When Breath Becomes Air by Paul Kalanithi

★★★☆☆ (3/5)

 The fact of death is unsettling. Yet there is no other way to live.

The review for this book is conflicted especially in terms of giving it a definitive rating. Firstly, I had a persistent feeling about this book being better understood and appreciated by readers who were more knowledgeable in the field of medicine, be it doctors or patients who had undergone similar experiences. Secondly, the inclusion of technical terminology (in reference to diseases and the medical system) somehow diluted the supposedly lyrical prose of the book. All reviews and blurbs praised the book for its poetic prowess, yet I felt that death (and life) was treated in more mechanical and medical terms than in a more wholesome, philosophic manner. Lastly, the content of the book gives the reader plenty to ruminate over but lacks in truly evocative and sublime passages which could radically impress upon the reader what the author was trying to convey.

To briefly summarize, “When Breath Becomes Air” is a heartfelt account of Dr. Paul Kalanithi, a neurosurgeon who was diagnosed with terminal lung cancer at the tender age of thirty-six. The book recounts his mediations on the inevitability of death and living a life in face of such certainty. He is plagued by having lost a future upon which he built his present yet aims to reconcile with his fate. His struggle is emotional, physical and spiritual as he philosophises on what it means to be alive in face of fast approaching death. Work, family, career goals are all affected by his illness bringing some aspects of life closer whilst another aspect drifts away. Literature, philosophy and religion provide an escape and act as a crutch to the ailing doctor who intends to come to total peace with his predicament. It is enriched with humanity and humility of the suffering whose very identity is confounded by unravelling of life events.

Variance in analysing this book arises from a simple fact that one is not supposed to speak ill of the dead. Bearing no judgement on Kalanithi’s exemplary and resilient character, the book in itself has been overhyped in my humble opinion. The question arises: would the evaluation be similar had he lived on, or does his death serve as a reminder to the readership of extending sympathy towards his ordeal, which in turn garners praise for his book as a final message? For me, the answer lies in three of my favourite passages from the book which unfortunately have nothing to do with Paul’s personal situation or meditations on life and death.

A PATIENT’S STORY

Replete with doctor-patient stories, this particular one struck a cord with me.

But the most sacrosanct regions of the cortex are those that control language. Usually located on the left side, they are called Wernicke’s and Broca’s areas; one is for understanding language and the other for producing it. Damage to Broca’s area results in an inability to speak or write, though the patient can easily understand language. Damage to Wernicke’s area results in an inability to understand language; though the patient can still speak, the language she produces is a stream of unconnected words, phrases, and images, a grammar without semantics. If both areas are damaged, the patient becomes an isolate, something central to her humanity stolen forever. After someone suffers a head trauma or a stroke, the destruction of these areas often restrains the surgeon’s impulse to save a life: What kind of life exists without language?

When I was a med student, the first patient I met with this sort of problem was a sixty-two-year-old man with a brain tumor. We strolled into his room on morning rounds, and the resident asked him, “Mr. Michaels, how are you feeling today?”

“Four six one eight nineteen!” he replied, somewhat affably.

The tumor had interrupted his speech circuitry, so he could speak only in streams of numbers, but he still had prosody, he could still emote: smile, scowl, sigh. He recited another series of numbers, this time with urgency. There was something he wanted to tell us, but the digits could communicate nothing other than his fear and fury. The team prepared to leave the room; for some reason, I lingered.

“Fourteen one two eight,” he pleaded with me, holding my hand. “Fourteen one two eight.”

“I’m sorry.”

“Fourteen one two eight,” he said mournfully, staring into my eyes.

And then I left to catch up to the team. He died a few months later, buried with whatever message he had for the world.

PAUL’S MESSAGE TO HIS DAUGHTER

Paul and his wife Lucy decided to have a child as a reminder that even amidst death, life blossoms. When excruciating pains and exhaustion racked his body, Paul’s newborn daughter ameliorated his agonies. In taking her in his arms he was reassured of the continuity of life even after his departure. His message to her exemplifies this belief.

There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past. That message is simple:

“When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.”

EPILOGUE BY LUCY KALANITHI

For me personally, the epilogue was magnificent, not just in terms of writing but bringing about a closure the reader deserves. Paul passed away without having finished the book which was published posthumously. His wife Lucy’s account on his life and death as a surgeon, a writer and as a cancer patient reinstates Paul’s intentions in writing this book. It evoked compassion and grace from the living; a befitting response to the theme of life running parallel to death.

I thought of our cozy bed empty at home, remembered falling in love in New Haven twelve years earlier, surprised right away by how well our bodies and limbs fit together, and thought of how ever since, we’d both slept best when entwined. I hoped with all I had that he felt that same restful comfort now.

