How We Die (23 page)
Authors: Sherwin B Nuland
The injured explorer had plenty of time to think about his narrow escape during the more than two months it took him to recover from the blood loss, the shattered compound fracture, and the serious infection that began draining pus within a short time. As much as he was amazed at his survival, so also was he by the equanimity he had felt while in the lion’s grasp. He would later describe the event and his ineffable sense of peace in the autobiographical work he published in 1857,
Missionary Travels and Researches in South Africa
.
Missionary Travels and Researches in South Africa
.
Growling horribly close to my ear, he shook me as a terrier dog does a rat. The shock produced a stupor similar to that which seems to be felt by a mouse after the first shake of the cat. It caused a sort of dreaminess, in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening. It was like what patients partially under the influence of chloroform describe who see all the operation but feel not the knife. This singular condition was not the result of any mental process. The shake annihilated fear, and allowed no sense of horror in looking round at the beast. This peculiar state is probably produced in all animals killed by the carnivora; and if so, is a merciful provision by our benevolent Creator for lessening the pain of death.
In that long-ago day when laboratory science was barely beginning its long partnership with bedside medicine, Livingstone’s explanation for his remarkable calm was one with which most people probably agreed. It would have taken prescience, or perhaps a disavowal of faith, to have invoked physiology in those dawning moments when microscopy and chemical analysis were but swaddled newborns. For Livingstone to have somehow intuited the principles of stress-related biochemical alteration of states of consciousness was quite improbable. Absent a supreme leap of prophetic vision, beyond the capability of even an ordained Christian missionary, he could not have foreseen the discovery of such a phenomenon.
I have had the personal experience of one such episode. I am not by nature a fearful person, and yet there are two situations that scare me to the point of pathological irrationality: finding myself looking down from some great height, and being immersed in deep water. I need only to think about either of those two hazards to set off a spasm of tightness in each of my sphincters, from the top of the alimentary tube right down to its very end. It is not just that I am cautious about deep water, or even afraid of it—I am unmanned by it, reduced to craven, phobic cowardice. In a swimming pool surrounded by healthy young adults, any one of whom is capable of rescuing me without so much as straining a single fiber of Schwarzeneggeroid muscle, I have more than once felt the dread certainty of imminent drowning; it has been exploded into my brain by the simple realization that I have wandered a few inches beyond my depth.
With an American colleague and a half dozen faculty members of the Hunan Medical University near the south-central Chinese city of Changsha, I was leaving the site of an elaborate banquet (during which my entire alcoholic intake had consisted of one bottle of Tsingtao beer consumed during the early portion of a two-hour meal), chatting and strolling along a curving walkway that stretched a short distance through what appeared to be a shallow reflecting pool. I was fully dressed, and carried a partially filled carry-on bag slung over one shoulder. Having been at the guest-house two years earlier, I was not unfamiliar with the terrain, but I seem not to have taken into account the narrowness of the winding pavement or the virtual absence of outside lighting on that starless night. As I turned partly around in midstride to address a remark to one of my hosts walking behind me, I suddenly found myself with nothing under my right foot. In an instant, I was immersed well over my head in the impenetrably black water, and still sinking. Simultaneously with the flash of realization that I was fully vertical and continuing to go ever deeper, I felt a stunned surprise and a mild but very distant sense of ironic amusement, as though I were involved in some ill-advised and silly stunt that hadn’t worked out quite as I had planned. At the same time, I was annoyed with myself for what I immediately recognized—even down there and seemingly headed through a narrow waterway leading through the earth’s crust directly back to New Haven—as a bit of clumsiness that might interfere with the successful completion of my mission in Hunan. Most remarkably, there was no sensation of fear and certainly no thought that I might be drowning.
Although I was not aware of it, I must have finally hit bottom and instinctively kicked off from it like an experienced swimmer, because I soon found myself rising straight up, until my head broke the surface. Taking hold of the outstretched hands of my shouting, frightened companions, I clambered out of the pool, using as footholds the irregular projecting rocks that formed its sides. The bag was still on my shoulder; all I had lost were a pair of eyeglasses and some of that necessary element of dignity the Chinese call
mianzi
, or “face.” For a few moments, I stood there on the walkway, feeling stupid, embarrassed, and suddenly very chilly.
mianzi
, or “face.” For a few moments, I stood there on the walkway, feeling stupid, embarrassed, and suddenly very chilly.
