When Breath Becomes Air

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All life is lived in the shadow of its own finitude, of which we are always aware — an awareness we systematically blunt through the daily distraction of living. But when this finitude is made acutely imminent, one suddenly collides with awareness so acute that it leaves no choice but to fill the shadow with as much light as a human being can generate — the sort of inner illumination we call meaning: the meaning of life.

That tumultuous turning point is what neurosurgeon Paul Kalanithi chronicles in When Breath Becomes Air (public library) — his piercing memoir of being diagnosed with terminal cancer at the peak of a career bursting with potential and a life exploding with aliveness. Partway between Montaigne and Oliver Sacks, Kalanithi weaves together philosophical reflections on his personal journey with stories of his patients to illuminate the only thing we have in common — our mortality — and how it spurs all of us, in ways both minute and monumental, to pursue a life of meaning.

What emerges is an uncommonly insightful, sincere, and sobering revelation of how much our sense of self is tied up with our sense of potential and possibility — the selves we would like to become, those we work tirelessly toward becoming. Who are we, then, and what remains of “us” when that possibility is suddenly snipped?

Paul Kalanithi in 2014 (Photograph: Norbert von der Groeben/Stanford Hospital and Clinics)

A generation after surgeon Sherwin Nuland’s foundational text on confronting the meaning of life while dying, Kalanithi sets out to answer these questions and their myriad fractal implications. He writes:

At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea. I could see a nice catamaran on that sea that Lucy, our hypothetical children, and I would take out on weekends. I could see the tension in my back unwinding as my work schedule eased and life became more manageable. I could see myself finally becoming the husband I’d promised to be.

And then the unthinkable happens. He recounts one of the first incidents in which his former identity and his future fate collided with jarring violence:

My back stiffened terribly during the flight, and by the time I made it to Grand Central to catch a train to my friends’ place upstate, my body was rippling with pain. Over the past few months, I’d had back spasms of varying ferocity, from simple ignorable pain, to pain that made me forsake speech to grind my teeth, to pain so severe I curled up on the floor, screaming. This pain was toward the more severe end of the spectrum. I lay down on a hard bench in the waiting area, feeling my back muscles contort, breathing to control the pain — the ibuprofen wasn’t touching this — and naming each muscle as it spasmed to stave off tears: erector spinae, rhomboid, latissimus, piriformis…
A security guard approached. “Sir, you can’t lie down here.”
“I’m sorry,” I said, gasping out the words. “Bad … back … spasms.”
“You still can’t lie down here.”
[…]
I pulled myself up and hobbled to the platform.

Like the book itself, the anecdote speaks to something larger and far more powerful than the particular story — in this case, our cultural attitude toward what we consider the failings of our bodies: pain and, in the ultimate extreme, death. We try to dictate the terms on which these perceived failings may occur; to make them conform to wished-for realities; to subvert them by will and witless denial. All this we do because, at bottom, we deem them impermissible — in ourselves and in each other.

Punctuating Kalanithi’s story are vignettes of those small yet enormous moments in which destinies pivot and the elaborate universe of priorities we’ve spent a lifetime constructing combusts into stardust. In those moments, there is a violent slamming shut of chapters we had naïvely thought would go on and on, leading to Happily Ever After and yet somehow not really ending there, for the endings we imagine for ourselves aren’t really endings. An ending is devastating and unsatisfying in its finitude, and the endings we imagine for ourselves are permanent states of ongoing, infinite satisfaction. Kalanithi recounts one such moment of enormous smallness as he finds himself a patient at the very hospital where he works as a neurosurgeon, awaiting the news of his dismal prognosis:

A young nurse, one I hadn’t met, poked her head in.
“The doctor will be in soon.”
And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

As a young man, Kalanithi bridged the lifelong love of reading instilled in him by his mother’s passion for literature with a sudden fascination with neuroscience — all thanks to a mediocre 500-page novel that, despite its questionable literary quality, posited an idea that turned his worldview upside down. He recounts how he found himself at the mesmerizing intersection of the life of the mind and the life of the brain:

The throwaway assumption that the mind was simply the operation of the brain [was] an idea that struck me with force; it startled my naïve understanding of the world. Of course, it must be true — what were our brains doing, otherwise? Though we had free will, we were also biological organisms — the brain was an organ, subject to all the laws of physics, too! Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it. It seemed like magic. That night, in my room, I opened up my red Stanford course catalog, which I had read through dozens of times, and grabbed a highlighter. In addition to all the literature classes I had marked, I began looking in biology and neuroscience as well.
A few years later, I hadn’t thought much more about a career but had nearly completed degrees in English literature and human biology. 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. Meaning, while a slippery concept, seemed inextricable from human relationships and moral values… Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection. My brief forays into the formal ethics of analytic philosophy felt dry as a bone, missing the messiness and weight of real human life.

