“But our machines have now been running seventy or eighty years, and we must expect that, worn as they are, here a pivot, there a wheel, now a pinion, next a spring, will be giving way; and however we may tinker them up for a while, all will at length surcease motion.” — Thomas Jefferson

The most difficult book that I have read recently is Sherwin B. Nuland’s How We Die: Reflections on Life’s Final Chapter (1993). It is difficult to read, not because it is poorly written or exceptionally long-winded (it is neither), but rather because the book’s subject is the manner in which people die, which Nuland, a surgeon and educator, describes in clinical detail. Nuland explains what is happening in our bodies when we have a heart attack or a stroke, or when we have been diagnosed with Alzheimer’s, AIDS, or cancer. He describes old age and the inexorable process that leads eventually to death, a reality that Thomas Jefferson was acknowledging in his letter to John Adams in 1814, quoted above. I come away from reading Nuland’s book with the realization that my own death is not likely to be dignified. Nuland writes:

“Death with dignity” is our society’s expression of the universal yearning to achieve a graceful triumph over the stark and often repugnant finality of life’s last sputterings….

But the fact is, death is not a confrontation. It is simply an event in the sequence of nature’s ongoing rhythms. Not death but disease is the real enemy, disease the malign force that requires confrontation. Death is the surcease that comes when the exhausting battle has been lost. Even the confrontation with disease should be approached with the realization that many of the sicknesses of our species are simply conveyances for the inexorable journey by which each of us is returned to the same state of physical, and perhaps spiritual, nonexistence from which we emerged at conception. Every triumph over some major pathology, no matter how ringing the victory, is only a reprieve from the inevitable end.

As painful and difficult as it is to read about my inevitable end, I accept Nuland’s premise that accurate knowledge of how a disease kills can serve to protect us from our own worst imaginings. Knowing what is happening to us and the likely course of events to come makes us better able to make rational decisions about treatment options that may be presented to us: “A realistic sense of what is to be expected serves as a defense against the unrestrained conjurings of warrantless fear and the terror that one is somehow not doing things right.”

The final disease that nature inflicts on us will determine the atmosphere in which we take our leave of life, but our own choices should be allowed, insofar as possible, to be the decisive factor in the manner of our going.

Nuland addresses the role of the doctor in treating serious illness. The quest of every doctor, Nuland writes, is to make the diagnosis and design and carry out the specific cure. He calls this quest “The Riddle” and notes that “a physician’s driving quest to solve The Riddle will sometimes be at odds with our best interests at the end of life.”

The boundaries of medical futility, however, have never been clear, and it may be too much to expect that they ever will be. It is perhaps for this reason that there has arisen the conviction among doctors—more than a mere conviction, it is nowadays felt by many to be a responsibility—that should error occur in the treatment of a patient, it must always be on the side of doing more rather than less. Doing more is likely to serve the doctor’s needs rather than the patient’s. The very success of his esoteric therapeutics too often leads the physician to believe he can do what is beyond his doing and save those who, left to their own unhindered judgment, would choose not to be subjected to his saving.

And so what hope is left as we die? Nuland offers his answer, which seems to me a rich insight. He concludes “the greatest dignity to be found in death is the dignity of the life that preceded it.” Hope, he says, “resides in the meaning of what our lives have been.”

And so, if the classic image of dying with dignity must be modified or even discarded, what is to be salvaged of our hope for the final memories we leave to those who love us? The dignity that we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars vivendi: The art of dying is the art of living. The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that preceded them. Who has lived in dignity, dies in dignity.


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