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After nearly 40 years as a general, cardiac and abdominal surgeon at Yale University's New Haven Hospital, Prof. Sherwin Nuland traded his scalpel for a 2.5 Eberhard pencil and a lined notebook and became a full-time writer of medical non-fiction books. His How We Die: Reflections on Life's Final Chapter - which like all the others just flowed as he wrote them by hand and then transcribed into a computer - won the 1994 US National Book Award and was a finalist for the coveted Pulitzer Prize. Others have been The Wisdom of the Body, How we Live, The Doctors' Plague, The Biography of Medicine and a biography of Maimonides.
Now, at 76, the multi-talented retired surgeon teaches bioethics and medicine at Yale University's School of Medicine, and last month made his first visit to Israel as a guest of Ben-Gurion University of the Negev's Dozor Visiting Professors Program - which has so far brought to Beersheba over 250 leading scientists and physicians for collaborative research in medicine, medical education and science.
Although belated, his personal "discovery" of Israel would have made "Bubbeh" - his Zionist, Yiddish-speaking maternal grandmother with whom he shared a tiny bedroom in the Bronx for eight years - very proud.
Nuland - born Shepsel Ber Nudelman, the son of poor Orthodox Jewish garment workers - was so awash with tragedy that his biography sounds like the Book of Job: His sickly-but-loving mother Vitsche died of colon cancer when Nuland was only 11. His brother Martin was felled by bronchial infection at the age of three, and another brother, Harvey, died 17 years ago of colon cancer. The surgeon's Russian-immigrant father, Meyer Nudelman, was a constantly irascible victim of spinal cord disease that made it difficult for him to walk. "Shep" (a nickname his wife Sarah still uses) walked to the subway station every day to accompany him home. The disease, Nuland learned only by putting two and two together as a medical student at Yale, was the result of an undiagnosed syphilis infection that Meyer never knew about even on his deathbed.
Weak and living from hand to mouth, speaking only Yiddish, Nuland's father was hypercritical and resentful of his two Americanized sons (an aunt who was a jazz enthusiast had a musical recording by Sherwin's Broadway Orchestra suggested Nuland's official name, "Sherwin Broadway") as well as their ability to fit into their new country. Nuland confessed in some of his books that he long wished his father dead. "My wrongdoing was constant," he recalled. "He was always lashing out, angry at seeming insults. What I carried with me was this sense that I was hurting this vulnerable man. What do you think it's like to be six or seven years old and have a father you know is not strong enough to be your father? To always feel that your father is so vulnerable you can destroy him by meanness, by a word? On one hand I was scared he was going to kill me, but on the other hand I was scared I was going to kill him... He would have been a substantial man if he had not had syphilis. He was very good-looking as a youth and would have been a different man without his illness. A lot of the family burden fell on Harvey and lot of the responsibility on me." Harvey, three-and-a-half-years older, "was able to separate himself from my father's sickness. I was not. We lived on charity. I was very attached to my mother, who did everything to survive for her children."
BROKENHEARTED BY his mother's death and left with his hated father, Nuland suffered clinical depression for the first time at 15 and then again at 20. "Everything I have become and much that I have not become I attribute to her death. That was the turning point of my life." His first marriage - a disastrous one that nevertheless produced two highly successful children - fell apart when he was 39. Finally, at the age of 42, he became so depressed, becoming bent and slow like his father, that Shep was hospitalized for a year and became a candidate for lobotomy (surgical removal of a lobe of the brain, once thought to be therapeutic for those suffering from mental illness or retardation). But Dr. Vittorio Ferrero, then a young psychiatric resident at Hartford's Institute of Living, saved him by trying electroshock therapy instead. Nuland dedicated one of his books to Ferrero, who is now a psychiatrist in Connecticut. With help from analytical psychotherapy and his family, Nuland said he hasn't suffered a major depression in decades and hasn't had to take psychiatric medication since 1973.
"When I'm not depressed, I'm the least depressed human being on Earth," he says triumphantly in an interview in Jerusalem's Mishkenot Sha'ananim, where he and Sarah were invited by the Jerusalem Foundation to stay for a few days. "I don't repress bad memories. They are part of my life; everything I am is a result of everything that came before."
His father died three days after Nuland was named chief resident in surgery at Yale-New Haven Hospital; since then, Nuland says, he "understands" his father more, although forgiving him is still too painful to contemplate.
Asked what advice he would give to youngsters raised by a parent with mental illness, Nuland says: "Nobody can cope alone. One needs a 'paid best friend' - a trained psychotherapist who offers understanding, kindness, gentleness and guidance. It costs lots of money and requires a big commitment of time. I don't see how any child can get out of such a situation without a professional therapist. As a child, I knew things were bad, and I made up imaginary scenarios, but nothing helped. A good sibling relationship or friend can help, but a child can't get enough insight into the problem just from that."
He thinks it is "utter nonsense just to give pills to the mentally disturbed. A chemical imbalance may have been caused by psychological changes. I don't doubt that are certain mental illnesses, such as bipolar disease, that are largely chemical in nature, but the environment and experiences have a very important role."