Kalanithi reflects on his decision to continue his education with a master’s degree in English literature:

I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion. A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form. It was the relational aspect of humans — i.e., “human relationality” — that undergirded meaning. Yet somehow, this process existed in brains and bodies, subject to their own physiologic imperatives, prone to breaking and failing. 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.
[…]
For my thesis, I studied the work of Walt Whitman, a poet who, a century before, was possessed by the same questions that haunted me, who wanted to find a way to understand and describe what he termed “the Physiological-Spiritual Man.”

As his friends pursued careers in the arts, Kalanithi remained animated by the seemingly quixotic quest to locate the intersection of literature, biology, philosophy, and morality, and to mine it for the raw material of meaning in human life. Eventually, several of his professors suggested that a degree in the history and philosophy of science might come closest to his inquiry, so he applied to the program in Cambridge and set off for the English countryside. He recounts:

I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them. Words began to feel as weightless as the breath that carried them. Stepping back, I realized that I was merely confirming what I already knew: I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action. I finished my degree and headed back to the States. I was going to Yale for medical school.

It was on the wings of this incisive idealism that Kalanithi soared through his life as a neurosurgeon, and it was on them that he rose to his death. He writes:

I had spent so much time studying literature at Stanford and the history of medicine at Cambridge, in an attempt to better understand the particularities of death, only to come away feeling like they were still unknowable to me… Such things could be known only face-to-face. I was pursuing medicine to bear witness to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.

But facing these twinned mysteries as a participant rather than an observer upended his most basic beliefs. He reflects on his conflicted mental state midway through his treatment as the tumors shrink and the cancer is momentarily under control:

No one asked about my plans, which was a relief, since I had none. While I could now walk without a cane, a paralytic uncertainty loomed: Who would I be, going forward, and for how long? Invalid, scientist, teacher? Bioethicist? Neurosurgeon once again…? Stay-at-home dad? Writer? Who could, or should, I be? As a doctor, I had had some sense of what patients with life-changing illnesses faced — and it was exactly these moments I had wanted to explore with them. Shouldn’t terminal illness, then, be the perfect gift to that young man who had wanted to understand death? What better way to understand it than to live it? But I’d had no idea how hard it would be, how much terrain I would have to explore, map, settle. I’d always imagined the doctor’s work as something like connecting two pieces of railroad track, allowing a smooth journey for the patient. I hadn’t expected the prospect of facing my own mortality to be so disorienting, so dislocating. I thought back to my younger self, who might’ve wanted to “forge in the smithy of my soul the uncreated conscience of my race”; looking into my own soul, I found the tools too brittle, the fire too weak, to forge even my own conscience.

Unable to find solace in science, he turned once again to literature, that supreme booster of the human heart that had once saved Oliver Sacks’s life in a very different way. Kalanithi writes:

It was literature that brought me back to life during this time. The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action. I remember the moment when my overwhelming unease yielded, when that seemingly impassable sea of uncertainty parted. I woke up in pain, facing another day — no project beyond breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.”
That morning, I made a decision: I would push myself to return to the OR. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.

As he nears the end, Kalanithi comes closer and closer to the vital substance of living, stripped of the conceits, delusions, and false refuges with which we hedge ourselves against our own impermanence. He reflects:

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 toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.

With an eye to his baby daughter — parenthood was a deliberate choice he and his wife, Lucy, made in the wake of the diagnosis — he considers what message he would give to this brand new being, blessed and burdened with her own infinite potential for an inherently finite life:

There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.
That message is simple:
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.

Kalanithi died in March of 2015, leaving behind When Breath Becomes Air — a ledger of precisely such enormity and a rare masterwork of duality in which the tragedy of death isn’t subverted or diluted but coexists, every bit as real, with the triumph of aliveness as the highest human potentiality.

–By Maria Popova

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