The Pastoral Role: A Look at Paul Kalanithi’s When Breath Becomes Air

“Be ready. Be seated. See what courage sounds like. See how brave it is to reveal yourself in this way. But above all, see what it is to still live, to profoundly influence the lives of others after you are gone, by your words.”
–Abraham Verghese, When Breath Becomes Air

Paul Kalanithi’s When Breath Becomes Air had been on my radar since its posthumous publication in 2016. A reader of the lifestyle blog, Cup of Jo, for many years, I knew bits and pieces of the Kalanithi’s story, Paul’s struggle with lung cancer, and the Pulitzer Prize nominated memoir that followed his death several years ago. Finally, in Birmingham, AL attending a training program for work, I bought my very own copy of his book.

The afternoon of my arrival, I decided to stroll downtown Homewood to avoid staying cooped up in my hotel room for my entire stay, and found Little Professor Book Center completely by accident. I’d walked into a boutique across the street initially, and when I left with a pair of earrings to gift to my cousin for her upcoming birthday, I looked up and saw the word “books,” which settled the question of my next destination. After much browsing and deliberation, I eventually left with Paul’s memoir, not knowing exactly what I would be getting myself into when I finally decided to read it seven months later.

I cannot say what exactly drew me to read this book when I pulled it from its perch on my bookshelf a couple of weeks ago. Perhaps my grandfather’s own battle with cancer steered my wandering hand as it lingered over the staggered spines of my books. Perhaps I was feeling lonely and craved the conversational tone of the memoir. Perhaps it was both of these things. What I can say is that no book has affected me quite as intensely and emotionally as Kalanithi’s in a very long time.

If you’re not already familiar with Paul’s story, he was diagnosed with lung cancer in May of 2013 at the age of 36. This is also where he introduces himself at the beginning of the book, sitting on a hospital bed with his wife, Lucy, as they grapple with their oncoming reality. However, in order for us to ascertain exactly how poignant his diagnosis is to him as a person, Kalanithi takes us back to his formative years, the years that led him on his path to neuroscience and neurosurgery.

As a child, his mother, fearing for the quality of his education in Kingman, AZ, where “the high school dropout rate was somewhere north of 30 percent,” instilled in him a love for literature by unearthing a college prep reading list from some unknown location and giving it to her son as literary guidance. At only ten years old, she had him read George Orwell’s 1984, which he wrote, “instilled in me a deep love of, and care for, language.” It was this book, in fact, that sent him on a reading frenzy, in which “books became [his] closest confidants, finely ground lenses providing new views of the world.” However, it was a former girlfriend’s suggestion to read Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S. by Jeremy Leven that got Kalanithi thinking differently about the relationship between the brain and the mind. “Literature provided a rich account of human meaning;” he writes, “the brain, then, was the machinery that somehow enabled it.”

Throughout his years at Standford, Kalanithi would work toward “a deeper understanding of a life of the mind.” He completed degrees in both English literature and human biology, and in his senior year of college, applied for a master’s in English literature to continue his work of marrying the literary with the molecular: “There must be a way, I thought, 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.” But even after completing his thesis, he felt that an English department could only take him so far in a specific direction. He needed to be free to plunder all directions, most notably the ones that allowed him to locate the intersection of biology, morality, literature, and philosophy. So he found himself applying for med school following a stint at Cambridge to study the history of medicine.

Studying medicine provided Kalanithi an access to reality that literature had failed to offer. When I was studying English in college at the University of South Carolina, one of my favorite professors wrote to me in an email that it’s almost better for writers to study something other than literature and writing if they can catch themselves before it’s too late. The marriage of a person’s proclivity for language with their chosen speciality can breed astounding insights into the human condition, and Kalanithi’s writing is nothing if not a testimony to that very notion. “Reading books and answering multiple-choice questions bore little resemblance to taking action, with its concomitant responsibility,” he writes. If his literary years allowed him to cultivate ideologies, his years studying medicine would “allow [him] a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay.”