Paul confronted death—examined it, wrestled with it, accepted it—as a physician and a patient

Paul’s voice in When Breath Becomes Air is strong and distinctive, but also somewhat solitary. Parallel to this story are the love and warmth and spaciousness and radical permission that surrounded him

 What happened to Paul was tragic, but he was not a tragedy

To sum up, Kalanithi’s dying thoughts are immortalized in this book which didn’t shatter me nor instilled any profound new ideas. It however did open up avenues into age-old questions on what it means to exist and then not exist, the perpetual struggle of survival in face of mortality and why is it necessary to come to terms with one’s circumstances no matter what the odds are.

Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence—and, eventually, death. Perhaps later than I think, but certainly sooner than I desire


LYRICAL PROSE

It was a futile task, and yet I was desperate to learn its secrets, tossing it aside in frustration, then picking it up again, unsure that it had anything for me but, in sounding the words, sensing that it did. I felt that I lacked some critical receptor for the letters to sing, to impart their meaning. It remained opaque, no matter how hard I tried.

She spoke in even tones, which only heightened the vertigo I felt.

I felt less like someone preparing to climb a career ladder than a buzzing electron about to achieve escape velocity, flinging out into a strange and sparkling universe.

I lay there in the dirt, awash in sunlight and memory

But craning your head back, you could see the day’s blue darken halfway across the sky, and to the west, the night remained yet unconquered—pitch-black, stars in full glimmer, the full moon still pinned in the sky. To the east, the full light of day beamed toward you; to the west, night reigned with no hint of surrender. No philosopher can explain the sublime better than this, standing between day and night. It was as if this were the moment God said, “Let there be light!” You could not help but feel your specklike existence against the immensity of the mountain, the earth, the universe, and yet still feel your own two feet on the talus, reaffirming your presence amid the grandeur

The scalpel is so sharp it doesn’t so much cut the skin as unzip it, revealing the hidden and forbidden sinew beneath, and despite your preparation, you are caught unawares, ashamed and excited

To me, the wound looked like a mass of disorganized tissue, yet to the surgeons it had an appreciable order, like a block of marble to a sculptor

A tureen of tragedy was best allotted by the spoonful. Only a few patients demanded the whole at once; most needed time to digest

I began to suspect that being so close to the fiery light of such moments only blinded me to their nature

The ground, having already buckled and roiled over the past few days, did so again.

ON LITERATURE

I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain

Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection

Books became my closest confidants, finely ground lenses providing new views of the world

A word meant something only between people

Words began to feel as weightless as the breath that carried them.

Alexander Pope: “A little learning is a dangerous thing; / Drink deep, or taste not the Pierian spring”

Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward.

From the Enlightenment onward, the individual occupied center stage. But now I lived in a different world, a more ancient one, where human action paled against superhuman forces, a world that was more Greek tragedy than Shakespeare

Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection

ON MORALITY AND PHILOSOPHY

Moral speculation was puny compared to moral action

like the ancient Greek concept arete, I thought, virtue required moral, emotional, mental, and physical excellence

However, it did make the throwaway assumption that the mind was simply the operation of the brain, an idea that struck me with force; it startled my naïve understanding of the world. Of course, it must be true—what were our brains doing, otherwise?

The human brain has rendered the organism’s most basic task, reproduction, a treacherous affair

Yet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth. We build scientific theories to organize and manipulate the world, to reduce phenomena into manageable units

Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete. And Truth comes somewhere above all of them

ON BEING A SURGEON

When there’s no place for the scalpel, words are the surgeon’s only tool.

If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite

But the truth was, it was joyless. The visceral pleasure I’d once found in operating was gone, replaced by an iron focus on overcoming the nausea, the pain, the fatigue

ON ILLNESS AND DEATH

Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused

Severe illness wasn’t life-altering, it was life-shattering. It felt less like an epiphany—a piercing burst of light, illuminating What Really Matters—and more like someone had just firebombed the path forward. Now I would have to work around it.

My carefully planned and hard-won future no longer existed. Death, so familiar to me in my work, was now paying a personal visit

It occurred to me that my relationship with statistics changed as soon as I became one

Racking back pain can mold an identity; fatigue and nausea can, as well

In fourteenth-century philosophy, the word patient simply meant “the object of an action,” and I felt like one. As a doctor, I was an agent, a cause; as a patient, I was merely something to which things happened

I was surrounded by success and possibility and ambition, by peers and seniors whose lives were running along a trajectory that was no longer mine

Moral duty has weight, things that have weight have gravity, and so the duty to bear mortal responsibility pulled me back into the operating room

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