BOOK REVIEW / When death is taboo, what hope for the dying?: How we die - Sherwin B Nuland: Chatto, pounds 15.99

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The Independent Online
DEATH is our last taboo. While the Victorians celebrated it and attempted to render sex unmentionable, our society, stripped of religion and promises of an afterlife, flies to the opposite extreme. But whether we eat, drink and be merry or diet, exercise and use HRT, to one end we will come.

Sherwin B Nuland, who teaches surgery and medical history at Yale, has outlined six of the commonest categories of death. His choices - heart failure, cancer, Aids, Alzheimer's disease, murder, accident and suicide - are described in a series of portraits and meditations on the dying that is wise, humane and poetic. Blending the personal, the clinical and the historic produces a book that is not going to cheer you up, but is essential reading to anyone remotely interested in the human condition.

Starting with his first dramatic experience of death - cutting open a dead man's chest and desperately massaging his heart with bare hands - Nuland systematically examines our various exit routes. His descriptions achieve his objective of demythologising the process of dying. Worn-out, besieged by microbes of pneumonia, racked with pain, drowning and suffocating in its own liquids, the patient's body is a battlefield, defended by drugs, the knife, immunities, but ultimately doomed. That the battle is tremendous and the enemy cruel is never in question; Nuland describes Aids as 'murderous', an adjective that could seem too anthropomorphic were it not for his explanation that 'not death but disease is the real enemy'.

His stories are moving, and full of paradox. The degradation of Alzheimer's is worse than the peaceful death of murder victims, cushioned by endorphins. 'The more knowledge we have . . . the more sensible we can be about choosing the time to stop or the time to fight on,' the doctor observes: yet he deplores suicide and euthanasia. There are, in fact, few choices.

His stories are suffused with useful etymology and wide reading; like Oliver Sacks, he has the knack of pinning down what is fascinating about each disease. However, the deeper fascination of How We Die is not pathology, but the way doctors and the dying cope with an event few now witness. Eighty per cent of American deaths now occur in hospital, with the dying isolated, encased in a panoply of tubes, machines and biotechnology. This 'invisible death' hides the dirt and ugliness of dying but deprives the victim and those who remain of the chance to depart with grace. Many hospitals fear that offering extreme unction is 'like telling a patient to die', whereas, as Nuland says, a priest may offer comfort even to atheists. Such comforts are not empty or cowardly, as anyone who has tended the dying knows. Hope lies not only in cure, remission or hope of an afterlife, but in the moment when a milestone is reached - a deed accomplished, an idea understood or the arrival of one we love.

Doctors usually abandon us in the hour of our death; as Nuland observes, drily, 'of all professions, medicine is the one most likely to attract people with high personal anxieties about dying'. They begin with the wish to succour, but what seduces the brightest is the quest to diagnose the disease and design the right cure. Such a quest may bring tremendous intellectual rewards, but often at the cost of the humane care for which Nuland pleads.

His wisdom is simple, but hard- won. We die so that the world may live. It is unlikely that we will die with dignity. But we should live, he says, each day is if it were our last, and yet as if we expect to go on forever. Is it possible? We must discover that for ourselves.