A Review of Paul Kalanithi’s When Breath Becomes Air
A young neurosurgeon’s heartbreaking memoir is also a testament to the importance of the humanities to medical education.
About a week after her breast cancer surgery, a friend of ours went to see the oncologist who had been assigned to her. The meeting did not go well. She explained:
“He was 45 minutes late for our appointment, breezed into the examining room, said ‘Hello, My First Name, I’m Dr. Last Name.’” Dispensing with any discussion of her options, concerns, or views on the subject, he announced: “Here’s the treatment we’ve planned for you,” and turned to scrutinize her MRI scans. When she indicated she had done considerable research and wanted to talk about some things she’d read, he replied, still with his back to her, “You shouldn’t believe all the stuff you read on the internet.” Had he bothered to ask about the person whose body he was going to deal with, he might have learned that our friend happens to be a doctor herself, a highly-respected academic who spends a good part of her time doing scholarly research online.
Our friend’s story made us think of When Breath Becomes Air by the neurosurgeon Paul Kalanithi because this frustrating encounter demonstrated the truth of his observation that doctors far too imperfectly “understand the hells through which [they] put patients” (102). Kalanithi should know. He writes from the perspective of both doctor and patient, thanks to the stage IV lung cancer whose terrible pain he called “the claws of the crab,” and which claimed his life in March of 2015, scarcely two years after its diagnosis.
Since its publication in January of this year, When Breath Becomes Air has received a great deal of attention and overwhelmingly positive reviews. Readers and critics alike have praised all the things one might expect from a well-crafted personal account of a good man cut down in his prime, indeed, on the very edge of at last reaping the rewards of more than a decade of unremittingly grueling medical training: its bracing candor, harrowing anecdotes from the neurological surgery theater, and above all, the author’s voice, so engrossingly introspective and almost disconcertingly alive, and that of his widow, Dr. Lucy Kalanithi, who is a quiet background presence throughout most of the book until gently assuming the narrative after her husband’s voice subsides. It is an effective memoir, a valuable addition to the expanding corpus of cancer literature, and like Atul Gawande’s Being Mortal: Medicine and What Matters in the End (2014), combines a meditation on death and dying with a call for a change in the philosophy of healthcare.
When Breath Becomes Air made us, two humanists, lament the attitude of the doctor caring for our friend; and her story made us notice that, in the outpouring of critical attention surrounding the memoir, few have considered the possibility that both Kalanithi’s voice and his superlative medical skill may have derived from his impressive background studying philosophy and literature. “I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain,” he explains (30-31). Kalanithi’s exceptional breadth of expertise, coupled with his tender determination to see the humanities and the sciences as complementary fields of expertise, makes his memoir a testament to the crucial role that the humanities can and should play in medical training.
Kalanithi makes clear that it was his background in the humanities that led him ultimately to a career as a physician and to the high, hard road of neurosurgery. Before his studies at the Yale School of Medicine, he majored in biology and English at Stanford, staying to complete an MA in English literature, then earning an MPhil in history and philosophy of science from Cambridge. That coursework formed the ground for his obsessive dedication to his profession, providing both a language and an ethos for answering its “unforgiving call to perfection” (71). From literature, Kalanithi derives a deep sense of what constitutes the essence of one’s humanity, not only his own, but also that of the patients with whom he worked. His profession placed him at the unavoidable intersection of the human brain and its capacity to relate its experience through language. Recounting the kinds of damage that strokes or head trauma can do to language processing and production centers, he discloses, “the destruction of these areas often restrains the surgeon’s impulse to save a life: What kind of life exists without language?” (109). Precision measured in millimeters determined the success of his work and the quality of a patient’s life, and all this based on language.
Later, when the effects of his cancer treatment have begun to upend his sense of professional and personal identity, it is once again to literature that Kalanithi turns. As startling as any of the other discoveries he makes as a doctor-turned-patient is the realization that eleven years of medical training and practice had failed to provide a means of interpreting his own experience of illness:
“The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to translate them back into language” (149). In a passage that would warm the heart of any literature professor, Kalanithi invokes Eliot, Conrad, Solzhenitsyn, Johnson, Tolstoy, Nagel, Woolf, Kafka, Montaigne, Frost, Greville, Nietzsche, and Beckett, among other writers, whose words “brought [him] back to life” (149). Life, he suggests, is located in language, admittedly a product of the brains on which Kalanithi operated, but not reduced to such.
Andrew Brown of The Guardian lauded Jenny Diski’s essays about her inoperable cancer (recently published in the collection In Gratitude): “She deserves our unfeigned admiration, not for her bravery or her struggle, or any irrelevant tosh like that, but for writing so well.” The same could be said for Kalanithi, though he deserves admiration also for being, by all accounts, an extraordinary surgeon to boot.
