Grand illnesses are supposed to be life-clarifying. Instead, I knew I was going to die – but I’d known that before. My state of knowledge was the same, but my ability to make lunch plans had been shot to hell. The way forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases. The truth that you live one day at a time didn’t help: What was I supposed to do with that day?Dr. Paul Kalanithi spent his too short life trying to understand what makes us human. Gaining an early love of literature from his mother, Kalanithi read all the classics; thinking that the ultimate answers could be found within their pages. When he got to university, however, an introduction to neurobiology made him wonder to what degree “humanity” is merely a result of the workings of the brain. Ultimately, Kalanithi grew to believe that the answers could be found within both disciplines, and he went on to earn not just a BA and MA in Literature from Stanford, but a concurrent BA in Human Biology, an MPhil in History and Philosophy of Science and Medicine from Cambridge, and an MD from Yale. He returned to Stanford for his Residency in Neurosurgery (where he also trained as a lab-based Neuroscientist), and by all accounts, Kalanithi was poised to begin an important and successful career.
Before operating on a patient's brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another's cross, one must sometimes get crushed by the weight.And yet, on the cusp of finishing his training at 36 years old, Kalanithi was diagnosed with Stage IV lung cancer. Just at the point when Kalanithi had finally learned how to take a holistic view of his patients – to transcend a mechanical approach to brain surgery and treat the person, body and mind – his situation was flipped; he became the patient; a role it took time and practise to learn. With an uncertain prognosis, Kalanithi committed to living: he finished his Residency; chose to start a family with his wife; and began to write When Breath Becomes Air.
The book itself is divided into two parts – the rise of the doctor and the decline of the patient – and as Kalanithi didn't live a full two years after diagnosis (and as he spent much of that time rehabilitating himself, reentering surgery to complete his Residency requirements, and then fading quickly), the book has a nearly unfinished quality to it; which is actually one of its strengths. Kalanithi demonstrates his lifelong knowledge and love of literature with frequently clunky quotes (when an author needs to write “to return to Eliot again”, he's probably gone to that well too many times), but since he died before the manuscript could be properly edited, I got the sense that his family and publishers decided to just leave his words as written: slightly genius, slightly amateur, wholly human. As another example, Kalanithi provides the word origins for common words like “hope” and “patient” which I didn't find to be too insightful to the points he was illustrating, but I really liked this effort:
The root of disaster means a star coming apart, and no image expresses better the look in a patient's eyes when learning a neurosurgeon's diagnosis.That made me look at the word “disaster” (same root as asteroid and astronaut?) in a whole new way that was really compelling for his point. Had Kalanithi lived through the editing process, the whole book might have reached this level. The fact that he did not live that long adds poignancy and humanity. Kalanithi died when his daughter was eight months old and the final paragraph of his manuscript was addressed to her:
When you come to one of the many moments in life when 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.You'd have to be a marble slab to not be affected by that. Kalanithi's manuscript has a foreword by Abraham Verghese (which, as I'm not a particular fan of his, I found wholly unnecessary) and an afterword written by his widow Lucy Kalanithi (a celebrated doctor in her own right). Lucy is able to add what Paul could not: a view of her husband's last days and hours and moments. She wants the reader to know “what happened to Paul was tragic, but he was not a tragedy”, and Lucy adds details about her husband's warmth and humour that didn't really come through in his own writing. And perhaps it's because Lucy had the benefit of thoughtful editing, but I actually admired her writing style even more than that of her husband:
I expected to feel only empty and heartbroken after Paul died. It never occurred to me that you could love someone the same way after he was gone, that I would continue to feel such love and gratitude alongside the terrible sorrow, the grief so heavy that at times I shiver and moan under the weight of it.In the end, I think that both Kalanithis add to our understanding of humanity, and it really is tragic – beyond the personal tragedy that his untimely death represents to his family and friends – that someone with Paul's particular training and interests didn't live long enough to investigate and share his further findings about the big questions. I completely understand why this book is a bestseller.
