‘When Breath Becomes Air’ by Paul Kalanithi (The Bodley Head, 2016).
A short and profound book, When Breath Becomes Air gets right to the heart of the matter; the prologue commences with a final-year neurosurgical resident analysing CT scan images. This is Paul Kalanithi at 36 years old, and he diagnoses his own terminal lung cancer. Almost at once, his future expectations waver, diminish, and vanish. Picking up on the intricate relationship between breath, soul and vitality, the pages after this striking and poignant moment portray Kalanithi’s memoirs as an odyssey to uncover not only the meaning of life, but his life. While it is the former quest that grounds the memories of his thirst for knowledge and the establishment of his career (which forms the majority of this autobiography), it is the latter that softly, and perhaps more compellingly, frames Kalanithi’s account of his final few weeks.
As a teenager living in the small desert town of Kingman, Kalanithi had no professional calling, but appears influenced by his doctor father’s standard of excellence, and his mother’s insistence he read the ‘college reading prep list’: Kalanithi pursued dual degrees in Biology and English Literature at Stanford University. He continued his studies with confidence, dwelling on the unrelenting question ‘what makes human life meaningful, even in the face of death and decay?’ (p. 42). This existential interrogation eventually led Kalanithi to medical school at Yale and a specialisation in neurosurgery given ‘its unforgiving call to perfection,’ and that ‘it seemed to present the most challenging and direct confrontation with meaning, identity and death’ (pp. 71-72).
Kalanithi’s self-assured, graceful writing navigates his exploration of the meaning of life at the forefront of medical practice during his residency at Stanford. He describes the social interactions of and with cadavers (whilst objects of study, they have variable, subjective significance), and notes that his first experience of birth was also his first experience of death. This confrontation was to become the norm, and, after listing a number of memorable deaths he had witnessed, Kalanithi considered that ‘at moments, the weight of it all became palpable. It was in the air, the stress and misery. Normally, you breathed it in, without noticing it. But some days, like a humid muggy, day, it had a suffocating effect of its own’ (p. 78).
This sense of awareness also seems to permeate the way Kalanithi experienced his illness and the eventuality of his own death: always evident, lived in every action, memory and goal, but with moments of conscious forgetting while concentrating on his demanding role as neurosurgeon. He writes that ‘The funny thing about time in the OR [operating room] … is that you have no sense of it passing … the intense focus made the arms of the clock feel arbitrarily placed’ (p. 104).
Upon returning to work after his cancer briefly stabilised, and taking on a greater workload in order to graduate residency (a graduation he was to be too ill to attend), Kalanithi reflects on how his views and practice of neurosurgery had changed to appreciate the perspectives of both patient and doctor; a greater mortal responsibility. This new outlook was also to bring acknowledgement of his apparent ‘hubris as a surgeon’ by believing that this responsibility was going to be more than only ever fleeting. This was because even after any procedure the uncertainty of mortality always ‘remains to be grappled with’ (p. 166).
It was here that I appreciated that I had read Kalanithi’s work alongside Havi Carel’s Illness: The Cry of the Flesh (2008). While very different works, both offer very honest accounts of living with illness, and experiencing uncertainty when faced with death. Carel eloquently details how living in the moment is how she now experiences ‘being in the world’ whilst living with chronic respiratory illness. She writes ‘And now is where reality is: liquid time solidified into a crystal drop of Now. I grasped that drop with both hands, clutching, savouring, enjoying. Now became the place for me, too, to be’ (2008: 124). This sense of an enduring and strategic present is also described by Kalanithi with his negotiation of the clichéd five stages of grief (denial, anger, bargaining, depression, and acceptance) the opposite way to the norm, finding himself living in an odd denial of his situation. He postulates that ‘Maybe in the absence of any certainty, we should just assume that we’re going to live a long time. Maybe that’s the only way forward’ (p. 162). This living in the moment was crystallised in the words of Samuel Beckett that saw Kalanithi through his hard days: ‘I can’t go on. I’ll go on’ (p. 149).
Carel’s work also raises the important question of whether happiness is viable within the illness experience. She proposes that this is indeed possible, as to separate a good life from a sick one is to divorce the biological body from the lived body. The synthesis of these is evident in Kalanithi and his wife’s approach to having children, knowing the joy that a child could bring to their family even when considering Kalanithi’s terminal cancer:
‘Will having a newborn distract from the time we have together?’ she asked. ‘Don’t you think saying goodbye to your child will make your death more painful?’
‘Wouldn’t it be great if it did?’ I said. Lucy and I both felt that life wasn’t about avoiding suffering.
The ‘futurity’ symbolised through the birth of their daughter, Cady, brings an unsettling wonder and satisfaction to Kalanithi’s final days. Noting that ‘words have a longevity I do not’ (p. 199), When Breath Becomes Air is dedicated to her.
This book forms not only a message to Kalanithi’s daughter, but achieves his lifelong dream to become a published author. When Breath Becomes Air, made possible via Kalanithi’s wife Lucy and colleague Abraham Verghese, provides a poignant reminder to live life as it comes and is a fitting and lasting tribute to Kalanithi’s philosophical journey. Highlighting the fluidity of identity and the importance of subjective temporality, it is a powerful and valuable resource for scholars, medical professionals and all those who seek to comprehend the experience of doctoring, being a patient, and negotiating meaning when living with terminal illness.
Reviewed by Dr Rebecca Oxley, a CMH Research Fellow on the Wellcome Trust funded ‘Life of Breath’ project. Her research will focus on ‘aware breathers’ and breathing techniques to contribute to a phenomenology of breath, breathing and breathlessness.
Correspondence to Dr Rebecca Oxley.
Carel, Havi. 2008. Illness: The Cry of the Flesh. Stockfield: Acument.