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When Breath Becomes Air by Paul Kalanithi

Reviewed by Tamanna Basu


‘When Breath Becomes Air’ is an autobiography; it is a memoir. It is also an epitaph in the form of a novel written by Paul Kalanithi for his own burial – an epitaph negotiating death, ensuring his memory lives on in time, creating a profound impact on anyone who visits it. Paul begins by introducing himself – a thirty six year old, second generation Indian American citizen in his final year of residency training in Neurosurgery, a father of a new-born daughter, a husband, an ambitious, self-reflexive individual, and a young man facing imminent death by cancer. There is no room for suspense. We are plunged immediately into the pathos, struggle and courage of young man standing at the edge of life. ‘Death’ and its antonym ‘life’ dominate the novel. The narrative walks the thin line between consciousness and nothingness; it is a heartbreaking attempt to negotiate the moment when “breath”, an indicator of being alive, of ‘being’, turns into “air” and one ceases to exist. In moments Paul goes from being a doctor to a patient. ‘Identity’ and its relation to ‘time’ are crucial points of interrogation within the novel. How does one conceptualize one’s identity or negotiate the present moment when the future, as an imagination, as an aspiration along a linear path of movement, is gone? Paul and the reader are taken aback by the glaring unpredictability, transience, and fragility of life – it’s ability to suddenly, simply, snap and end. Through Paul’s mortality, we realize our own. Paul dies leaving behind a powerful narrative that is a testimony to his life and to the active, intelligent, sensitive state of consciousness he inhabited. Writing an autobiography, as Paul tells us, is an act of courage rooted in the ability to be vulnerable and honest. The book is written with a sense of purpose to retain meaning, to leave something behind, to have existed. His wife, Lucy, writes in the epilogue, “This book carries the urgency of racing against time, of having important things to say.” Paul achieves his purpose and goes beyond – he created ‘When Breath Becomes Air’ and through it, Paul Kalanithi lives on.

The prologue opens in the first moment of confirmation. In a hospital room, Paul and Lucy flip through his CT Scans that show stage IV lung cancer. For a year Paul had sensed the symptoms but ignored them. A frightful suspicion turns into fact – death, as the most likely possibility, is brought home for the first time. They hold each other and cry. The reader, without warning or preparation, is plunged straight into the heart of death, sickness and pain. Despite working in the midst of death with patients, Paul is not prepared to face his own mortality. “Why?”, Paul wonders, “was I so authoritative in a surgeon’s coat but so meak in a patient’s gown?” He is referring to the gap between the ‘known’ and the ‘felt’, between studying the states of death, sickness or pain and inhabiting them; it is the divide of empathy and experience that stretches between the doctor and the patient – a theme Paul repetitively grapples with throughout the narrative. Paul’s residency and schedule had taken a toll on his marriage. With unfaltering honesty, he reveals the friction and troubled state of his marriage to the world only to demonstrate death’s ability to change reality, to transform perspectives and rearrange priorities. With his condition, a fading marital love is instantly recalled and highlighted. A lifetime imagined together is cut short and each passing instant becomes precious. Paul’s training was about to conclude and with that his work hours were to relax; there would be time to become the husband he wanted to be, to become a father. He was at the pinnacle of success. After years of relentless hard work, he was emerging as a leading neurosurgeon, flooded with the best opportunities and offers. Dreams were coming true and then a CT scan passed a judgment.

“And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.” – Paul Kalanithi

Part One of the book aptly named ‘In Perfect Health I begin’, traces Paul’s childhood in the Arizona countryside up until the watershed moment of cancer. He describes the countryside as a place of adventures where he grew up with his friends, listening to “country facts” and tales, battling various poisonous and harmless insects that would thrive in the heat, and playing games and exploring nature as they matured. His mother, ambitious about her children’s education, introduced him very early to the joy of literature. At the age of ten he read George Orwell’s ‘1984’ and discovered, in his words, “a deep love of, and care for, language.” He went on to pursue a BA and MA in English and BA in human biology from Stanford. As a part of his human biology classes, Paul visits a home for people who had suffered severe brain injuries – the zone of the abandoned. The visit has a profound impact on him, making medical science central to his fascination. He is driven by a desire to build bridges between science and literature – his two great affairs: “Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it. It seemed like magic” (Kalanithi). Through the novel Paul demonstrates a drive fueled less by achievements and more by curiosity; his prose is a testimony to his ambitious, hungry intelligence. As his Masters draws to an end, he realizes that his rapidly growing relationship with medical science cannot thrive in an English department. He applies, and is awarded admission to Yale School of Medicine where he arrives with a burning question in his mind – “Where did biology, morality, literature and philosophy intersect?”

