Reading “When Breath Becomes Air”: Life, Death and the Meaning of Life

Air

A year and a half ago I read an incredibly touching book called “The Last Lecture”. It told the story of an extremely intelligent academic, Randy Pausch, who was diagnosed with an extremely lethal pancreatic cancer.

It was an incredibly emotional book and one which resonated deeply with me as both I and author shared a burning curiosity for the world’s wonders.

Since then, I have recognized that “The Last Lecture” was sadly not a singular book.

Many amazing people still die of various types of cancer and reading their stories can be truly heartbreaking. Yet, reading such stories is also a great way to reflect on life and its meaning. After all, it’d be foolish to leave dying for our last days only to discover we had focused on the wrong goals all along.

Ultimately, this is how I came to “When Breath Becomes Air” (an allusion to the last moments of life where the breath once more turns into air to never repeat again) by the neurosurgeon Paul Kalanithi.

The book itself is divided into two parts — Paul’s early life before cancer and his life after and despite it.

The most unfortunate thing about this type of books is that they always present you to an exceptionally great person, only to end up delivering the final tragic news of their death. There is never a happy ending and everything seems to go to worse.

So it was in Paul’s case.

Yet, as Paul reflect on numerous occasions in the book, isn’t this unhappy ending something we all share after all?

***

Of our many childhood mysteries, chief among them was not why our father decided to bring his family to the desert town of Kingman, Arizona, which we grew to cherish, but how he ever convinced my mother to join him there.

The beginning of Paul’s story is really one shaped by his mom. As the quote above suggests, she was an unlikely resident of any desert town, but the reason stays unclear.

Eventually, however, we learn that Paul’s mom’s source of worry was the level of education her son would receive in the secluded desert parts of Arizona.

So, as any mom would do, she took in on herself to create an Ivy league-worthy reading list for her child.

In Paul’s words:

„Endless books and authors followed, as we worked our way methodically down the list: The Count of Monte Cristo, Edgar Allan Poe, Robinson Crusoe, Ivanhoe, Gogol, The Last of the Mohicans, Dickens, Twain, Austen, Billy Budd…By the time I was twelve, I was picking them out myself, and my brother Suman was sending me the books he had read in college: The Prince, Don Quixote, Candide, Le Morte D’Arthur, Beowulf, Thoreau, Sartre, Camus. Some left more of a mark than others. Brave New World founded my nascent moral philosophy and became the subject of my college admissions essay, in which I argued that happiness was not the point of life. Hamlet bore me a thousand times through the usual adolescent crises“

This approach worked beautifully. Paul ended up touring some of the world’s best campuses.

But something else is worth pointing out here, namely the power one driven individual has to completely change a whole culture and many of the lives affected by it.

Paul’s mom might have been driven by love for her child, but she ended up transforming the entire city for the better. It’s extremely inspirational. 

Just look at the following quote:

„Senior year, my close friend Leo, our salutatorian and the poorest kid I knew, was advised by the school guidance counselor, “You’re smart—you should join the army.”

He told me about it afterward. “Fuck that,” he said. “If you’re going to Harvard, or Yale, or Stanford, then I am, too.“

I don’t know if I was happier when I got into Stanford or when Leo got into Yale.

***

As all curious young adults, Paul seemed to always be reading and learning.

Yet, youth offers more than just books as Paul was well aware. Having to choose between a summer of academic work and a summer camp that, as Paul says, promised “the best summer in your life”, Paul chose the latter.

„After delaying for as long as possible, I finally chose the camp. Afterward, I dropped by my biology adviser’s office to inform him of my decision. When I walked in, he was sitting at his desk, head in a journal, as usual. He was a quiet, amiable man with heavy-lidded eyes, but as I told him my plans, he became a different person entirely: his eyes shot open, and his face flushed red, flecks of spit spraying.

“What?” he said. “When you grow up, are you going to be a scientist or a…chef?”

