A matter of LIFE AND DEATH
Diagnosed with terminal cancer, young neurosurgeon Paul Kalanithi set out to find some meaning in mortality. His exquisitely written, inspiring memoir is inevitably unfinished, but delivers the final word on dying with dignity
At the age of 36, Paul Kalanithi was ready to step centre stage. His lengthy training was about to bear fruit. He had just 15 months to go before becoming a fully fledged professor of neurosurgery.
‘I had earned the respect of my seniors, won prestigious national awards, and was fielding job offers from several major universities... I had reached the mountain top; I could see the Promised Land.’
But then he was diagnosed with terminal lung cancer. This touching memoir begins with him examining his own CT scan with his wife Lucy, also a doctor. In that moment, his imagined future evaporates to nothing.
When Breath Becomes Air is a book of two halves: the first is about becoming a doctor and saving life, the second about becoming a patient and facing death.
As a young man, Kalanithi had struggled to find his true vocation. He found philosophy too dry and unreal, and science too divorced from human relationships. He had gained degrees in English Literature and in Human Biology, but was looking for an area where the various disciplines intersected.
‘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… There must be a way, I thought, that the language of life as experienced – of passion, of hunger, of love – bore some relationship, however convoluted, to the language of neurons, digestive tracts and heartbeats.’
He was in his fourth year at medical school when, sitting in on a meeting between a brain surgeon and the parents of a severely ill child, he finally realised that he should pursue neurology.
The child had been diagnosed with a large brain tumour, most likely malignant. The surgeon had, he says, ‘not only delivered the clinical facts but addressed the human facts as well, acknowledging the tragedy of the situation and providing guidance… By the end of the conversation, the family was not at ease, but they seemed able to face the future’.
A Christian, he was unembarrassed to regard the work of the neurosurgeon as a sacred calling. Every day, he would be confronted with questions of life and death, and of the meaning of existence. ‘Would you trade your ability – or your mother’s – to talk for a few extra months of mute life? How much neurologic suffering would you let your child endure before saying that death is preferable?’
Anyone who has ever been in a ward of patients with severe head injuries will understand what he means. You emerge perplexed by things you had previously taken for granted. How are these people related to who they were before? What is human consciousness? And, as Kalanithi himself puts it, what makes life meaningful enough to go on living?
As a young doctor, he was driven to exhaustion and, occasionally, despair by his own fruitless pursuit of perfection. ‘Learning to judge whose lives could be saved, whose lives couldn’t be and whose shouldn’t be, requires an unattainable prognostic ability. I made mistakes… The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt.’
Alongside these soul-searching reflections, Kalanithi offers vivid descriptions of the endlessly fascinating work of the neurosurgeon. Removing tumours next to the language areas of the brain, surgery is performed with the patient awake and talking. The surgeon delivers a small electrical current to stun small areas of the cortex while the patient performs various verbal tasks, such as reciting the alphabet.
‘When the electrode sends current into a critical piece of cortex, it disrupts the patient’s speech :‘ ABCD E guh guh guh rrrrr... F G HI ....’ The brain and the tum our are thus mapped to determine what can be resected safely.’ When Kalanithi is diagnosed with terminal cancer, his role is immediately transformed from doctor to patient, and from active to passive. ‘As a doctor, I knew not to declare “Cancer is a battle I’m going to win!” or ask, “Why me?” – Answer: why NOT me?’ His poor father tells him that he is going to beat cancer, that he will somehow be cured. ‘How often had I heard a patient’s family member make similar declarations? I never knew what to say to them then, and I didn’t know what to say to my father now.’
His marriage had been going through a rocky patch, but this brought them together. ‘In truth, cancer had helped save our marriage.’ In one of the most moving parts of the book, he and his wife discuss the possibility of having a baby. Lucy wants him to decide, he wants her to. ‘ Don’t you think saying goodbye to your child will make your death more painful?’ she asks.
‘Wouldn’t it be great if it did?’ he replies, adding: ‘Lucy and I both felt that life wasn’t about avoiding suffering.’
In his quest for meaning, he avidly reads books about death – Tolstoy’s The Death Of
Ivan Ilyich, Solzhenitsyn’s Cancer Ward, Montaigne’s Essays, and ‘anything by anyone who had ever written about mortality’. He was, he writes, ‘searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again’. He finds seven words by Samuel Beckett
‘You filled a dying man’ s days with a sated joy, a joy that does not hunger for more but rests, satisfied’
that sum up the paradox of his condition, its perfect balance of despair and hope: ‘I can’t go on. I’ll go on.’
For a time, he goes back to work, but then a fresh tumour develops. He goes through debilitating rounds of chemotherapy. The neurosurgery department determines that he has met all the criteria for graduation. The ceremony is scheduled for a fortnight before their baby is due. But as he is getting dressed for it, a terrible wave of nausea strikes him, and he starts vomiting uncontrollably. ‘I would not be going to graduation, after all.’
Their baby daughter, Cady, is born. She seems to give him the meaning for which he has been looking all his life. He realises that their lives will overlap only briefly, but writes her a simple message, to read some time in the future. It’s worth quoting in full: ‘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.’
Paul Kalanithi died on March 9, 2015, not long after writing those words. ‘I’m ready,’ he said, before bidding his family farewell and slipping into unconsciousness. He left this book unfinished, but it still has a com- plete quality, a feeling that it contains all that needs to be said.
His wife Lucy has contributed an extraordinarily moving epilogue, in which she describes his determination to keep writing his book right up to his last moment, sitting beneath a blanket, often having to wear gloves as a protection against the painful fissures on his hands due to the chemotherapy. ‘This book carries the urgency of racing against time,’ she says.
Lucy Kalanithi’s piece reminded me of another widow’s postscript to her husband’s book. The final diaries of the maverick British Conservative MP Alan Clark end in his death, also from cancer. In the published book, his wife Jane then adds her own diary of those final days. ‘I cried tears for a future that Al was not to share,’ she writes. In the same way, Lucy Kalanithi writes of ‘a grief so heavy that at times I shiver and moan under the weight of it’. But she also rejoices that his memoir can ‘teach us to face death with integrity’. And, one might add, to face life with integrity, too.