When Breath Becomes Air (2016)
5 Stars out of 5
Paul Kalanithi
208 pages
“Even if I’m
dying, until I actually die, I’m still living.”
“The main message of Jesus, I
believed, is that mercy trumps justice every time.”
Paul Kalanithi
How does one approach the subject of death, especially when
it is one’s own death? We all live with the knowledge that our day will come,
but by not knowing the “when” of it, permits us to live a kind of fantasy that
says, “Well, someday, but not today”, i.e. never. In the case of Stanford
neurosurgeon resident, Paul Kalanithi, nearing the end of his multi-year
training in medicine, it is a question that had gained vital urgency some
twenty-two months previously when he learned that he had inoperable lung
cancer. The manner in which Paul faced the question of "How to live a life of purpose" is a lesson for everyone. His journey from Chief Resident to patient is an example that one mightily
hopes could be taught in med school, or indeed to the public at large. Everyone
should read this book.
Paul begins his book writing
to a friend about the cancer with the fluid prose and gentle humor than infuses
the book as a whole:
“The
good news is that I’ve already outlived two Brontës, Keats and Stephen Crane.
The bad news is that I haven’t written anything.”
By beginning the book in this manner, he is
signaling to his readers several points that play a major role in who Paul
Kalanithi is and was, a man with lofty ambitions, a man determined to live his
life as long as he was living and also an allusion to his past as a student of
literature; an alluded topic that would strongly inform his 2016 memoir “When
Breath Becomes Air” and also provide a lovely segue to the opening sections of
that memoir.
Paul began his
life in Westchester NY as the second child to a successful cardiologist.
Suddenly, or it must have seemed so to the youthful Paul, his father moved the family to
Kingman AZ. It is hard to imagine two worlds further apart. And yet it provided Paul with an opportunity that he might have otherwise missed: homeschooling with his mother.
Paul left behind the incredible school system in NY for what was essentially private tutoring in AZ. Paul refers in his memoir to the literature his
mother encouraged him to read (to help him prepare for college) as the key
component to his education. He became fascinated with how artists looked at the
question of “what is the meaning of life and how one should live it”. He will go on
to earn two B.A.s and a M.A. in literature at Stanford, and just for good
measure a M.A. in philosophy at Cambridge before starting his medical training.
He started his
training in literature and philosophy as he pursued his quest to understand
better how one lives his life. As he neared the end of his artistic tenure at
Stanford, he came to the conclusion that he needed to understand the “how” of
the human mind, not just the “why”. He would return from Cambridge to earn his
M.D. at Yale and to meet his wife to be, Lucy; she too would become a physician
and would in fact finish his unfinished memoir. She would become an internist
while Paul would train to become a neurosurgeon, both at Stanford.
Paul’s memoir’s
reflection of life as a physician in training is interesting in its own right.
Consider his description of life in his first day as an intern where during his
rotation in OB/GYN he helped give birth to a pair of severely premature twin
boys – two boys who would begin and end their short lives on the same day as
Paul’s first day. It is a sobering moment in the book as the reader feels most
acutely Paul’s empathy for his patients, and also how this tragic day for those
twins’ parents aligns so well with the core message of this book’s discussion
of life and death.
Paul will
also describe how in his early years as a med student/intern he continued his
struggle to understand the role of physician and the role of the patient in how
we all view death:
“Death comes for all of us. For us, for our patients: it
is our fate as living, breathing, metabolizing organisms. Most lives are lived
with passivity toward death -- it's something that happens to you and those
around you. But Jeff and I had trained for years to actively engage with death,
to grapple with it, like Jacob with the angel, and, in so doing, to confront
the meaning of a life. We had assumed an onerous yoke, that of mortal
responsibility. Our patients' lives and identities may be in our hands, yet
death always wins. Even if you are perfect, the world isn't. The secret is to
know that the deck is stacked, that you will lose, that your hands or judgment
will slip, and yet still struggle to win for your patients. You can't ever
reach perfection, but you can believe in an asymptote toward which you are
ceaselessly striving.”
These early parts of the memoir are all written from the
vantage point of the caring physician, but that will all change once Paul is given his
earth-shattering diagnosis of stage 4 lung cancer; his perspective changes radically. He
will enter the same hospital and the same hospital rooms where days before he
had led as chief resident, but this time as a patient. He will now be treated
by attending physicians and nurses he knew as colleagues. He will also in time
find out first-hand how mistakes are made as a young oncology resident mistakenly stops
a drug than had been keeping Paul alive. He will survive that experience only
to return to his immediate situation: he wants to live each day as anyone
would, but how many does he have; he knows it is few, but just how few?
“Grand illnesses are supposed to be life-clarifying.
Instead, I knew I was going to die—but I’d known that before. My state of
knowledge was the same, but my ability to make lunch plans had been shot to
hell. The way forward would seem obvious, if only I knew how many months or
years I had left. Tell me three months, I’d spend time with family. Tell me one
year, I’d write a book. Give me ten years, I’d get back to treating diseases.
The truth that you live one day at a time didn’t help: What was I supposed to
do with that day?”
That Paul was a polymath,
someone brilliant in his multiple fields of literature, philosophy and medicine
plays a terribly important role in this book. This is not just an average Joe
looking death in the eye, but a man who had and still lived to his final day a
fully examined life. His academic achievements underscore this point, but it is this
incredible elegiac book that makes the point all so clearly. His wife will provide
an epilog that comes with her own narrative flow, but one that is consistent
with that of Paul’s. The book also comes with a forward from a fellow Stanford
physician Abraham Verghese. I do not deny
Dr. Verghese’s writing talents or his enthusiasm for Paul’s work, but the tone
of his forward felt awkwardly out of place with the book that follows. My
opinion is to skip the forward and read the book and epilog first, and then
return to the forward. It will be less tonally jarring. But however you decide
to read this book, I strongly recommend that you do so. It may be the best book
you read from 2016.
Below is a picture of Paul, his wife Lucy and the daughter Cady they conceived after he knew he was to die. Their discussion on this point is heartbreaking and enlightening and the same time.
