Book Review: Through the Valley of Shadows

Through the Valley of Shadows CoverAlthough Samuel Brown’s new book, Through the Valley of Shadows, is not a book that focuses on Mormonism, I jumped at the chance to review it for Times and Seasons simply because the subject matter fascinated me. Death, after all, is something that we all face, and I was already tangentially aware that technological advances are creating thickets of ethical and emotional—not to mention economic—concerns around this final encounter. I didn’t really have any preconceived opinions about the topic, however, just a curiosity that made me eager to read Brown’s book. I was not disappointed.

The book covers an impressively wide range of territory. Of course there is a lot about medical care in modern ICUs—both from the standpoint of academic research as well as from first-hand accounts from Brown’s own career—but aside from that the book also delves into social history, cognitive psychology, and legal theory.

Brown’s central argument is that two sea changes in modern society have left us naked and alone in the final confrontation with death. The first is the Dying of Death, which removed the narratives and social infrastructure that had provided a template of a “good death.”

By the end of the Dying of Death, Americans had contained the terror of death by simply ignoring it until the moment of crisis, but the sanctity of death had disappeared along with its menacing presence… Since twentieth-century Americans had not generally spent their lives in the shadow of death, when they came to approach Death, as every human being inevitably does, they discovered just how culturally defenseless they were before it’s terrible power. (Page 27)

The most interesting thing about the Dying of Death was that it was “already complete by the time physicians actually began to have useful treatments to offer their patients [in the 1960s].”(Page 32) When these medical advances did arrive, they compounded the problems of the Dying of Death because they provided the possibility—at least in the short run—to exercise meaningful discretion over the time and manner of our deaths. There was nothing much doctors could do before the 1960s to prevent a person dying, but with the advent of modern ICUs, we were condemned—as Sartre would say—to live with that inescapable freedom. As a result, we could not have gone back to the stoical, fatalistic approach to death that had existed prior to the Dying of Death even if we had wanted to: modern medicine effectiveness forever shut the door to the old ways of dying.

Brown describes the two alternatives to this predicament as “the Scylla of paternalism and the Charybdis of bare autonomism.” (Page 7) Paternalism reigned initially, and during that time patients and their families were protected from the awful responsibility of making choices about when and how to die by medical professionals who simply made those decisions without consulting or (in many cases) informing them. About that time period, Brown writes that:

Physicians were secretly making decisions about treatments and were widely separated from the rest of American society. The conspiracy of silence about death was very real. Physicians had in fact committed ethical abuses in research and experimental transplantation surgeries. (Page 64)

Clearly, that could not go on, and the effort to reform these abuses led to living wills and medical directives. Although the impetus behind these kinds of approaches is noble, Brown astutely notes that the autonomy they claim to provide is a hollow and lonely one; it “protects a nominal rather than robust autonomy.” (Page 69)

I found this one of the most interesting parts of Brown’s argument. It certainly has the widest implications, which he acknowledges by framing it as a criticism of disclosurism writ large: including everything from living wills to EULAs. Instead of bare, legalistic notions of consent, Brown defines “robust autonomy” as “what the individual truly desires when he is well and fully supported and allowed to explore what is authentic to him as a person.” (Page 213, emphasis added)

I found Brown’s arguments persuasive on a strictly philosophical basis, but what really made them hit home was some truly shocking data about the extent to which ICU stays are traumatic for patients and their families. Citing studies, Brown concluded flatly that “Many people leave the ICU with emotional scars as severe as those carried by combat veterans. Only a minority skate by without anxiety, depressing, or PTSD or some combination of the three.” (Page 167) Whatever you think about his critique of disclosurism, that is a pretty clear indication that something is really going wrong.

This is especially true given that a lot of the sources of trauma are unnecessary. On the one hand, Brown is incredibly frank about the unavoidably brutal nature of some life-saving treatments that are unavoidable in the ICU, stating that “ICU physicians do things that would qualify as torture if they were performed with any other goal than prolonging life with the individual’s consent.” (Page 11)

On the other hand, while some otherwise brutal procedures may be necessary, many practices of the ICU are not. Brown cites the arbitrarily restrictive nature of visiting hours and overuse of practices when they have no reasonable benefit as one example. The ubiquitous use of patient restraints and urinary bladder catheters are two more. He mentions one heartbreaking story of a devout Catholic who desperately tried to make the sign of the cross after being given last rites while the ICU attendees never even considered loosening the purposeless restraints. He also points out that the fact that “it’s common for female patients to have memories of rape from urinary bladder catheters” should be another reason—in addition to “the risk of bladder infection”—why the catheters should be avoided when possible instead of being used by default. (Page 140) PTSD, physical trauma on par with torture, and mental and emotional trauma including false rape memories all combine to give serious, practical weight to Brown’s arguments that something in how we face death in the ICUs must change.

In the end, Through the Valley of Shadows is ultimately a call for us to being to begin to socially reconstruct death. We can’t go back to where we before—at least not while we continue to be a technological society—but the place where we find ourselves today is intolerable and unnecessarily so. Brown includes several specific, practical policies that can help to create this new conception of death, but a social construction has to be more than a set of statutes or policies, and that is where this book is at its strongest.

