Doctors exist so that people can live. Christian priests of most denominations don cassocks that are black — the colour of death — because the religion vests in them the role of preparing believers for dying. By contrast, doctors — men of science — wear white. What must then be the attire of a doctor who made it the mission of his life to understand death?
When Breath Becomes Air is a slim book in which neurosurgeon Paul Kalanithi dissects, in black and white, his nearly year-long experience with terminal cancer just as he was to begin a promising career as a neurosurgeon. Doctors and surgeons reflect on their practice; the suffering of their patients and their personal metamorphosis from being merely bright students to surviving the inhuman training that makes them the gatekeepers of life and death isn’t new.
But Kalanithi’s memoir is unique because it speaks of all of this from the vantage of someone who’s aware that he has no more than a year to live and who, in his college application, wrote an essay on why happiness wasn’t the purpose of life. Kalanithi studied English literature, Walt Whitman and biology and finally chose neurosurgery as his vocation to — as he reveals — understand death. In his words: … I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being.”
Kalanithi was 37 when he died last March leaving behind a wife, a two-year-old daughter and a 200-page-book, which includes an epilogue by his wife.
The economy of his prose, which probably results from an awareness of the limits imposed by time, constitutes some of the most striking passages in the book. “If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed.” There’s also operating room banter and jibes at surgeons who work slowly: “I get your strategy: by the time you finish sewing the top half of the wound, the bottom will have healed on its own! Half the work — very smart!”
Kalanithi’s transformation from promising neurosurgeon to terminally-ill patient is only one of the several metamorphoses that Kalanithi lets us bear witness to. There is the evolution of a boy who never wanted to study medicine, being surrounded by doctors in his family; the change from doctor to patient, of accepting the limitations that come from fully understanding anatomy, metastases, cancer-survival rates, treatments and entrusting oneself completely to the wisdom of your doctor, and, significantly, the shattering powerlessness of cogently witnessing your body fail to execute it’s most elementary faculties: a visit to the bathroom, the nausea toward your favourite breakfast and — the uniquely doctorly experience — of knowing with acute, clinical precision the irrevocability of your suffering. An example of this is Kalanithi describing the searing back-pain of lying flat on a bench in a railway station and “naming each muscle as it spasmed to stave off tears: erector spinae, rhomboid, latissimus, piriformis…”
Most works about people overcoming suffering and pain derive their vital force from the protagonists emerging victorious or having conquered — or at least putting up raging fight against — their affliction. From page 1, we know that nothing of the sort will happen to Kalanithi, and yet it’s a book that carries hope simply because it is expressed succinctly sans pathos and bathos and doesn’t treat death as an adversary.
Surgeons constantly engage with death not only by way of the patients they operate on but by constantly refining the way they convey, communicate and offer succour to the families of those wheeled in. When operating on a cadaver as a trainee, Kalanithi speaks of a “craving for a burrito” catalysed by the formaldehyde that’s used to preserve bodies. He confesses to being overwhelmed and overworked and moments of viewing patients as “paperwork.”
Again we see transformations and the epiphanies of not merely understanding but feeling the full weight of the moral responsibility that comes from being a doctor. “The secret is to know that the deck is stacked, that you will lose, that your hands or judgement will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” When Kalanithi’s cancer significantly started to impede his surgical commitments, he — a scientific man — dwelt on the limits of the scientific method and the New Testament and its words of ‘mercy’ and ‘redemption’ and ‘forgiving.’ Around his last days as a surgeon, we begin to see the why of doctors’ white coats. “The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence… Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought.”