My deep dip could not have lasted more than a few seconds, and the summoning of endorphins is only another presumption without possibility of proof. But I relate this episode as a personal testimony to a sudden unanticipated circumstance that should have provoked chaotic loss of control, and yet resulted only in a detached imprint of calm and quite reasonable observations about the fix I had (literally) fallen into. The element of emotional shock seems to have triggered a stress response that deprived me of the awareness of danger, thereby preventing the panic-stricken disintegration that might otherwise have taken place. I was saved, it appears, from the ineffectual flailing of arms and the aspiration of a few quarts of stagnant water, not to mention the virtual certainty of slamming my thrashing head against the jagged rocks that were only inches away.
My brief moments of peril were hardly of the magnitude of sensory assault visited on a Montaigne or a Livingstone, and I am not so insensitive as to compare them with the tragic events that befell little Katie Mason. And yet, except for a vast difference in degree, they all seem to illustrate the same phenomenon—apparent tranquillity instead of terror, and resignation in the place of self-defeating struggle. Many have pondered the reasons these things should be so, and the answers are spread out over a philosophical terrain as wide as the distance between spiritualism and science. Whatever the source, humankind and many animals often seem to be protected at the instant when sudden death approaches—protected not only from the horror of death itself but from certain kinds of counterproductive actions that might ensure it or extend its anguish.
Here I approach hazardous, but unavoidable, territory. The phenomenon called (and frequently capitalized for emphasis) the Near-Death Experience has been much discussed of late. No sensible observer can discount the many tales from the almost-beyond that have been collected by reliable investigators interviewing credible survivors. Those seeking to interpret their findings on a reasonably scientific basis have invoked a variety of possible causes, from the psychiatric to the biochemical. Others seek clarification in religious faith or parapsychology, while still others accept the experiences at face value, believing them to be not only real but, in fact, the first stages of entrance to a blissful afterlife, virtually always in heaven or its equivalent.
The psychologist Kenneth Ring has interviewed 102 survivors of life-threatening injuries or illnesses. Forty-nine of them met his criteria for deep or moderate near-death experience, and fifty-three were found to be what he called “nonexperiencers.” The great majority of illness interviewees had suffered a sudden episode, such as a coronary infarction or a hemorrhage. Dr. Ring found certain basic sequential elements among his positive responders: peace and the sense of well-being; body separation; entering the darkness; seeing the light; entering the light. Other, less universal characteristics include a review of one’s life, an encounter with a “presence,” meeting deceased loved ones, and making the decision to return. Some of Dr. Ring’s patients were medically so far gone that they were thought to be clinically dead, but most were not yet at that point, being merely life-endangered.
I have no more basis for interpreting this so-called Lazarus syndrome than do most others who have pondered it, but I would like to be a little more respectful of the observed facts than have some of the more wishful among them, especially those who go so far as to call the object of their lucubrations the
After
-Death Experience. To do that, I find it helpful to look at the phenomenon’s possible biological consequences—what might its function be, and how is it beneficial in the preservation of individuals and the species?
After
-Death Experience. To do that, I find it helpful to look at the phenomenon’s possible biological consequences—what might its function be, and how is it beneficial in the preservation of individuals and the species?
I believe that the near-death experience is the result of a few million years of biological evolution, and that it has a life-preserving function for the species. Very likely, it is similar in nature to the process described in the foregoing pages. The fact that it seems in some few instances to occur even when “death” has been prolonged or relatively stress-free does not alter my expectation that it will one day be proven to be driven, if not specifically by endorphins, then by some similar biochemical mechanism. I would not be surprised if some of the other elements that have been thought to be possible causes do prove to play a role, such as the psychological defense mechanism called depersonalization, the hallucinatory effect of terror, seizures originating in the temporal lobes of the brain, and insufficient cerebral oxygenation. In turn, release of biochemical agents may, in fact, be the consequence or the instigator of one or several of such processes. In the few possible cases where the phenomenon takes place during the lingering death of terminal patients, of course, other factors may play a role, such as injected narcotics or toxic materials produced by the illness itself.
