Book Review: “How We Die” by Dr. Sherwin Nuland

Sherwin Nuland was a doctor, surgeon, author, speaker, teacher, philosopher, husband, and father. His life was quite extraordinary and filled with amazing highs tumultuous lows. Sherwin battled through debilitating depression that was successfully treated in the 1970s by electroshock therapy. Dr. Nuland through his own experiences as a doctor coupled with his own personal experiences with the process of dying, wrote a book that is a must read for every person. It explains in detail the six ways most of us will meet the end of life. The book will prepare each person with the understanding that dying with dignity is all about dying on your own terms according to your own set of values. The process of dying is a personal experience and it is not a universal rule that all must do “whatever is available” to prolong life regardless of the cost to mind, body or soul.

Sherwin Nuland Biography

Sherwin Nuland was born in the Bronx on December 8, 1930 to immigrant Russian Jewish parents. He was raised in an Orthodox Jewish manner but later in life became an agnostic. Sherwin was a graduate of the Bronx High School of Science, New York University and the Yale School of Medicine where he also did his surgical residency. Sherwin’s mother died from colon cancer when he was 11 years old and the treatment and kindness shown his mother at such an early age influenced him so much, he decided at a young age o become a doctor to help other people and always remembered the doctor who treated his mother as a pseudo-mentor to him his whole life. Dr. Nuland was married twice and had four children, two from each marriage. He has two daughters and two sons from these marriages. His daughter, Victoria Nuland is the Assistant Secretary of State for European and Eurasian Affairs at the United States Department of State.

Sherwin Nuland and his depression

Because of a troubled childhood and a fear and shame relationship with his father, Dr. Nuland suffered severe bouts of depression. These bouts became more severe and so debilitating that in his early 40s, he was institutionalized for more than a year for treatment. Senior staff at the psychiatric hospital recommended a lobotomy but thankfully a young resident psychiatrist interceded and his recommendation for electroshock therapy was the path of treatment that was chosen. After twenty sessions it became clear that the treatment was a success but was he direct cause of the dissolution of his first marriage. Dr. Nuland returned to medical practice and his surgical duties and still had some issues of depression but they were more manageable and had less negative impact on him.

“How We Die”

Written in 1994, Sherwin Nuland took on the medical profession by writing this book challenging the long standing paternalistic role of the physician that lent it self to a less pragmatic philosophy on treating death. The prevailing philosophy was that the doctor was the only one who knew the proper treatment to handle disease and all avenues of treatment would be expended even if they were in fact pointless treatments that exacerbated the suffering of the dying patient. This book arrived at the perfect time as palliative medicine and hospice care was in it’s infancy. Dr. Nuland arrived at this philosophy at embracing death watching his brother try every means necessary to beat his terminal colon cancer. The treatment in his case and many people is worse than the disease and robs people of a dignified death.

The “Ah-Ha” moment in the book for me

A particular aspect of the book talked about the psychological make-up of doctors which I found interesting. Dr. Nuland hypothesizes that doctors by nature are high functioning, “type A” intellectuals with massive egos and the unrelenting desire to succeed. They are highly competitive and without that ambition would not have survived and excelled in the competitive and grueling study to become a doctor or a surgeon. He opined that many doctors think of medicine as a battle of wills between the disease and the doctor. And because of their competitive drive and wantonness to succeed will often become apathetic to the patient and their emotional well being and sacrifice that for even the slimmest chance at conquering the disease.

Dr. Nuland’s evolution in philosophy on treating terminal patients

Dr. Nuland concludes that life and death are parallel journeys and that a dignified death is preceded by a life of dignity. That people should not blindly follow the advice of the medical establishment but to follow their own set of values regarding quality of life and death. Dr. Nuland realized this when his brother was dying. He did him an injustice by not telling him how dire and hopeless his prognosis was and this lapse in judgment, withholding the severity of his brother’s malignancy, caused more harm than good. It gave his brother unrealistic hope when there just was no hope with the universal spreading of the cancer beyond his colon into almost every organ in his abdomen. His brother chose to try an experimental treatment that caused him to become a shell of his former self and die a death that was not in any realm associated with dignity. It was the exact opposite, he did extend his brother’s life for a few months, but the cost was so high that his brother and his family suffered more than peacefully succumbing to the ravages of the disease with acceptance and giving closure to his family.

The Cure is sometimes worse than the disease

In summary, I have a new philosophy on life and death after reading this book. I read it many years ago when it first came out and before writing this article, just finished re-reading it as a 50 year old man. This book will be a game changer for me one day in the not-so distant future. It will give me the courage to say no to my doctor if I feel that the quality of my life will be forsaken for a few more miserable months doing anything to “beat” the disease. One thing is for sure, we will all go to our death alone. It is one of the few experiences in life that is a journey you take by yourself. The question is, should the time preceding the inevitable be a time of peace and comfort, or pain, discomfort and sadness trying to grasp at anything to extend life regardless of cost to quality of the final days of life.

Dr. Sherwin Nuland’s Legacy

Dr. Nuland died on March 3, 2014. The world is not a better place with his absence and he will be missed but he left us all his legacy. He helped and cured thousands of people in his career and he helped many meet their dignified death. He has also given us all the gift of his philosophy on life and death. It is up to you if you want to listen to his advice. Dr. Nuland would tell you to read his book and then with your own set of values, come to your own working philosophy on what life and death means to you and figure out at what point should death be accepted as the right path to a dignified life.

Sources: The New York Times, NPR , Los Angeles Times, “How We Die”

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