NULAND SAID he was bowled over by Israel and intends to visit again. "We were always told how brusque Israelis are, so I wasn't prepared for the warmth and kindness and ease in which people get along with each other. Everybody seems to be equal, and we found that so engaging. Israel is something you have to see to believe. Some American Jews are resentful of how often Israel is thrown in their face. But only when you are here, in 24 hours, do you know what those committed to Israel are talking about. You have to experience it!"
Why did he make his first visit only at the age of 76? "My whole focus as a child and young man was for me to become an American. English was for me the language of liberation from my Eastern European roots. I was always very self-conscious about coming from a shtetl mentality. I didn't come to Israel before because I am basically a shtetl Jew trying to become an American. In my mind, Israel was not what it turned out to be once I finally got here. My Bubbeh had no money, but she used to save her pennies in a pushka for the upkeep of yeshiva students in the 1920s at Mesivta Tiferet Yerushalayim. Harvey and I wanted to become explorers of America. I was blond with blue eyes and looked non-Jewish. Zionism was not in our minds; American socialism was," he explains in a tone expressing disappointment with himself. "The Holocaust didn't change this for us. I grew up seeing the establishment of the State of Israel as an important event, but it was not something I personally felt. I am very sorry I have not come before. It is more than I imagined - inconceivable."
His two younger children Will and Molly, born to his wife Sarah - a Quaker from Baltimore who converted on her own volition - were converted at birth even before their mother. "Through her belief, Sarah came to Judaism and learned to read Hebrew. I am an agnostic Jew who believes in cultural, not spiritual, Judaism, and we regularly go to our Conservative shul in the New Haven suburb where we live. We don't eat kosher, but on Shabbat, we observe it at home and don't drive." His first wife was born to a Jewish mother but converted to the Church of England at a young age. Their two children were raised as Jews. Thirty-eight-year-old Victoria Nuland is currently the US ambassador to NATO and married to a Jew, while 35-year-old son Andrew, a business executive in China, married a Chinese woman, and their baby was converted to Judaism and circumcised.
DURING NULAND'S stay here, he was powerfully impressed by Israeli medicine, which he says "is as good as it gets anywhere in the world, on a par with American medicine. It's a small country, but the top doctors and researchers here are equal to the best in the US." During his visit to BGU, he was "impressed from the very beginning that doctors want to take care of everybody. The focus is on making sure that everyone has the right to good medical care. I had not been aware of it, as in the US medicine is less humanistic and more macro, focusing on what is best for the largest number of people - not on the individual patient you are facing. I believe medicine is a humanistic profession, an art, with relationships between healer and those to be healed. I am excited to be in a country where my philosophy of medicine - of the individual doctor trying to cure a person like myself - is applied. There is too little of this in US medical schools."
Despite his personal background, Nuland didn't end up as a psychiatrist to better understand mental illness. "I was fascinated by psychiatry. I went into internal medicine, but then into surgery, even though the image of a surgeon then was of a large man who smoked cigars and had pinkie rings, a big car but not deep thoughts," he recalls. "But I met surgeons who had an aesthetic sense of beauty. Surgery is the most profound of of all arts of medicine. To me, blood was beautiful. I liked the color of organs, the way instruments felt in my hand. In surgery, I was a member of a team. Surgery helped me understand the human condition: You see patients and families at their lowest and highest points."
His writing, especially that about his own life and suffering, is a kind of therapy. "I want everybody to know about me. "You are honest with yourself if you are honest with others. Until I had my breakdown, I played the part of an assimilated American Jew who had everything sorted out. It was very burdensome to carry it alone. My writing has relieved me of it. It's also very nice my writing is popular and to be financially comfortable because of it. It's nice that strangers speak and write to me because of it. I answer almost very letter."
He did not initiate the Maimonides (Rambam) book, but was assigned to it by Schocken, his publisher. "I did't realize how complex it would be until I sat down. I don't see him as a great medical innovator in the 12th century, but he was a great physician. I described his life and how difficult it was in great detail. The Rambam's ethics are essentially the ethics of Western medicine. He was ahead of his time in that few doctors carried the heritage of both the Talmud and Greek ethics. Taking care of patients, he realized the enormous value of ethics."
Nuland approves of new Israeli legislation that determines what the health system can do for dying patients. "A Shabbat clock [to turn off the respirator of a terminal patient who stated in a living will that he doesn't want his life to be prolonged artificially] is a great solution. Israel is the only country in which there is a difference between passive and active euthanasia. The Dutch experience of wholesale active euthanasia is a disaster. A quarter of the doctors there have done euthanasia without their patients' consent. I have done it on two occasions with Demerol: One woman I knew very well had a gangrenous intestine, too little intestine to live and unconscious. I couldn't allow her family to go through 24 hours of misery. The other was a patient with an advanced malignancy who developed one infection after another and was suffering terribly. I discussed it with his brother-in-law and decided to do it."
Nuland says he's not afraid of death, even though it has been a near-constant companion to him. "It's easy not to be afraid of death when you feel fine. Death is the end of consciousness to me; I think there is nothing after - no punishment and certainly no rewards. I am an agnostic, not an atheist; to be one is to be sure. I don't believe in the Hereafter, but maybe I will wake up and see the Garden of Eden. I am moral not because I was told to be, but because Jewish morality of gentility and politeness is the right thing to follow."