Eventually the term ended and I was on the windy mountain road to camp, still slightly worried that I’d made a wrong turn in life. My doubt, however, was short-lived. The camp delivered on its promise, concentrating all the idylls of youth: beauty manifest in lakes, mountains, people; richness in experience, conversation, friendships. Nights during a full moon, the light flooded the wilderness, so it was possible to hike without a headlamp. We would hit the trail at two A.M., summiting the nearest peak, Mount Tallac, just before sunrise, the clear, starry night reflected in the flat, still lakes spread below us“

For me, this passage reflects the fact that truth is not everything we as people care about. Beauty matters too. And a sense of purpose can never be ignored. 

***

Nevertheless, Paul’s main dedication remained his conquest for truth. In particular, that about the meaning of life (and death), in particular.

„Lucy and I attended the Yale School of Medicine when Shep Nuland still lectured there, but I knew him only in my capacity as a reader. Nuland was a renowned surgeon-philosopher whose seminal book about mortality, How We Die, had come out when I was in high school but made it into my hands only in medical school. Few books I had read so directly and wholly addressed that fundamental fact of existence: all organisms, whether goldfish or grandchild, die“

The search for answers eventually led Paul to medical school and ultimately to the role of a neurosurgeon. 

(a role which, by the way, seemed almost inhumane in its demands — 36-hour work days, constant stress and responsibility for other people’s lives; as Paul recalls a general surgeon friend of his saying: „Well, I guess I learned one thing: if I’m ever feeling down about my work, I can always talk to a neurosurgeon to cheer myself up.“)

It has always been interesting to me to read about those who meet death on a regular basis. How do they deal with it? Do they still experience it as a tragedy or do they become numb to it?

There is certainly a mental struggle one has to contend with before choosing a similar profession. After all, the stakes are high, both for the patient and for the doctor himself. After a colleague of Paul’s took his own life, Paul commented on exactly this struggle:

„Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. 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. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.“

***

And then cancer happened…

„I began to realize that coming in such close contact with my own mortality had changed both 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. The fact of death is unsettling. Yet there is no other way to live.“

Somewhere between all the work and studying, Paul had managed to get married. Needless to say, the terminal diagnosis took its toll on the marriage as well.

Consequently, Paul and his wife decided to visit a therapist in hope of coping with the newly found stress.

„Well, you two are coping with this better than any couple I’ve seen,” the therapist said at the end of our first session. “I’m not sure I have any advice for you.”

I laughed as we walked out—at least I was excelling at something again. The years of ministering to terminally ill patients had borne some fruit! I turned to Lucy, expecting to see a smile; instead, she was shaking her head.

“Don’t you get it?” she said, taking my hand in hers. “If we’re the best at this, that means it doesn’t get better than this.”

If the weight of mortality does not grow lighter, does it at least get more familiar“

The lesson to take home here is to never automatically assume that if only you were coping as well as somebody else, things would feel better. Because, ultimately, maybe they won’t…

***

We all know that a terminal illness cannot help but change one’s priorities fundamentally. However, something that seems a bit overlooked is that it also changes one’s identity too.

„I began to look forward to my meetings with Emma (note: his oncologist). In her office, I felt like myself, like a self. Outside her office, I no longer knew who I was. Because I wasn’t working, I didn’t feel like myself, a neurosurgeon, a scientist—a young man, relatively speaking, with a bright future spread before him. Debilitated, at home, I feared I wasn’t much of a husband for Lucy. I had passed from the subject to the direct object of every sentence of my life. In fourteenth-century philosophy, the word patient simply meant “the object of an action,” and I felt like one“

The lessons here apply to any illness or distress whereby one starts feeling like just another object in the world. Here is Paul’s way of dealing with the problem:

„I began reading literature again: Solzhenitsyn’s Cancer Ward, B. S. Johnson’s The Unfortunates, Tolstoy’s Ivan Ilyich, Nagel’s Mind and Cosmos, Woolf, Kafka, Montaigne, Frost, Greville, memoirs of cancer patients—anything by anyone who had ever written about mortality“

„And so it was literature that brought me back to life during this time. The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action. I remember the moment when my overwhelming unease yielded, when that seemingly impassable sea of uncertainty parted. I woke up in pain, facing another day—no project beyond breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.“

„If I no longer sought to fly on the highest trajectory of neurosurgeon and neuroscientist, what did I want?

