Remembering Sherwin Nuland

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The death last week of Dr. Sherwin Nuland, author of the prize-winning 1994 book, How We Die, reminded me of a line in that book “about our society’s denial of the naturalness, even the necessity of death.” Death in an ICU, he wrote, was the “purest form” of that denial, but more broadly he wrote, “Nowadays, the style is to hide death from view.” I suspect that death has become more open since then, in great part because of his book. It is still not an easy topic for most people.

Shep, as he was known to those close to him, was a friend and a colleague, a professor of surgery at the Yale School of Medicine, who retired at age 50 to be writer, mainly of medical history. I had a curious experience when his book came out. I was writing a book of my own on death in 1994. I wanted the title to be In Search of a Peaceful Death, but my editor at the press said, “No, we can’t sell a book with the word death in the title. No one would buy it.” I gave in and the title became The Troubled Dream of Life. Five months later his book came out, won many prizes, and sold 500,000 copies.

Shep was also one of the co-editors of the Over 65 blog and one of his books was on aging. He is a real loss, both to us, his fellow editors, but even more our society, sorely in need of his wisdom and insight.

But the “naturalness” of death that Nuland wanted has faded away as a common way of talking. That word, or the phrase a “natural death,” once common in obituaries (along with “died of old age”), has been gradually retired and replaced by the medical cause of death. We don’t just die any more. We die of something. Meanwhile, during the same transition era there has been tidal wave in the use of the word “natural” as a term of virtue and praise. The best food is natural and organic, the best water is natural spring water, and the best clothes are made of natural fibers. But death is no longer allowed in that exalted company, even though I would argue that death is as natural as childbirth or the law of gravity.

Sometime in the not too distant past death became a medical event. When medicine came into its modern curative era in the late 19th century, nature was forced since then to give way until it almost disappeared. If the causes of death can be medically named, then something can be done about them. It is not coincidental that many obituaries now end by requesting, in lieu of flowers, a contribution to organizations devoted to finding a cure of the disease that killed the deceased.

A provocative study some years ago by a medical anthropologist found that hospital physicians believed patients die because the available technologies fail to keep them alive—not because of the failure of their bodies. That helps explain, perhaps, why sometimes physicians feel they have failed when a patient dies, even if nothing more could possibly have been done. When some philosophers came along in the 1970s claiming that there is no ethical distinction between turning off a respirator to allow a patient to die and directly killing that patient by a lethal injection, nature was further diminished as a cause of death.

I have a kind of bemused memory of an exchange I had after a lecture in Arkansas almost 25 years ago. I argued that there is such a thing as a natural death, but was vigorously attacked by some younger members of the audience for using that outdated phrase. Death, they seemed to be saying, is wholly fluid and changing. What may be “natural” for one generation will not be for a later one. That may be true, I responded, for, say, an increase in average life expectancy, but not for the death that will finally come despite life’s greater length. I was pleased that after the lecture an elderly man with a rich Southern accent came up to me and said, “I’m a farmer with lots of animals. We all understand what you are talking about.”

When Pete Seeger died in 2013, his son said that he had “died a natural death.” That was all the more appropriate because he spent much of his life and music focused on finding a good fit between our human nature and the environment from which we draw our food, water, and resources. It is natural for trees and plants to die and be replaced by new ones that grow in their place, but not natural to have them killed by air pollution. Clear and clean water is natural, but water like the Hudson is still rendered dirty from PCBs. We remember the line from Ecclesiastes about “a time to be born and a time to die” because it well catches one of the important rhythms of life. People continue to die because death has the last word, as always. Maybe it will once again be possible for people to die a natural death. That natural death for most people will now be in old age, and it should be acceptable to use that phrase as well.

As it turned out, Shep’s obituary said that he had died of cancer of the prostate at age 83. I think he would have preferred “natural death,” but I never thought to ask him about that. It was, I was told, a difficult and painful death. The great strength of his book, which was influential in bringing death out in the open, was that he did not romanticize death nor did he think of it as an enemy. It was just death, a natural event in human life.