The self-portrait that emerges, wrought in the author’s clear, occasionally gorgeous prose, is of an intensely focused and exceptionally skilled young man who was also exactly the sort of doctor any of us would hope to find at our bedside during a medical crisis. Far from ignoring his patients’ complaints, Kalanithi anticipated them, demonstrating great social intelligence and compassion even when explaining options and possibilities to patients.
This approach demonstrates the importance of what Rita Charon, Professor of Clinical Medicine and Director of the Program in Narrative Medicine at Columbia University, calls “narrative knowledge.” She is only one of many clinicians to call for a practice of medicine informed by an acknowledgment of the importance of patients’ stories, and the willingness and skill to participate in interpreting them:
Medicine can benefit from learning that which literary scholars and psychologists and anthropologists and storytellers have known for some time: […] what narratives are, how they are built, how they convey their knowledge about the world, what happens when stories are told and listened to, how narratives organize life, and how they let those who live life recognize what it means. (9)
It is precisely this work that Kalanithi performs, in practice and in his memoir. “The physician’s duty,” he comes to realize, “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 make sense of their own existence” (166).
When Breath Becomes Air is a beautiful book, and one whose insights could be invaluable for many types of readers, not least doctors themselves. If one comes away from reading this memoir with a sense of awe for the feats of endurance that highly-specialized surgeons perform, and filled with deep sympathy for the impossible decisions these members of the new priestly caste are called upon to make, Kalanithi also awakens us to just how inadequate to the pastoral role many of them are.
After describing the emotional aftermath of an unsuccessful emergency C-Section that had resulted in the death of infant twins, Kalanithi reflects on the weight of uncertainty that settled over him. “How could I ever learn to make, and live with, such judgment calls? I still had a lot of practical medicine to learn, but would knowledge alone be enough, with life and death hanging in the balance? Surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too” (66).
The extent to which the book attests the fulfillment of that hope depends on how one defines “wisdom.” A sense of our own ultimate limitedness might provide the humble kind of wisdom that combines intelligence and moral clarity, the wisdom to which Kalanithi aspires. Aranye Fradenburg notes that humanists have always sought “to remind the wealthy and powerful […] of the laws of change and death” (37). If this is a message with little market appeal, it is nevertheless a vital one, and one that offers a strange kind of mercy to doctors impelled by the necessary but always impossible “unforgiving call to perfection.”
Of course, to physicians feeling overwhelmed and inadequate in the face of rapid systemic changes in the profession, of the kind Dhruv Khullar M.D. blogged about recently, a call for a greater emphasis on humility in medical training might well seem anachronistic. Indeed, physician autonomy has been steadily encroached on by insurers and other outside systems for whose logarithms the health of individual patients is not necessarily the foremost consideration, and it doesn’t help that medical authority has been affected by the same erosion of institutional authority afflicting, for example, climate scientists. Even given all of those frustrations and challenges, however, the respect (and, not incidentally, its material markers) still accorded physicians remains unmatched by any other profession in our current cultural moment.
It would be hard for this fact to have no influence over the psyche of doctors, something Kalanithi himself realized early on in his career. Taking scrupulous inventory of his drives and motivations in the early days of his medical education, he finds both egotism and self-preserving remoteness. “I had thought that a life spent in the space between [life and death] would grant me not merely a stage for compassionate action but an elevation of my own being . . . surely a kind of transcendence would be found there?” (81). But as he proceeds to describe, transcendence was in rather short supply.
Kalanithi gives an honest account of the enticements of his profession, but also candid glimpses of the diminished idealism of his fellow medical students, most of whom elected to pursue higher paying, less time-intensive “lifestyle specialties.” In one of the book’s more damning passages, he recalls that when it came time for the Yale tradition of rewriting the graduating class’s commencement oath, several of his fellow students “argued for the removal of language insisting that we place our patients’ interests above our own” (68).
Even this episode, though, Kalanithi recalls with understanding for his colleagues’ motivations and acknowledgment of his own similar faults. Even here, in a passage that is as close as he comes to being a scold, he is a humane scold—which is kind of the point. As his wife writes in the book’s epilogue, “His strength was defined by ambition and effort, but also by softness, the opposite of bitterness” (215).
It must be asked, how much should a few years of immersion in the humanities be credited with the insight and empathy Kalanithi exhibits? To the extent that his memoir conveys wisdom, surely it is as much a result of his years of practicing medicine, to say nothing of the illness that provoked him to write in the first place. Unquestionably, that is the case. But Kalanithi, in one of the book’s many moments of searing honesty, shows us that bearing constant witness to the sufferings of others can also have the opposite effect: applied daily, the suffering of others acts as lidocaine to the soul. Kalanithi describes a fellow resident so physically exhausted that she found herself flushed with relief and gratitude—followed by crushing shame—when an exploratory surgery revealed that a patient’s cancer had metastasized, thus obviating the need for what would otherwise have been a grueling nine-hour surgery.