For example, one of the most arresting observations in the entire book of all was Brown’s observation that “families do better when they see CPR” because CPR is “a distinctly American ritual related to mortality.” (Page 220-221). That is not to say that CPR is not also a useful, technologically sophisticated treatment. It is. It just also happens to be “a reasonable way to shake our fists against the sky.” (Page 222) What I like about this analysis, besides how unexpected and profound it is, is that it shows a way to unify the two, disparate imperatives involved in our technologically empowered and emotionally laden confrontation with death: practical efficacy and emotional authenticity. It makes me think that such a unification is possible.

Social construction is not a job of individuals; it’s the result of social networks, relationships, and trends. Still, it is possible—and necessary—for individuals to contribute meaningfully to such a project. Brown’s book is one such contribution, and a vital one at that.

7 comments for “Book Review: Through the Valley of Shadows

  1. It’s an interesting point. I remember my dad saying that something like 20% of the kids he started school with were dead by the time he graduated high school. And that was in the period from the mid 40’s through the 60’s. Very recently. It was almost certainly worse in the decades before WWII.

    Honestly while I’ve known people who’ve died, I can’t say I’ve had anyone I was in a close relationship at that time die. Even when my grandparents died I was either too young to really understand but also wasn’t with them daily such as to have a close relationship. My parents and siblings are still alive. All my friends are alive. Acquaintance who have died have done so typically after a few years from when I stopped hanging out with them. Effectively I’m cut off from a certain experience of death. Even most people I do know who died, like my grandmother, died well into their 90’s when death seems like a mercy for a worn out body to end the pain.

    Like most Americans, I’m cut off from people I’m deeply close to like my children being taken away too early. That affects so much of how I think about these things.

    The points about end of life care are also well made. The difference between legal “right to non-intervention” and a kind of respect for end of life is well made. So much that’s well intended in end of life care is invasive and unhelpful. I remember just a few years ago while in the hospital with very, very bad pneumonia how it really changed how I thought about things. (The doctor came in one night and noted that my oxygen was up as high as it could go that if I didn’t improve by morning I’d be taken to ICU and might die. Talk about a shock out of complacency.)

  2. Thank you for this review. I just bought a copy, hoping that reading this book can help me. I am not entirely sure what I hope for or need, but as a survivor of a wicked bout of viral myocarditis who experienced the post-ICU trauma your review referenced, I have avoided thinking about and discussing end-of-life care with my family. All I know is that I don’t want to go through such a severe and violent experience again. Thanks for the resource.

  3. Anon, if you have PTSD from the ICU experience, be mindful that the book talks honestly about how painful the experience of the ICU is and how difficult recovery can be. In contemporary language, “trigger warning” for PTSD flashbacks related to pain, confusion, how alone you felt, the nightmarish memories of the ICU. I’ve hoped that this book will be helpful to ICU survivors and their families, if only to let them know that they are not alone. But, especially with PTSD, be mindful of the risk of triggers. For people with a therapist, I’d recommend discussing it with the therapist. For people with a trusted advisor, discuss it with them as you consider reading. It’s my fervent hope that this book will be helpful to all participants: clinicians, general public, and survivors, but it’s not written primarily as a guide book for ICU survivors.

    I’m hopeful that the book and the related reform efforts will make ICUs less violent than they have been, while also helping clinicians to do a better job of providing personal and personalized care to people in the ICU.

    On the general topic of ICU survivors, I recommend SCCM’s THRIVE initiative, which is doing wonderful work to support survivors and their families: .

    You may also be interested in the WSJ piece today that talks about one relatively straightforward part of making ICUs better places:

    All best wishes, Sam

  4. Samuel Brown, Are these practices the same throughout the first world, or are there places where it is handled better?

  5. Sam,

    Thank you for addressing my comment (#3). I appreciate the caution regarding the PTSD trigger warning. Also, I appreciate the link to patient resources. I wish I had known how and where to get help following my trauma. Although I felt the follow-up cardiac support and care I received was excellent, I had to find my own therapist and navigate the landscape of emotional healing on my own. I wish I had understood what might happen following discharge and had been prepared with resources.

  6. True Blue, there are pockets of excellence. Seattle and Vanderbilt and Intermountain do great work in this domain. UCSF has a solid history. BIDMC in Boston has done great work. It’s pretty spotty overall, though, and people are generally at the whim of call schedules (i.e., some clinicians are much better than others, and you get the clinician who is on call when you arrive). There’s a group in Madrid that is working on this, and pockets in various places in Europe. We should all be calling for better work from everyone involved.

    Anon, the leading group for post-ICU followup is the Vanderbilt group, as I outline in the book. They have a nice website: . It’s been my private hope that this book will actually be useful to survivors. I’ll be interested to hear what you think of it. If you feel comfortable, I’d be glad to hear your feedback (contact info is under Contact on ).

    All best wishes.

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