The dying of the light

One big change has happened in the last few years, without almost anyone noticing. Death has lost its taboo status. It's not clear why this has happened, and there are probably many reasons. One thing is sure - our interest in understanding death is alive and well.

A newly published work, Modern Death by Haider Warraich, a fellow in cardiology at Duke University Medical Center, joins a fairly short but growing list of books written by doctors about death, the process of dying, and how we deal with it. It’s difficult to pinpoint the exact start of this relatively new sub-genre; doctors have always written about the final days and hours, but publishers have in the last couple of decades cottoned-on to the fact that readers are curious about medicine and the end of life. There’s money to be made from memoirs, particularly from memoirs that once upon a time would have been regarded as simply morbid.

The best of this sub-genre can be very good indeed. Twenty-three years ago Sherwin Nuland, then a consultant surgeon at the Yale-New Haven Hospital, where he had worked for more than 30 years, published his excellent book How We Die, a superb work that is both compassionate yet unsentimental. Nuland suffered from depression and there’s a great video of him discussing that and electroshock treatment. He died in 2014 but his book, which won a US National Book Award for non-fiction, ought to live forever. At the close of his book he wrote: “The dignity that we seek in dying must be found in the dignity with which we have lived our lives…the art of dying is the art of living.”

Two other notable books have followed where Nuland led, both published in 2014. Atul Gawande – a fairly prolific writer who also is a surgeon at Brigham and Women’s Hospital in Boston – published Being Mortal, which followed what has become by now the standard practice, combining medical knowledge and expertise with a sprinkling of personal anecdote and reflection. It’s an interesting read but not a patch on Nuland.

The dignity that we seek in dying must be found in the dignity with which we have lived our lives…the art of dying is the art of living.

The other 2014 medical best-seller was Do No Harm by the British brain surgeon Henry Marsh, ladened with critical praise, and which I thought was brilliantly written and immensely humane, though some readers disliked what they thought was Marsh’s pomposity and arrogance. Having seen him give a talk on his book and work, I feel he is anything but arrogant; he’s just rather fed up with all the bullshit the NHS imposes on its medical workers these days. And anyone who regularly visits Ukraine to practice pro bono brain surgery deserves all our respect.

While I have read and can therefore sensibly recommend those, two books I haven’t read within this sub-genre are worth mentioning. Paul Kalanithi, another neurosurgeon, helped his book, When Breath Becomes Air, become a massive best-seller in 2017 by the unfortunate act of dying in 2015 at just 37. Simon Westaby, a heart surgeon, made less money (I suspect) for his publishers from his Fragile Lives, also published in 2017; it may have been just as good a book as Kalanithi’s but was relatively overlooked by the fickle mass media, for which a dead author pulling on the heartstrings seems to be more interesting than a live one.

So one thing we can conclude is that publishers are now keen on books written by doctors about the process of trying to preserve life and failing to do so. Which no doubt helps explain why Haider Warraich found a publisher for Modern Death, which is a good title, at least. But is it any more than that?

Yes it is, because it advances our consideration about death and dying into what is possibly the most difficult area of all: medicine can prolong life beyond all previous hopes – but should it? Warraich’s book pinpoints the crux of the contemporary debate over death: “Far from being clearer, the line between life and death has become far more blurry. These days we can’t even be sure if someone is alive or dead without getting a battery of tests.”

Along the way Warraich trots out not just the familiar personal experiences of any doctor when it comes to facing death and terminal illness in patients, but also a host of fascinating oddities, such as the fact that a nematode called Caenorhabditis elegans survived the February 2003 Columbia space shuttle disaster; when these millimetre-long worms die they “emit a blue light just prior to their demise.” He points out that “age continues to eat away at us even as we find better ways to prevent, cure, and manage disease.” And the fact that “the average American lives for 2,481,883,200 seconds.” He makes the point that, today, “as we learn more about the final few seconds of our lives, and the first few after our death, we are finding things that nothing in the past could ever have prepared us for.”

I also enjoyed the way he delves into some of the murkier corners of modern medicine, such as his account of a French doctor, Alexis Carrel. Carrel learned from a seamstress and, from her example, pioneered suturing techniques; but was so frustrated by his failure to gain promotion in France that he left for the University of Chicago, and thus became the first US Nobel Prizewinner for Medicine in 1912. He continued his experiments and, funded by the world’s then richest man, John D. Rockefeller, his lab kept a chicken’s heart – grown from an embryo – beating.

Carrel’s reputation was destroyed by his later life. He returned to France during the Second World War and set up a field hospital, which he continued its work under the pro-Nazi Vichy government. After the Vichy government was overthrown Carrel was put under arrest, and died in November 1944. It wasn’t just his work under the Vichy government that sullied his name. In his best-selling book, Man, The Unknown, Carrel had written in support of eugenics, writing that all criminals and those who have “misled the public in important matters, should be humanely and economically disposed of in small euthanasic institutions supplied with proper gases.” The chicken’s heart carried on beating in his former lab after he died, aged 68; later investigations showed that Carrel had, in any case, rigged the experiment.

Warraich has written a wise book. “At any given time, we always find it easier to look back and comment how wrong people were in the past” he says. He identifies the rapid rise of ‘the hospitalisation of death’ by pointing out that in 1969 about 1% of people (presumably in the West) were hospitalised in the last year of their life, while by 1987 the number was 50%. There are several possible explanations for this but one of them has to be the development and growth of expertise in fending off death, thanks to the intensive care units (ICUs) in hospitals.

He is the type of intelligent doctor, who listens to patients and doesn’t just treat their body, I’d like to have in my own final days

Warraich clearly thinks that the intensive manner in which we intensively care for the inevitably dying is a mixed blessing. He says: “As people age, their schedules become [today] increasingly governed by their medical appointments and hospital admissions, their diet is affected by their diseases and their medications, they become increasingly enslaved. In bygone times, dying didn’t leave people this helpless. In fact, people orchestrated their own last speeches and their own deathbed scenes. Only they were the experts on themselves.”

His important book is, in essence, a challenge to his own profession. The recent staggering and rapid technological advances in medicine have, he suggests, come at an enormous cost, one that we barely recognise. We have become brilliant at prolonging life, but much worse at dealing with death, precisely because the prolongation of life usually means a diminution of life-quality. Bravely, considering that he’s a doctor and therefore committed to the tenet ‘do no harm’, Warraich asks “why have physicians provided the greatest opposition to assisted suicide throughout history?” Patient’s wishes are not just about living an extra month, week, day…hour. They are, as Warraich says, “about how they would want their lives to conclude and, importantly, what can be done to help them achieve that in the way they would want…some of the most pressing questions of our time. And despite all our progress, they haven’t been fully addressed.”

He is the type of intelligent doctor, who listens to patients and doesn’t just treat their body, that I’d like to have in my own final days.