What makes a meaningful life in the wake of inevitable, if not immediate, death becomes Kalanithi’s specialty. This is the concern, he believes, from which good doctors are made. And the neurosurgeon, further still, “work[s] in the crucible of identity.” As he surmises:

“Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?”

This question becomes the basis on which Kalanithi stakes his claim in the world of medicine, neurosurgery being the most attractive field of study for its “direct confrontation with meaning, identity, and death.” And, of course, when he returns to Stanford for his residency, neurosurgery is the superior speciality, and neurosurgeons the elite of the hospital. But Kalanithi grazes over this with a few paragraphs before, one by one, leaning into the cases that molded him, not just as a neurosurgeon, but as a physician. And while he confronts falling prey to moments of fatigue and impatience, blockading his ability to connect with his patients at their most vulnerable, it is through this struggle to remain human in the wake of their illnesses that drove him in his practice. “Openness to human relationality,” he writes, “does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.”

Perhaps the most illustrative quote of this image he held as being the ideal doctor: “Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought.”

In a specialization that prides itself on perfection, the place of failure on and off the operating table was notably agonizing to Kalanithi. But that he gleaned one of the most poignant passages in the book from these experiences is a testimony in itself to the kind of doctor he was becoming:

“Being with patients in these moments certainly had its emotional cost, but it also had its rewards. I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul—was obvious in its sacredness.
Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking another’s cross, one must sometimes get crushed by the weight.”

This passage is especially gratifying during the second installment of the book in which the narrative surrounds his diagnosis. He is struck by this sudden lack of life his future self was once able to enjoy. But as is common when the word CANCER appears in the headline of one’s life, the ways in which that life must stop being lived are prominent in the mind of the cancer stricken. So Kalanithi is surprised when his own doctor opens the discussion for him to continue his life as he lived it before. He can go back to work, he can have children. “The fact of death is unsettling,” he writes, “yet there is no other way to live.”

So live he does. He and his wife, Lucy, visit a sperm bank, and in time he goes back to work. Pain wracks his days, not just physically but mentally, as he comes to terms with the unknowable time left to him and his family. But keeping his life moving in a forward direction consumes him. “Maybe,” he writes, “in the absence of any certainty, we should just assume that we’re going to live a long time. Maybe that’s the only way forward.”

Just before his graduation, Kalanithi flies to Wisconsin for a job interview. Though he loses a professorship at Stanford, the chairman of this department, unnamed, excites him with possibilities. They know the time he has left is uncertain, and still they woo him with compelling offerings that make Kalanithi think it just may work, this life he’s been working so hard for, even in the face of his imminent demise. But then the reality of the situation hits him as he and the chairman are overlooking a frozen lake after dinner one night. “It was like a fantasy,” he says. There was no reasonable solution in which his dreams and goals reached fruition. In realizing this, he spends a lot of time wondering what he should do, where his focus should lie, what his values are, as his oncologist steadfastly reminds him. Who does he want to be now? In all of this searching, he comes to realize:

“…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.”

Kalanithi’s life continues in waves of physical chaos and stabilization. So he focuses on keeping his body strong. When his daughter is born, he finds in her “a blank page on which [he] could go on.” From here, he shifts his narrative from past to present. In her, he sees only future, and so he spends the remaining chapter in a kind of ode to her becoming. The reader may feel anxious, anticipating what is to happen. But even as his words near their end, as that final paragraph looms over an empty margin, Kalanithi, ever the physician, is there to ease our pain over a death that isn’t even ours with a message not intended for us, yet prescribing the very practice we should all make a habit of while there’s still time for ourselves and our loved ones. “That message is simple,” he writes:

“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.”

Through this book, Kalanithi became a steward for death, a philosopher on meaningful living, and a testimony to how a person dies manifesting in the quality of his life. For Kalanithi is not remembered by his cancer, but the substance of what his cancer brought out of him. As his wife, Lucy, gorgeously writes in the epilogue: “Writing the book was a chance for this courageous seer to be a sayer, to teach us to face death with integrity.” And thus, our lives, which are certainly better for having read his story.

wren michelle brock