Paul’s medical education challenges him to navigate a novel set of philosophical and ethical concerns. He repeatedly describes the experience of dissecting cadavers. The cadaver is what he, us, will all one day be – is it human or an object of study? He is amazed by the simultaneous coexistence of the total deadness and total humanness of the cadaver and is deeply concerned by the position that he, the doctor, occupies in this scheme of things. The doctor must negotiate the space between compassion and callousness. Being constantly in the glare of death, is one made more sensitive to its loss and pain, or simply immunized, normalized to it? How does the doctor hold on to the personhood of the cadaver while cutting it apart? Paul struggles: “In our rare reflective moments we were all silently apologizing to our cadavers, not because we sensed the transgression, but because we did not.” Practical training in medicine, he realizes, is very different from theoretical studies. He assists a variety of procedures – healing and losing patients. The stress and misery of being constantly surrounded by death stand out in his narrative. He struggles to understand what makes life meaningful even in the midst of death and decay – a question that stays with him till the end. His unrelenting strife to engage with the moral questions of his profession dominates the narrative. The doctor has to make judgment calls and find the ability to live with them, to take responsibility for the patient’s health as well as death. Paul’s courage lies in his ability to navigate moral dilemmas, accept that he will fail and yet find value in striving – “The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients” (Kalanithi). The reality and the importance of the ‘other’, in this case, the patient, strongly factor into Paul’s empathy and imagination. He writes that the doctor’s relationship with the patient cannot be premised solely upon saving lives but has to include guiding, and aiding the patient to an understanding of life, sickness, and death with compassion; the patient has to be met as a “person” and not as “a problem to be solved” (Kalanithi). Upon the conclusion of general training, Paul selects Neurosurgery as his specialization. He is driven to it with a passion and practices it with a deep conviction. Paul writes, “While all doctors treat diseases, neurosurgeons work in the crucible of identity.” “It is a sophisticated, elegant skill. In Neurosurgery, life and death, or rather, the patient’s identity, is a matter of millimeters.” Skill, Paul writes, is a moral responsibility for a neurosurgeon. Paul had struggled with intellectual puzzles, in various forms, since his childhood and they were finally beginning to piece themselves together – “It felt to me as if the individual strands of biology, morality, life, and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent whole and a sense of my place in it.” At this juncture, Paul received the call of death. The first part of his memoir that describes him, not as a sick man, but as a healthy one, teeming with ambition, hard work, passion and sensitivity, is crucial. It tells us, readers, who Paul was, so that we may know, ever more deeply, who was lost.

Part two is called ‘Cease Not Till Death’ and, standing true to its title, it is an unfailing demonstration of Paul’s ceaseless spirit of striving. “The defining characteristic of the organism,” he writes, “is striving.” In the blank space between the two parts, Paul has gone from being a doctor to a patient; an identity inversion has taken place and he realizes that death, for all his philosophical and professional engagement with it, is not familiar. Facing imminent death, Paul is confronted, overwhelmingly, with a sense of powerlessness. The Fates have snapped his thread of life and robbed him of his sense of agency, his sense of control. He is advised to take one day at a time. It is a sound advice but what is one to do with one’s today, if tomorrow is removed. Can the present be conducted, and one’s identity be conceived, outside an imagination of the future? Attempting to solve these mysterious relations between identity, time and language, Paul asks a simple, profound question, “What tense am I living in now?” Upon detecting stage IV lung cancer, Emma, Paul’s doctor puts him on a pill called Tarceva that has shown to yield positive results. He begins to heal. His second scan displays a major recovery; it is almost entirely clear of tumors. A hope he had abandoned begins to somewhat shine through the clouds surrounding him. His life is strapped between an emerging possibility of life and a looming probability of death. Chained to a state of uncertainty, Paul decides, “…even if I am dying, until I actually die, I am living.” He works hard at physical therapy and significantly rebuilds his bodily strength. He resumes work as a neurosurgeon. Lucy and he decide to have a child. Neurosurgeon, husband and soon a father to be – he begins to piece his identity back together. A scan is conducted and it reveals a relapse; a new tumor has grown. He wonders, “If the weight of mortality does not grow, does it at least get more familiar?” The experience of decaying towards death is a gradual erasure of identity. The thrust of pathos rises from the loss of all Paul was, aspired for and could certainly have been. He writes, “My life had been a building potential, potential that would now go unrealized. I had planned to do so much and I had come so close.” Rigorous chemotherapy begins, designed to revive through breakage. Emma, very much the personification of the doctor and guide Paul had aspired to be, advises him, throughout his journey, to find his values, his priorities and conduct his days through them. In his final days, Paul devotes himself to his wife and his newborn daughter. He is awarded his graduation as a Neurosurgeon. He also returns to literature. He reads and ultimately, he writes. Passionate to the end, Paul writes with an urgency, with a purpose to be known, to be remembered, to leave behind a proof, a memoir, a monument consecrating his existence. Paul dedicates ‘When Breath Becomes Air’ to Cady, his daughter. Holding her in his lap he concludes, “Looking out over the expanse ahead I saw not an empty wasteland but something simpler: a blank page on which I would go on.”

Paul died on Monday, 9th March, 2015. In the Epilogue, Lucy Kalanithi writes, “When breath becomes air is, in a sense, unfinished, derailed by Paul’s rapid decline, but that is an essential component of its truth, of the reality Paul faced.” She speaks of their love, of love itself, as a way of managing sickness. She speaks of death with a stark realism. Death and struggle are not to be romanticized, nor are they to be infused with an unnecessary bravado, there is a loss, and it has to be grieved. ‘When Breath Becomes Air’ is a heartbreaking, impressive, powerful testimony and narrative to be recommended to anyone, to everyone.

Tamanna Basu is an academic scholar, social worker and activist. Tamanna completed Bachelors and Masters in English from Hans Raj College, Delhi University in 2016. She is currently pursuing M.Phil in English at Delhi University as a research scholar. Tamanna works with Shakti Shalini, an NGO, in the the capacity of ‘Manager: Human Resources’. She also manages and edits ‘Darmiyan’, an online literature platform hosted by Shakti Shalini.