When Paul Kalanithi’s short (unfinished) memoir When Breath Becomes Air was released in early 2016, it went on to become, with some assiduous marketing, a non-fiction bestseller on both sides of the Atlantic. The story it tells is a poignant one, of final acceptance of a fatal illness and marital reconciliation, while offering a very American allegory of thwarted ambition. Its message is one that the great French essayist Michel de Montaigne expressed in a single line four hundred years ago: we do not die, he writes, because we are ill but because we are alive. In other words, there is no safe distance from death; it stands at the same distance from us all our lives.
“Most patients believe/ dying is something they do,/ not their physician” begins W.H. Auden’s 1969 poem “The Art of Healing”, a moving tribute to his personal physician David Protech, who had recently died of pituitary cancer. Many physicians slip into this belief too, and some even become doctors to protect themselves from the eventuality. But as Paul Kalanithi reminds us, whether we adopt an attitude of passivity, try to ward it off by magical thinking or philosophise about it, “death comes for all of us.”
This hardly qualifies as news, but the acute knowledge of his impeding death from disseminated lung cancer imbues Kalanithi’s short memoir When Breath Becomes Air, parts of which were first published as stand-alone articles, with a peculiar pathos. He knew, even as he was working on his manuscript, that if it were ever published as a book he would not live to read it. In fact, after a sudden unexpected decline in his condition in early 2015, it had to be completed, in an equally eloquent epilogue, by his wife. Since publication, the book has gone on to become a bestseller on both sides of the Atlantic.
Born into a medical family (his father was a cardiologist in the Arizona city of Kingman), Kalanithi had initially no desire to become a doctor. He had seen too little of his father to think it a worthwhile career. He studied English literature and human biology at Stanford, learning with Richard Rorty and writing a thesis around Walt Whitman’s notion of “the Physiological-Spiritual Man”. Stanford was followed by a year at the history of science programme in Cambridge, during which he came to the conclusion that “Moral speculation was puny compared to moral action.” Only medicine could offer him the direct experience he craved, “getting right there”.
From this disputable assumption, he chose, after acquiring his basic degree at Yale, to enter the Stanford training programme in neurosurgery, a tough residency requiring long working weeks and hundreds of complicated operations, often on head injury victims. Neurosurgery seemed to him to present “the most direct confrontation with meaning, identity, and death.” He was assuming his vocation, the yoke of “mortal responsibility” (though this surely hangs around the neck of all doctors), puritanically looking askance at the lifestyle choices of his contemporaries who opted for easier options, such as dermatology or ophthalmology, where the emergency nocturnal call-outs are uncommon. Neurosurgeons, according to his chief resident, had to be the very best doctors in the hospital, a conviction that may stem not just from the medical pecking order but the contemporary obsession with the “cerebral subject”—the assumption from SF films to neurophilosophy that all we need to be ourselves is a brain.
Then, on the verge of qualification, in sight of “the Promised Land”, this dedicated young surgeon developed night sweats, rapid weight loss and severe back pain. He stalled going to a colleague to hear the diagnosis that would have prompted itself in any patient. His wife Lucy, an internist, realised what was going on only when she accidentally discovered that he had been searching on the internet for information about cancer statistics. It was a freak diagnosis: “only 0.0012 percent of thirty-six-year-olds get lung cancer.”
Less than six days after a heroic thirty-six hours in the operating room, he found himself an invalid—“My body, and the identity tied to it, had radically changed.” Having almost ruined his marriage through denial of his illness, Kalanithi (always a planner) decided to freeze his sperm before undergoing chemotherapy. He fretted about his Kaplan-Meier survival curves, but the oncologist refused to speculate. In fact, his tumour responded so well to the first cycle of chemotherapy that he was able to put on his blue garb and go back to work again, even though he had to take an array of drugs to suppress nausea and pain. Crestfallen to find that the surgeon-scientist position to which he was “heir apparent” at Stanford had, in his absence, been filled, he flew to Wisconsin for another job interview. On the point of accepting the position it became clear to him that he had been fantasising. His cancer was merely in abeyance. How would his wife (now that she was expecting their child) be able to cope should he relapse so far from friends and family?
A few months later, having failed to respond to third-line drugs, Paul Kalanithi died in a hospital bed not far from the delivery ward where his daughter Cady had entered the world eight months before. Although his cancer had seeded the leptomeninges, the membranes around his brain, he found strategies to retain “the mental focus needed to write” almost to the end, typing with seamless gloves after the chemo fissured his fingertips, convinced, as his wife says, that he had “important things to say.” This might suggest that the popular appeal of his book lies in its being an ars moriendi, the kind of consolatory literature on dying well that was so popular before the modern era. Alas, neurosurgeons know as much, or as little, about what it means to die as anyone else. From having started his career intending, in a full-on manner, “to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking”, he confesses that it may well be that “being so close to the fiery light of such moments only blinded me to their nature.” François de La Rochefoucauld had felt much the same, when he stated that neither the sun, nor death, can be looked straight in the eye.
When Breath Becomes Air is better described as a sparely lyrical account of excruciated ambition. Weakened by his illness (and its treatment), Kalanithi returns not just to literature (Beckett’s “I can’t go on… I’ll go on”) but his childhood faith, and the Biblical dimensions of that inspiring word “breath”. While his little book is dotted with insights, not least about the ambiguity of the doctor’s role as enemy and ambassador of death, his analogies are sometimes forced and occasionally wrong (for instance, in what he writes about the “asymptote”); indeed his bite at Beckett suggests a misreading of the latter’s absurdism, as if life in general ought to make demands on literature rather than the other way around. It doesn’t occur to him either that he himself has become a variant of Whitman’s dualist (who could now go as something like “the Existential-Probabilistic man”) when he admits that survival rates have never been a great help to anyone faced with their imminent demise—“my relationship with statistics changed as soon as I became one.”
© Iain Bamforth. First published as “Heart doctor” in TLS, June 3, 2016