Having sat down to produce a column about the vice-presidential debate, I found that any topic, even death from cancer, was preferable. So I finished reading a remarkable book on the subject called “When Breath Becomes Air,” written by Dr. Paul Kalanithi and completed by his wife, Lucy.
Along with Tom Brokaw’s recent, graceful reflections on his multiple myeloma, Kalanithi’s memoir has given a first-person voice to cancer. This review is late because the book sat on my desk — really rested within my Kindle — for months. As a cancer survivor (kidney), I had little interest in a maudlin voice from the grave.
Kalanithi’s account is nothing of the sort. It is a vivid picture of a driven and accomplished professional — a neurosurgeon — on the verge of a brilliant career, facing a disease that humbles and then kills him. It is a situation we sometimes see from a distance. It is a gift to be given an honest account from inside.
For cancer survivors, the book has the added weight and urgency of describing the road behind, and perhaps — we pray not and hope not — the road ahead. But it is, of course, the road traveled by everyone, in some form, eventually. “He who was living is now dead,” wrote T.S. Eliot (a source of inspiration for Kalanithi). “We who were living are now dying/ With a little patience.”
We meet the author applying almost superhuman energy and intelligence toward perfection in the most difficult of the medical specialties. Every cancer death ends a world; the continuation of this particular world would have involved the saving of many other lives. Cancer is first the limiter of horizons, laying waste to planning and ambition. Following his diagnosis of advanced-stage lung cancer at age 36, Kalanithi says, “My imagined future and my personal identity collapsed.”
The interesting thing is what we build on the ruins of our ambition. The challenge seems especially difficult for a doctor, trained to assume, not renounce, control. “Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused,” the author recounts. When he finally releases the direction of his care to another doctor, it is the preview of another release, the last and necessary one.
Given a year to live, we think we would fill it with climbed mountains, balloon rides and an arm-long bucket list. But one of the cruelties of cancer is that it can take away motivation and pleasure. “All of my joys were salted,” says Kalanithi. It is hard to set new goals when your days are consumed with surviving, and when lifting a water glass requires both hands.
So what life lessons does the author take from a disease that kills him? There is the priority of family. The author’s story of resistance can only begin when his wife, Lucy, says, “I will never leave you.” The couple also make the decision to have a child, throwing new life in the face of death. While the prospect of an early parting between father and (we later find) daughter was terrible, they concluded, “The easiest death wasn’t necessarily the best.”
The author deals gently with spiritual matters. He is a scientist and a Christian, which is not as rare as you’d imagine. He recoils from the prospect of a universe in which scientific knowledge is the only form of human knowledge. “To make science the arbiter of metaphysics,” the author says, “is to banish not only God from the world but also love, hate, meaning — to consider a world that is self-evidently not the world we live in.”
“When Breath Becomes Air” clarifies the important distinction between optimism and hope. The positive thinking of “We’ll beat this thing” can be useful, but it is not sufficient. Eventually we don’t beat death. The real courage comes in drawing hope from the heart of suffering. And even if this fails, to find a kind of hopeless grace.
Kalanithi finds a way to die, not with dignity — because cancer seldom allows it, given the nausea, pain and weakness, and the emotional mess of denial, hope and despair — but with integrity. He shows perseverance and concern for those around him, until the moment is right for honorable surrender.
Kalanithi ends up leaving his infant daughter before her first birthday. But he will be a presence in her life, and in the lives of many others, as a model of purposeful living and of purposeful dying. We need examples of both.