
This screed, with a uniquely American perspective by a typically tunnel-visioned American journalist, was a Christmas gift from my uniquely American economist daughter. I keep hoping that she sent it my way because of my background and interests, and not because of some hunch about my near future. Like Atul Gwande’s Being Mortal and H. Gilbert Welch’s Less Medicine, More Health, Butler exposes the warped, fragmented, impossibly complex, and dysfunctional system called health care, more appropriately dubbed wealth care, in America. Based on free market economics, it prioritizes the fiscal health of practitioners, institutions, and pharmaceutical companies over true care, particularly for the elderly and debilitated. 1000 Washington lobbyists for pharmaceuticals and institutions push for ever more high tech interventions and costly toxic medications, but none advocate for discussion of realistic limitation of interventions toward the often miserable end of life. Oncologists are paid a percentage of the fee charged to the patient for their prescribed toxic medication of limited utility, but not for discussing the real futility of further chemotherapy.
The author divides the process of living and dying into seven arbitrary stages, while acknowledging that the time of anyone’s death is unpredictable. There is a lot of generalization and doctor bashing that seems to be very popular, but no acknowledgement of the fundamental flaws of a private health care system. The sacrilegious thought that any other country might have developed more compassionate fairer systems of health care apparently never crossed Butler’s mind. Thus, the generalizations are of limited applicability outside of the U.S. Even the terms ‘hospice’ and ‘palliative care’ seem to be defined differently in the U.S. than in the rest of the world.
The discussion of the pros and cons of dying at home, in a nursing home, or in a hospital is balanced and interesting. Dying is usually messy, smelly and stressful. I don’t care where I do it, provided those helping me know what they are doing and preferably are professionals and not already-stressed family members. And there are some positives to doing it alone, like the elderly Inuit nomads who can no longer keep up with the tribe and simply lie down in the snow to become bear bait, or Sir Robert Scott who sent his team on ahead and died alone after realizing that he would never make it back from the South Pole. The importance of various forms of advance directives is stressed appropriately. There is an abundance of data cited about causes of death, but I distrust much of it. Having filled out dozens of death certificates, the listed cause of death is often an arbitrary choice from the International Classification of Diseases, when several would be equally appropriate. ‘Dwindles’ is not acceptable to the keepers of Ontario Vital Statistics. Before electrocardiograms, many people died of ‘acute indigestion.’
There are also glaring deficiencies in this discussion. In spite of the abundance of deathbed humour in our culture, there is no leavening humour in this book. There is not a word about the ultimate altruism- organ donation, whether after declaration of brain death or the now accepted donation after cardiac death. The discussion of laws concerning assisted dying is limited by the complexity and limitations of these laws in different jurisdictions. There is little discussion about the value of carefully planned distribution of physical assets and real estate. My heirs will have no real estate to fight over, and I try to limit my physical assets to what is really important and useful to me. When a new item of clothing (usually courtesy of my wife) or a new book arrives, a similar older item goes to a charity or library. And my irrational fear of becoming dependent made me write my obit (just fill in the date and location) so nobody needs to dream up something positive to say about my life. The recommendation to join a support group for specific diseases can be problematic. In my experience, such groups often degenerate into little more that mutual self-pity societies.
The terminally ill Peter Schjeldahl (December 16 New Yorker) quipped that a major problem with dying is that one cannot get advice about how to go about it from anyone who has actually done it. Some people try.
This is an important, interesting book, but not particularly useful for non-Americans. The brutally honest late Sherwin B. Nuland’s How We Die is a better treatise on this grim subject, of wider timeless applicability.
Thanks, Andra.
















