Jottings - Slice of life - 202 ( When Breath becomes air - a Memoir Dr Paul kalanithi)

Jottings - Slice of life - 202 ( When Breath becomes air - a Memoir Dr Paul kalanithi)

Rinku Kundu mentioned Paul Kalanithi’s book “ When breath becomes air” in her comment on my essay on Dr Sherwin Nuland couple of weeks ago. Since then, my pen has been throbbing to write about Paul and his book written in the last few months of his life, tragically taken away couple of years ago by lung cancer. What a wonderful title to a book, and to a life, which was as incandescent and light and seamless as air, yet so full of energy, intensity and meaning. Between the covers of 200 short pages, sandwiched between a luminous and thought provoking prologue by novelist Dr Abraham Verghese, and an epilogue written by Paul’s beautiful and compassionate wife Lucy, the book “When breath becomes air” is very much like the book of meditations by Marcus Aurelius, the Roman emperor, who wrote his aphorisms on life and death on a battlefield strewn with bloody corpses. Only in Paul’s case the battlefield was his own body, the degeneration was his cellular structure, and the enemy was his own mortality. This book was his attempt to make sense of himself and what happened to him. What it feels to have been a doctor once, and a patient now, and what remains after stripping away every vestige of personality, desires and possessions, and the stark fact of death looming in front of him as the only tangible truth, nothing else.

At 37 years, Paul kalanithi was at the cusp of life and a brilliant career awaiting him in neuroscience. He was happily married, and living the American dream, when death decided to surreptitiously enter his life in the form of lung cancer and turn him into a sage, a contemplative , a lyricist, a writer, a thinker, and above all a father who realized his only chance of redemption would be to father a child and hold her in his arms for few more months, not many more. In the last eight months of life, Paul strove to live completely in the present, however fleeting or illusory it may be. For anyone who has ever dreamt of prosperous and successful future, the act of forcibly living only in the present with no future at all, must be excruciatingly painful, but not for Paul; he conquered his own mortality by consciously deciding to be completely mortal. In that instant of realization and acceptance, death loses it sting. Pauls’s book recounts those precious moments of transformation.

For a second generation American, he had all the freedom America had to offer, and he flowered into a man for whom nothing seemed impossible. As a youngster, he juggled between literature and medicine; as an adult, he chose neuroscience for its cutting edge work on that thin but important intersection of consciousness and neurology ; as a surgeon he was entrusted with human brains and nerve endings to correct. As a student , he scaled levels of excellence in his chosen field in quick time, and, in parallel, grappled with insecurity, complacency and even disregard - that a morally demanding profession of medicine can sometimes bring. Paul realized early in his career that in every other scientific field technical excellence can be divorced from Moral responsibility, but not in medicine. Here, a Man’s life and well being is at stake. And good surgeon should know when to push and when to stop pushing. The meaning of doctor patient relationship, the meaning of life and death, the role of a doctor not as a man who promises immortality, but as guide who supports gentle transition from one state of being to another began to synthesize in Paul’s attitude and demeanor. He was maturing fast. At 35, Paul could afford to think far ahead. He had long term plans, the best universities and hospitals were seeking him, luring him in fact, before Cancer changed the rules of the game forever.

There are moments, when I read “When breath becomes air”, unconscious tears formed in my eyes. Here was a man, who saw death coming full speed towards him; yet found time and focus to pen some of the most beautiful and lyrical passages on life, relationships and illness. Paul confesses in his book his love of literature as a medium to understand human suffering and pain. Widely read from Wittgenstein to Tolstoy to TS Eliot to Hemmingway to Beckett, he writes with supine grace and sensitivity. If only life had given him more time, he would have written more. There is a sense of hurriedness in the book. He flits from one episode to the other with feverish speed of a man who is racing against chronological time. His wife, Lucy, recounts in her epilogue, how he would carry his silver laptop wherever he went during those last few months. he would hammer away at the keyboard sitting, lying down, waiting at hospitals, during chemotherapy and at all possible times. Even when his fingers were calloused after month of toxic medication, weak and wouldn’t respond, he would attempt to type. He had this overpowering need to translate what he had felt, known and understood about life, death and living to a broader audience; more importantly , to his little daughter, who would grow up one day to ask of her father’s legacy. The most beautiful parts of his narrative are when he describes his fears about his mortality, yet willing to accept and face death as the only way of living well. This paradox, this janus faced reality of life and death bursts with vivid clarity from his well chiseled sentences. In several passages, in different contexts, he writes how as a doctor, his words of consolation has healed many and stalled imminent death; but as a terminal patient himself, those very words now seems empty and void of any concrete meaning. It seems pure luck that others survived, and he will not. Human agency counts for nothing in the overall scheme of things, yet that is the only way to measure up to life.

It is strange psychological fact that prisoners with confirmed death sentences become more focussed and relaxed. Even the most hardened criminals seem to settle down internally, once they know that death is not an existential uncertainty anymore. They know its coming and there is end to this drama, and that brings tremendous sense of relaxation and compassion. It is the intellectual process of thinking about death that is painful to most of us. The uncertainty kills us. In Aldous Huxley brilliant book “ the Brave new world”, humans are born programmed to live for certain length of time depending upon which class of society they belong to. They know it, hence there is no regret. Paul kalanithi emphasizes this throughout his book. We plan a future because we dont know the end; but when the end is known, future becomes irrelevant, inconsequential and every passing flower, every whispering wind, every crimson twilight, every human face will be seen for what it is - what the mystics have always called “The eternal now”. A zen master was once asked what is enlightenment. His enigmatic response was “ before enlighmentment, I saw mountain and trees; after enlightenment I see mountain and trees”. In other words, nothing changes except the intensity of subjective realization which cannot be explained. In similar terms Paul in one unforgettable passages in this book writes and I have to it quote in full:

“ I began to realize that coming in such close contact with my own mortality had changed nothing and everything. Before my cancer was diagnosed I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely. The problem wasn’t really a scientific one….. there is no other way to live”

Paul left his book unfinished and unpublished when he died in March 2015. His last words to his wife was a request to get it published, which she did with a moving epilogue and tribute to her husband. This is a kind of book which everyone must read, when they are young and vibrant. Contrary to public opinion, such books dont make one sad and pessimistic; quite the opposite. It gives one energy to live the present day with zest and gratitude. After all, this is the only moment we truly possess.

Thanks Rinku for inspiring this essay.

God bless…

yours in mortality,

Bala