Like so many other biochemical explanations of obscure, seemingly mystical phenomena, this one has no argument with the religious among us. I am neither the first to wonder about the mysterious ways in which God is thought to work His inscrutable will nor the source of the rumor that He may use chemicals to do it. As a confirmed skeptic, I am bound by the conviction that we must not only question all things but be willing to believe that all things are possible. But while the true skeptic can exist happily in a permanent state of agnosticism, some of us have a wish to be convinced. Something within my rational soul does rebel at the invoking of parapsychology, but certainly not of God. Nothing would please me more than proof of His existence, and of a blissful afterlife, too. Unfortunately, I see no evidence for it in the near-death experience.
I do not doubt the existence of the near-death phenomenon and of the equanimity that is sometimes felt when mortality suddenly threatens. Nevertheless, I question the frequency of its occurrence in circumstances other than those that are sudden. Certainly, the comfort and peace, and especially the conscious serenity, of final lingering days on earth have been vastly overestimated by many commentators; we are not well served by being lulled into unjustified expectations.
VII
Accidents, Suicide, and Euthanasia
I
N A FREQUENTLY
quoted 1904 address at Harvard, the Ingersoll Lecture on the Immortality of Man, William Osler spoke of having in his possession what he described as the deathbed records of about five hundred people, “studied particularly with reference to the modes of death and the sensations of the dying.” The case histories of only ninety, said Osler, showed evidence of pain or distress. Of the five hundred, “the great majority gave no sign one way or the other; like their birth, their death was a sleep and a forgetting.” The dying are, in Osler’s description, “wandering, but uncertain, generally unconscious and unconcerned.” Lewis Thomas goes even further: “I have seen agony in death only once, in a patient with rabies.” At the time of their utterances, both Osler and Thomas were (Thomas still is) among the most highly respected medical savants of their eras.
N A FREQUENTLY
quoted 1904 address at Harvard, the Ingersoll Lecture on the Immortality of Man, William Osler spoke of having in his possession what he described as the deathbed records of about five hundred people, “studied particularly with reference to the modes of death and the sensations of the dying.” The case histories of only ninety, said Osler, showed evidence of pain or distress. Of the five hundred, “the great majority gave no sign one way or the other; like their birth, their death was a sleep and a forgetting.” The dying are, in Osler’s description, “wandering, but uncertain, generally unconscious and unconcerned.” Lewis Thomas goes even further: “I have seen agony in death only once, in a patient with rabies.” At the time of their utterances, both Osler and Thomas were (Thomas still is) among the most highly respected medical savants of their eras.
And yet I am puzzled. I have seen too many people die in suffering, too many families tormented by the deathwatch they must helplessly keep, to think that my own clinical observation is somehow a misapprehension of reality. The last weeks and days of far more of my patients than Osler’s one in five have been overfull with a plethora of purgatory, and I have been there to see it. Perhaps Thomas’s different vision is the result of his having spent by far the greater part of his career as a researcher in laboratories; perhaps Osler’s interpretation of the five hundred records is reflective of his well-known optimism that the world is really a much better place than we take it to be and of his zeal as a universal mentor to transmit that rosy philosophy. Whatever it is that may have motivated these two most humane of medical scholars to their statements, I must, as we say in such awkward instances of seeming to doubt our own household gods, respectfully disagree.
But then again, I may not disagree at all. Or maybe it is Osler and Thomas who disagree with their own idealizations but have just not been willing to say so. It seems quite possible that they have both begged the question, and done it artfully. In describing what they purport to be the absence of agony in dying, they have conveniently ignored the events that immediately precede the final days or hours of which they speak so reassuringly. With deep sedation or the blessed respite of terminal coma that comes to some at the end of a difficult struggle, the actual hour when the heart stops is indeed often tranquil. Many do, in this way, avoid a tormented passage; but many others are in physical and mental distress till nearly the last moment, or even
at
the last moment. There is a nice Victorian reticence in denying the probability of a miserable prelude to mortality, and it is what everyone wants to hear. But if peace and dignity are what we delude ourselves to expect, most of us will die wondering what we, or our doctors, have done wrong.
at
the last moment. There is a nice Victorian reticence in denying the probability of a miserable prelude to mortality, and it is what everyone wants to hear. But if peace and dignity are what we delude ourselves to expect, most of us will die wondering what we, or our doctors, have done wrong.
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