for the resurrection of the family doctor. Each of us needs a guide who knows us as well as he knows the pathways by which we can approach death … At such times, it is not the kindness of strangers we need, but the understanding of a longtime medical friend.” Health care reformers, please note.