Daniel Callahan, 83, is co-founder and President Emeritus of The Hastings Center and an editor of Over 65.

3 Responses to “Remembering Sherwin Nuland”

  1. Steve Moffic

    I’d like to add some comments on how this giant of our field lived. He could be a role model for changing fields as one ages, as he went from surgeon to painfully give up being considered a healer, by turning to be a full-time writer. Of course, as Dan Callahan covers, he was a different kind of healer in his writings. I, too, in a much less noticeable way, have transitioning from psychiatrist clinician to part-time writer and have actually been called a healer more than I used to be as I spend more time in the public sphere of life.

    Dr. Nuland was also open with having to overcome an angry, difficult father, which seemed to related to a severe personal depression. With ECT and other help, he recovered, and recovered to do all his masterful writings. Here, he is a role model for recovering in psychiatry and a counter-force for stigma.

    Dr. Nuland showed us much about how to live and die. Let us learn from him.

    -Steve Moffic

  2. Carol Eblen

    I’m sure Dr. Nuland would be delighted with the tributes paid to him in this Article by the talented writer, Dr. Callahan, and the comment written by Dr. Moffic, another talented writer.

    How fortunate Dr. Nuland was to retire young and to do something that he loved to do after he retired from medicine and after he recovered from terrible depression with psychiatric assistance. It would have been wonderful if he could have died in his sleep right after his terminal diagnosis and not have suffered the terrible prognosis of pancreatic cancer. Did he die in Hospice at home or in a Hospital Hospice, and did he communicate with others as to his “final” thoughts on dying?

    Dr. Callahan indicates that it was a difficult and painful death? Did Dr. Nuland ever think about a “final fast” —refusing food and water —while he was on Hospice —which would have shortened his suffering unto death? Most elderly and ill patients will die in six to twelve days if they refuse food and water. If they are on Hospice and have made known their desire to “fast unto death” the fast will be eased with pain medication and they will sleep unto death.

    I am still waiting for Dr. Callahan or Dr. Moffic to respond to my questions and comments about the epidemic of unilateral covert and overt(default) DNR code status that is extrapolated into the charts of elderly Medicare/Medicaid patients when the hospitals KNOW that there will be no reimbursement from CMS and private insurers for any further hospital treatment.

    I understand that Dr. Callahan and Dr. Moffit support the compassionate dying of elderly/disabled Medicare/Medicaid patients outside of expensive ICU and CCU care in Public Hospitals that receive public funds, But! do you both support the unilateral, involuntary euthanasia of of the elderly/disabled for the fiscal expediency of Medicare/private big insurance and the hospitals? —when the treatment withheld with the unilateral covert/overt (default) DNRs is not medically futile under any existing law?

    Obviously, because of the NOW 26 or 27 Adverse Events, starting in 2005, that are NOT reimbursed by CMS and private insurance, as well as the pay for performance standards, the Diagnosis Related Group Caps, and the Present on Admission (POA) criteria Medicare/Medicaid patients are victims also of disparate discrimination because of CNS reimbursement protocols. ( Dr. Gillick demonstrates in her Hastings Center Article “Keeping the Elderly out of the Hospital” that elderly Medicare and the disabled are more prone to suffer from adverse events in the hospital

    My husband and I spent four years at Yale and had great respect for the integrity of the academics who contribute to the law and public policy of our great democratic Republic.

    But, haven’t the bioethicists protected the physicians and big insurance and big medicine at the expense of the American public who pay Medicare and Social Security Taxes all of their working lives?

    Aren’t both of you wealthy enough and old enough that you could respond to my questions or write an article about the problematic DNR Code Status (covered by Dr. Gillick of Hastings) and the rumor of unilateral DNRs that would push the Congress into clarifying the goals of the 1991 PSDA?

  3. Daniel Callahan

    I made an error in my blog on Sherwin Nuland. He died of prostate cancer, not pancreatic cancer.