Book review / Voyagers to the undiscovered country

Oliver Sacks has a lot to answer for. He has single-handedly created a vogue for philosophical musings on disease with catchy titles by literary doctors, verging on the pretentious. Now Bert Keizer, a Dutch doctor who works in a nursing home in Amsterdam, has out-Sacksed Sacks by producing, as the blurb has it, an "unexpected bestseller'' on contemporary ways of dying, replete with references to Beckett, Kafka and Wittgenstein. His own lively translation of Dancing with Mister D into English may well make the charts here too.

It deserves to. It is a rich confection of thoughts on what Keizer calls "the sadly underrated and ignored history of medicine, the nature of the quarrel with alternative medicine, the placebo effect, the meagre scientific content of medical practice, the failure of cancer research, the anatomical ideas of the average citizen, the incredible overestimation of the power of medicine, the things people do to allay their fear of death, the inscrutable ways our minds are anchored to our brains (to have a mind - to be a body)'', and so forth. From this alone it will be clear that Keizer has strong views. He is not averse to having the last word either.

But above all this is an examination of the use of euthanasia in modern medicine, a meditation on helping people to die. The handling of this theme is what makes the book so impressive and timely. Keizer is not only clever and widely-read - he took a degree in philosophy at Nottingham University before turning to medicine. He is also humane: as considerate and gentle in action, it would seem, as he is verbally aggressive and opinionated. A witty man, too: Wilde is another of his literary idols.

Sylvia Plath (not quoted here) famously wrote: "Dying / Is an art, like everything else. I do it exceptionally well.'' Helping others to die is also an art, and nobody who reads this book could possibly go away with the idea that euthanasia is an easy option - for anyone, either the dealer of death or the recipient. As Keizer indignantly tells one stroppy patient who demands it: "You can't order that like an omelette, you know.'' Leaving aside legal considerations (and the law in Holland is obviously more liberal than here), doctors have to be sure that the patient's death wish is not a passing whim, and that it is justified by the hopelessness of his or her medical condition. Keizer's "First Commandment'' is: "Don't ever terminate a life for cosmetic reasons. I mean, don't do it because it's so hard on the spectators to have to watch the suffering".

Timing is everything. Patients may leave it too late: they may be beyond asking for it, however much they might desire it. Keizer points out that there's no answer to the question, "When should you end your life?'' Often it's only "when it's too late [that] you know when you should have done it''. But the book has several examples of "good'' deaths, where people are eased out of life painlessly, at their express wish and with a suitable sense of occasion. The surprising thing (surprising if one hasn't thought about it) is the doctor's suffering. Keizer experiences anxiety dreams on the nights before he is called on to administer death. Yet the relief when all goes according to plan is commensurate and that, as Keizer says, provides the job satisfaction.

Then there are the relationships between doctors, nurses, priests, patients and their families, as well as the inter-relationship between the three doctors working at the nursing home. Bert Keizer, or ''Anton'' as he calls himself here, is the middle one of the three in both age and attitude, standing between a laconic old-timer called Jaarsma and the recently-qualified and still starry-eyed De Gooyer. The last-named, along with one or other of the priests, often acts as a foil for Anton's anti-religious and anti- alternative medicine diatribes, but is allowed the occasional pithy remark of his own: "Jaarsma reads to us during lunch, 'The Vervet Monkey has to outwit three predators: the leopard, the eagle and the python.' To which De Gooyer immediately replies, 'That's nothing in comparison with the Patient, the Family and the Nurses.' "

All these relationships are established with economy and wit. One of the many charms of the book is Keizer's refusal to mask his likes and dislikes among staff, patients and their families with the patina of professionalism. He shows his irritation with a male nurse, whom he describes as "one of those homos who will never come out of the closet because he doesn't know he's in it'', and he has a go at another nurse, this time a woman, who refuses to give a demented 96-year-old a morphine injection because of her faith. He overhears this same woman saying of him, "Can't he ever be serious?'' and is surprised how much the remark bothers him, even from such a source.

Keizer is serious all right, no one more so. Mister D is his constant companion. Cycling to work in a bad humour on a cold morning, he thinks of the earth "as one big death camp''. To "the bringer of hemlock'', he lets slip on another occasion, the last five minutes of a patient's life "are always such a cross''. What the nurse does not understand is that serious doesn't mean solemn, that the irreverence of his wit has nothing to do with frivolity.

When my time comes, should I be fortunate enough to recognise the moment, I only hope that I may be able to call upon someone of Keizer's humanity to ease me over the threshold. In the meantime, I recommend his book as a thoroughly stimulating tussle with the grim reaper.