I wonder if Paul Kalanithi remembered, as he wrote this book, the childhood dream of the father of modern neuroscience. This was a Spanish anatomist called Santiago Ramón y Cajal, who, as a child, wanted to become an artist. “At eight or nine years old,” Ramón y Cajal wrote, “I had an irresistible mania for scribbling on paper, drawing ornaments in books…” The boy’s father discouraged such frivolity. Ramón y Cajal went to medical school, where he grew devoted to histology, the microscopic study of cells.
At that point in the 19th century, inferior microscopes, which failed to show the fine structure of the nervous system, had stalled neurological investigation. (The vague term “gray matter” is a product of this period — coined, one imagines, by exasperated scientists.) So it must have been with excitement that, in 1887, Ramón y Cajal learned about a staining technique, using silver nitrate, by which nerve cells finally revealed their intricate features. “A look was enough,” he wrote. “All was sharp as a sketch with Chinese ink.” He drew what he saw. His illustrations would lead to the discovery that the neuron was the basic unit of the nervous system.
The artist’s pencil advancing science — such is the intellectual traffic that might have intrigued Paul Kalanithi. Kalanithi was a neurosurgical resident at Stanford when, in his mid-30s, he was diagnosed with lung cancer. While his peers fretted about careers, his life tilted toward a reckoning with mortality all the more ferocious for how, as a doctor, he had spied death in the corner of his eye. His own encounter with death contained his patients’, too. “I had pushed discharge over patient worries,” he remembers, critical now of his actions, “ignored patients’ pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged into various diagnoses, the significance of which I failed to recognize — they all returned, vengeful, angry, and inexorable.”
Death is one thing, and dying another. Dying might bring a series of humiliations and panics, time choking upon itself, or it might slyly resemble living. Kalanithi and his wife had a child, a daughter, while he grew increasingly sick. When his wife questioned his wish to become a father, asking if having to say goodbye to a baby wouldn’t make death more painful, he replied, “Wouldn’t it be great if it did?” Avoiding pain was never a priority for Kalanithi. Pain signalled love and meaning. In his professional life, Kalanithi continued to perform surgery, resting his aching back against the wall of the operating room, until, one day, he declined to schedule any more operations. It was time, he accepted, to discard plans for his future. Looking to his past, he wrote this book, typing with painful fingers soothed by silver-lined gloves.
Kalanithi died on March 9, 2015. The book he worked on in his final months — this memoir, When Breath Becomes Air — has achieved tremendous recognition as a moving narrative of a doctor’s dying. Rightly so. Unclasped, however, the book is also an argument for an intellectually rousing way to live. Why have we not seen, in widespread and admiring coverage of the book, engagement with the ideas Kalanithi held dear? Might not such an engagement honour the doctor’s life?
Within the mortal man — never a smoker, yet whose lungs grew dense with tumors — there agitated a rare intellect that continued to consider questions of science and art even while life’s end alighted nearby.
Kalanithi argues that the great divide between science and literature is false.
As a teenager with literary aspirations in Kingman, Ariz., Kalanithi read what sounds like an awful book. Still, Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S., loaned him by a girlfriend, offered the astounding realization that the mind was simply a function of the brain. “Of course, it must be true,” he writes. “What were our brains doing, otherwise?” The revelation turned his mind to neuroscience. At Stanford, he added, to his list of literature classes, courses in biology.
Though Kalanithi went on to complete graduate studies in English literature, ever present on his mind were the physiological systems, sturdy and fallible, that undergirded meaning. He writes, “There must be a way…that the language of life as experienced — of passion, of hunger, of love — bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats.”
(What does he do by referring to languages rather than fields? Well, even while admitting how the humanities are positioned against the sciences, he planes smooth the friction of their edges. This might be to the credit of the philosopher Richard Rorty, under whose tutelage the young Kalanithi began to see academic disciplines not as separate regions but separate vocabularies. When we see sociology and chemistry as vocabularies, we perceive that they are methods, not subjects, of investigation. Under unified examination across literature, the humanities, and the hard sciences: consciousness, living, the world.)
Kalanithi continued to grapple with the opposition between science and literature, and to live, in his life, with commitment to each. He worked his instruments — blades, electrodes — into bodily interiors as unfamiliar to his patients as a foreign country. Yet these interiors were the matter of which their personhood was composed. In one operation, Kalanithi placed an electrode nine centimeters deep in a patient’s brain to treat a Parkinson’s tremor. The patient protested, “I feel…overwhelmingly sad.”
“Current off!” said Kalanithi. And the patient felt better.
At the same time, faced with cases where surgical instruments could do little, Kalanithi drew on words to comfort patients. More important for him than saving lives — in the end, everybody dies — was the task of bringing patients and family members to an understanding of illness with which they might make peace. How else to do this but by speaking, and listening? By asking us, in this book, to consider how a life in medicine is essentially composed of — not merely ornamented with — the light and shelter of language, Kalanithi foregrounds one of the ways in which literature and science are continuous. We encounter both through the medium of language.
It is difficult, here, not to think about the language of this book, both gentle and relentless, retrieved and arranged not only by Paul Kalanithi but also by his wife. Lucy Kalanithi took on the work of gathering his words from e-mails and other documents to complete the book after he was gone. In a moving epilogue, she shares her husband’s final moments. A machine helped him breathe in a hospital bed — he’d stood over this very bed as a doctor — while his daughter, too young to be grave, played atop his prone body.
As a younger man, Kalanithi had turned to medicine as a way to find the truth — perplexing, knotty — of human experience. Within the hospital he had found it rewarding to confront the persistent irresolution of life. “Would you trade your ability — or your mother’s — to talk for a few extra months of mute life?” he writes. “Your right hand’s function to stop seizures?” He had felt then that true experience of mortality and suffering came not from text but from immersion in the world.
Diagnosed with a serious illness of his own, however, the doctor found that he needed literary translation of his experiences. When scientific studies and survival statistics offered little, he turned to books: Aleksandr Solzhenitsyn, Leo Tolstoy, Virginia Woolf. He read memoirs by cancer patients. “It was literature,” he writes, “that brought me back to life during this time.”
Throughout When Breath Becomes Air, which is, true, a moving memoir of a man’s dying, but very much more than that, Kalanithi directs us to consider the braiding of science and literature. Kalanithi might have grasped, more intuitively than many, how meaning originates both in a book that moves us, and in an electrochemical operation in the anterior insula.
Ramón y Cajal’s drawings of dendritic branches and axons, an artist’s hand tracing scientific truth, remain. The representations are arboreal. They are beautiful. Kalanithi might have asked: What do we do when we call a neuron beautiful? Aesthetic appraisal expands the proper place of the nerve cell. The cell crosses the boundaries of scientific study, and submits itself to humanistic consideration.
What we come away with is not just a sense of science and literature’s abutment, but something greater. Shining a beam on the beauty of a neuron asks that we consider not just neuron but also beauty. Isn’t it true that the humanistic notion of beauty is then allowed access to the laboratory, and to the clinician’s office? Such visitation might have pleased Paul Kalanithi — neurosurgeon, reader, and writer. For in his life, as in few others, the disciplines appeared, their hostilities eased, to show themselves as forms of the same revelation.