When Breath Becomes Air

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Paul Kalanithi’s When Breath Becomes Air was perhaps one of the most beautiful and heart-breaking memoirs I have read. This is due, in part, to the fact that like many women, I felt that I knew Paul Kalanithi, through varying degrees of separation. I say this because I am one of the one million or more women who read the blog Cup of Jo every month, and Cup of Jo was created by Joanna Goddard who is the twin sister of Paul Kalanithi’s wife, Lucy. I’ve known of Paul, and the rest of Joanna’s family, since I began reading her blog in late 2010. Paul and Lucy were featured on Cup of Jo several times, most memorably when they gave a tour of their home in San Francisco. Like many other readers, I was utterly fascinated by their gorgeous home, the eclectic selection of books filling their shelves (everything from the classics to Roald Dahl, if I am recalling correctly), and by their careers at Stanford.

Then in January 2014 Joanna wrote a post titled “How Long Have I Got Left”? in which she revealed that her sister’s husband had been diagnosed with incurable lung cancer. The Cup of Jo readers, myself included, were stunned, to say the least. She shared this essay Paul wrote for the New York Times about his experience in being diagnosed, the reality of transitioning from doctor to patient almost overnight. For months after this post many readers commented, wondering how Paul and Lucy were doing. By this point I felt obligated to know his status, to pay close attention to any updates on the blog because, again, through however many degrees of separation, it was as if I knew him personally. Joanna expressed her appreciation for readers’ good thoughts and wishes for a speedy recovery, but out of respect for her family she did not divulge any further information. We waited, we wondered. And then last year, he died. I would be very surprised if you hadn’t heard of his passing as it was widely publicized, the death of a thirty-seven year-old Stanford neurosurgeon would of course not go unnoticed.

When Breath Becomes Air was published posthumously, unfinished, the final version pieced together by Lucy, whose epilogue at the end is incredibly moving and beautiful. I bought a copy immediately, wanting to show support for the family, and also because at this point after reading his two New York Times essays I was gripped by his story and wanted to know more.

Talking about death, reading about death, writing about death, is hard. There is no getting around the fact that death and dying are a cultural taboo right now. As a doctor, Paul was confronted with death constantly, and reading his firsthand accounts are jarring; the cases he’s dealt with are at times disturbing. The man is a saint for doing what he did for so many years. He’s the doctor you’d wish you could have when, or if, you need it.

Through this book Paul proves that he is more than just a talented surgeon. He is an incredibly talented writer. His words are thoughtful, philosophical, and witty, showing the world from his perspective in a way that is full of candor and wonder. Paul spent his life searching for a deeper meaning, both figuratively and literally, through the study of scripture and literature and the study and practice of medicine.

“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” (30-31).

This is not a book for the squeamish. Paul writes honestly about his time as a medical student, and later as a neurosurgeon. He tells about the first cadaver he ever worked on, the hammering and chiseling of bones, breaking of rib cages, the studying of organs. He describes what was left inside the stomachs of those who died before their last meals, pills, were digested. He says that many medical students change their course of study by about their fourth year of medical school, preferring to work in “lifestyle” areas such as dermatology (68). But Paul chose neurosurgery. He sums up the complexity of this particularly area of specialization here:

            “While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact. In addition, to the patient and family, the brain surgery is usually the most dramatic event they have ever faced and, as such, has the most impact of any major life event. At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability – or your mother’s – to talk for a few extra months of mute life. The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?” (71).

Common threads in his memoir are death and time. Death is imminent, but when will we die? Twenty years? Thirty? Six months? Paul does little to sugar-coat the fact that he was faced with death much, much sooner than he anticipated.

“During my residency, I had sat with countless patients and families to discuss grim prognoses; it’s one of the most important jobs you have, as a physician. it’s easier when the patient is ninety-four, in the last stages of dementia, with a severe brain bleed. But for someone like me – a thirty-six-year-old given a diagnosis of terminal cancer – there aren’t really words” (134).

With no way of knowing how much time he had left, Paul was at a loss for how to spend what very valuable time he had. His doctors had no way of providing him a solid time frame because it was impossible to determine how his cancer would change with various treatment plans. Lucy had recently given birth to their daughter, who brought new life and happiness to their lives and the lives of their families. Still, time was pressing:

“If I had some sense of how much time I have left, it’d be easier. If I had two years, I’d write. If I had ten, I’d get back to surgery and science…torn between being a doctor and being a patient, delving into medical science and turning back to literature for answers, I struggled while facing my own death, to rebuild my old life – or perhaps find a new one.” (137-139).

As Lucy clarifies in her epilogue, Paul ultimately spent his last months writing. Once they learned that his cancer had spread to his brain, it was all a matter of writing as much as he could as quickly as he could while he still maintained the mental clarity to do so. She says:

“This book carries the urgency of racing against time, of having important things to say. Paul confronted death – examined it, wrestled with it, accepted it – as a physician and a patient. He wanted to help people understand death and face their mortality. Dying in one’s fourth decade is unusual now, but dying is not” (215).

Death is not, in fact, unusual. It is the suddenness of being faced with it when we least expect it that is hardest to understand. And yet, Paul faced his mortality with strength and grace, which Lucy makes clear in the final part of her epilogue:

“Paul’s decision to look death in the eye was a testament not just to who he was in the final hours of his life but who he had always been. For much of his life, Paul wondered about death – and whether he could face it with integrity. In the end, the answer was yes” (225).

Paul has given so much of himself in this book and although it is impossible to pinpoint just one or two life lessons he’s given, it is worth noting that primarily, he’s encouraged us to live meaningfully, and to be unafraid of death. There is nothing that can surmise this memoir better than Paul’s words himself, so I will leave you with these:

“Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder towards the goals of life, flattens out into perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed…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, 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” (198-199).

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