A more difficult question might be, did Kalanithi’s exceptional compassion and insight owe more to his own suffering than to his literary studies? Clearly, gazing into the abyss of his own mortality afforded him glimpses of something not even his surgical spelunkings into the innermost recesses of his patients’ brains could reveal. But although suffering can form character, sometimes its chief lesson is merely that suffering is awful. As Leonato reminds us in Much Ado About Nothing, “there was never yet philosopher / That could endure the toothache patiently” (V.1.35-36). Though Kalanithi admits that “my relationship with statistics changed as soon as I became one” (134), he emphasizes repeatedly that his own experience of illness served primarily to apply the pressure of the sharp awareness he had long carried of his own mortality.
Kalanithi advises his fellow physicians, “When there’s no place for the scalpel, words are the surgeon’s only tool” (87).
As our friend learned first-hand from her skilled but inattentive oncologist, a doctor’s words, carelessly wielded, have the power to hurt as well as heal. And this damage can cut both ways. She concluded, “I was fuming by the time I finally got out of the office, refused to set up any future appointments with him or the nurses who would be administering the treatments I was ‘supposed’ to take. I never went back to him or anyone else in that department.” (Happily, the treatment she sought elsewhere was effective, and her cancer is now in full remission.)
One lesson of When Breath Becomes Air is that the narrowing of professional specialization and training need not narrow our cultural intelligence or limit our access to a range of vital modes of knowing. Few doctors plan, as Kalanithi did before his illness, to spend twenty years as a scientist-surgeon, followed by twenty as a writer. But that does not mean the lessons of his story are not broadly applicable. Dr. Charon advises,
Even if medical educators cannot require a student to respond to a patient’s suffering with compassion, they might be able to equip students with compassion’s prerequisites: the ability to perceive the suffering, to bring interpretive rigor to what they perceive, to handle the inevitable oscillations between identification and detachment, to see events of illness from multiple points of view, to envision the ramifications of illness, and to be moved by it to action. (8)
Although humanist approaches to medical education are gaining recognition , they remain peripheral to the way most medical training is carried out. Erin Gentry Lamb, chair of Hiram College’s Biomedical Humanities major, explains that “undergraduate humanities training can be excellent preparation for medical education and practice, a reality we need recognized more widely within the medical schools admissions process.” Indeed, a tradition that segregates disciplinary priorities, as Fradenburg explains, has consequences for all concerned:
Because of our failure to recognize that scientific method and humanist styles of interpretation and research enhance one another (in practical as well as theoretical ways), our ships pass in the night, bearing fantastic images of the O/other disciplines—oblivious to the fact that the improvisational, artful nature of real-time knowing is not a failed attempt at empiricism, but rather adaptation (and creativity) in action. The humanities specialize in training students in the arts of managing the uncertainties of experience— learning to see and hear better, to read quickly but with care, to write and speak persuasively. (81)
Such uncertainties are, as Kalanithi articulates so masterfully, at the heart of medical practice. In fact, an educational formation that lacks focus on the way that narratives “let those who live life recognize what it means” leaves one ill-equipped to occupy the space that drew Kalanithi to medicine—that mysterious space between life and death. What should not be overlooked among the book’s lessons is the possibility that When Breath Becomes Air’s engagement with literature and philosophy not only enabled its author to narrate his life and work so memorably, but played a crucial role in making them so memorable, and their truncation that much more devastating.
Kalanithi turned to literature and philosophy at the precise moment that his position between life and death became as much personal as it was professional. This turn offers us hope and yet another way of conceiving of medical education differently:
Literature, in the form of Kalanithi’s memoir, an object whose material presence is not subject to death’s limitations, keeps his story alive for the rest of us, doctors and patients alike, on our own search for transcendence.
Charon, Rita. Narrative Medicine: Honoring the Stories of Illness. Oxford: Oxford University Press, 2006. Print.
Fradenburg, L.O. Aranye. Staying Alive: A Survival Manual for the Liberal Arts. Brooklyn: Punctum Books, 2013. Print.
Gawande, Atul. Being Mortal: Medicine and What Matters in the End. New York: Metropolitan Books, 2014. Print.
Kalanithi, Paul. When Breath Becomes Air. New York: Random House, 2016. Print
For more information about humanist approaches to medical education, please see the report on Health Humanities Baccalaureate Programs in the United States co-authored by Vital board members, Erin Lamb and Sarah Berry.