To be a father?

To be a neurosurgeon?

To teach?

I didn’t know. But if I did not know what I wanted, I had learned something, something not found in Hippocrates, Maimonides, or Osler: 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.“

„Verb conjugation has become muddled, as well. Which is correct: “I am a neurosurgeon,” “I was a neurosurgeon,” or “I had been a neurosurgeon before and will be again”? Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection. So what tense am I living in now? Have I proceeded beyond the present tense and into the past perfect“

***

Of course, the question of God is bound to make an appearance when talking about death.

„I began to do a little bargaining—or not exactly bargaining. More like: “God, I have read Job, and I don’t understand it, but if this is a test of faith, you now realize my faith is fairly weak, and probably leaving the spicy mustard off the pastrami sandwich would have also tested it? You didn’t have to go nuclear on me, you know…” Then, after the bargaining, came flashes of anger: “I work my whole life to get to this point, and then you give me cancer?“

Nonetheless, Paul gave off the impression of having found some meaning to religion, whether he ultimately believed in it as true or not.

„During my sojourn in ironclad atheism, the primary arsenal leveled against Christianity had been its failure on empirical grounds. Surely enlightened reason offered a more coherent cosmos. Surely Occam’s razor cut the faithful free from blind faith. There is no proof of God; therefore, it is unreasonable to believe in God.

Although I had been raised in a devout Christian family, where prayer and Scripture readings were a nightly ritual, I, like most scientific types, came to believe in the possibility of a material conception of reality, an ultimately scientific worldview that would grant a complete metaphysics, minus outmoded concepts like souls, God, and bearded white men in robes. I spent a good chunk of my twenties trying to build a frame for such an endeavor. The problem, however, eventually became evident: to make science the arbiter of metaphysics 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.“

„Between these core passions and scientific theory, there will always be a gap. No system of thought can contain the fullness of human experience. The realm of metaphysics remains the province of revelation (this, not atheism, is what Occam argued, after all). And atheism can be justified only on these grounds. The prototypical atheist, then, is Graham Greene’s commandant from The Power and the Glory, whose atheism comes from a revelation of the absence of God. The only real atheism must be grounded in a world-making vision. The favorite quote of many an atheist, from the Nobel Prize–winning French biologist Jacques Monod, belies this revelatory aspect: “The ancient covenant is in pieces; man at last knows that he is alone in the unfeeling immensity of the universe, out of which he emerged only by chance.”

Yet I returned to the central values of Christianity—sacrifice, redemption, forgiveness—because I found them so compelling. There is a tension in the Bible between justice and mercy, between the Old Testament and the New Testament. And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it.

„About God I could say nothing definitive, of course, but the basic reality of human life stands compellingly against blind determinism. Moreover, no one, myself included, credits revelation with any epistemic authority. We are all reasonable people—revelation is not good enough. Even if God spoke to us, we’d discount it as delusional.

So what, I wonder, is the aspiring metaphysician to do?

Give up?

Almost.“

***

As I wrote in a previous post about cancer, there is one thing which consistently remains valuable in the face of death: human relationships.

In Paul’s case, it was his family and his wife’s support. But it was also his daughter, conceived after the news of cancer was already well-known. I don’t know what it must feel like to name a child you will never grow up with, but it must certainly hurt immensely.

In any case, Paul seemed to enjoy the cosmic dance of life and death which his cancer and daughter-to-be revealed before his eyes. This is why his final words in the book are addressed precisely towards the girl that carries his genes, yet he would never come to know:

„When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.“

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