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When Breath Becomes Air by Paul Kalanithi

Writing.ie | Memoir

By Berni Dwan

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Looking Death in the Eye

Having endured the emotional battering of reading Paul Kalanithi’s When Breath Becomes Air, I was reluctant to recommend it. As a fully paid up member of the feint hearted class, the slightest background knowledge I had about this book was enough to make me a reluctant reader; especially because it is a true story written by a dying man.

And so, curiosity overtaking my fear, I read When Breath Becomes Air in a few anxiety-filled days, leading me to contradict myself. Now, I strongly urge you to read it if you can summon up the courage. I’ll be honest though; you will probably feel low and even a little insecure or unsettled for a few days after you finish it. You will be silently outraged at the random unfairness of life when the story unfolds about how a young and gifted neurosurgeon is forced to exit this mortal stage at thirty-seven while crooked bankers, lawyers, property developers, politicians and speculators can survive into healthy old age to regale each other with tales of self-aggrandising schemes, or, as Arthur Koestler might say, “killing time by chewing the cud of old adventures.”

As I travelled deeper into Kalanithi’s life and his journey towards death, that phrase beloved of every aggrieved child kept rising to the surface; “It’s not fair.” When Breath Becomes Air is not comfortable reading; real-life sad endings being more gut wrenching than literary ones, especially when roles are reversed, as in this case, with the doctor becoming the patient.

When I came to the end of Kafka’s The Trial, I buried myself in denial; ridiculously optimistic that Josef K. would, on his thirty-first birthday, prevail. Like Kalanithi, he is unexpectedly invited to fight a losing battle with an elusive enemy. Having fought the brave fight they settle on allowing acceptance to take over from resistance while trying to retain their powers of reason and analysis until those final moments. Indeed, it is this determination to retain your intellectual faculties until the last second that differentiates extraordinary mortals from mere mortals.

It surfaces again in an older man who I think about more and more as I try to understand Kalanithi. When the diffident anti-Nazi hero, Otto Quangel, is executed by guillotine in Hans Fallada’s Alone in Berlin he accepts the situation in an almost saint-like manner. After losing his only son in action, Quangel strikes out against Hitler by posting up hundreds of anti-Nazi messages knowing full well that his simplistic yet risky action will have little impact. Edmund Burke said, “The only thing necessary for the triumph of evil is for good men to do nothing.” Cut from the same cloth as Kalanithi, Quangel does something and it makes him feel fully alive and useful. Quangel even decides to endure his execution rather than bite on the cyanide pill; wanting to experience even the tragic shards of what remain of a harsh life.

We would all like to believe that somehow, in some small way, the world is a better place because of the time we spent in it. Paul Kalanithi, in his short, hectic and demanding life, strived to understand life in its fullest sense. This incessant drive, through literature and medical science, to discover what makes life meaningful recurs throughout his book. The juxtaposition of a human being, possessing a free will, while also being a bunch of biological organisms struck him as magic. “Literature provided a huge amount of human meaning; the brain then, was the machinery that somehow enabled it.” This realisation prompted him to study human biology alongside his beloved literature as an undergraduate in Stanford University. Still grappling with the idea that literature provided the “best account of the life of the mind” Kalanithi remained at Stanford to complete a master’s in English literature. “I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimetre-thick skulls, into communion.” His thesis – “Whitman and the Medicalization of Personality” – a quirky mix of psychiatry, neuroscience and literary criticism – was prophetic.

The path was becoming clearer though. While many of his friends headed to New York to pursue careers in the arts, Kalanithi made the impossibly difficult decision to embark on the gruelling preparatory journey to medical school. Still wavering ever so slightly though, he spent a year studying the history and philosophy of science in Cambridge University where he found himself increasingly arguing that “direct experience of life-and-death questions was essential to generating substantial moral opinions about them.”

I am guessing that Kalanithi was probably the best read undergraduate medical student in Yale – an enviable position on both counts. I am reminded of the doomed protagonist, Inman, in Charles Frazier’s Cold Mountain who like Kalanithi, takes solace and enlightenment from literature, his constant companion in his perilous journey being Bartram’s Travels. The wounded Confederate soldier with a heightened sensitivity that most of his peers likely do not possess, is cut down in the final minutes of the final furlong of his journey home.

“Medical school,” says Kalanithi, “sharpened my understanding of the relationship between meaning, life, and death,” but the journey to understanding seemed relentless and almost unattainable. “I had spent so much time studying literature at Stanford and the history of medicine at Cambridge, in an attempt to better understand the peculiarities of death, only to come away feeling like they were unknowable to me.” But the business of a speciality beckoned, and I won’t even try to explain the dizzying and rocky voyage of completing a neurosurgery internship; let’s just say that if many of us think that we are busy – read this section to realize that most of us certainly are not. Furthermore, when you consider that Kalanithi completed the final stages of his training while struggling with a terminal cancer diagnosis it becomes clear that you are acquainting yourself with someone who will incite you to dismiss the half measures and lame excuses in favour of unstinting effort at everything you do from hereon in.

And so, it comes full circle, the book that opens with the line “I knew with certainty that I would never be a doctor” meanders its way to that affecting scene with Kalanithi scrubbing up for what he knows will be his last operation; the finality laced with pathos as he stands for hours using his exceedingly hard-earned, intricate and complex surgical skills to mend the afflicted, while the agonising back pain that signals his own worsening condition hovers like an elusive phantom.

Like many great books, When Breath Becomes Air is unfinished. Kalanithi’s final thoughts reflect on the gift of a baby daughter, Cady, who was born eight months before his death. The epilogue, written by his wife, Lucy, is a sobering yet inspiring account of living with someone who was brave enough to “look death in the eye.”

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