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Unusual encounter with death 

Valson Thampu

It is now a year since Paul Kalanithi’s When Breath Becomes Air was published (February 2016). Not surprisingly, it has made its way into the Booker list for 2016.

It is remarkable how this book has gripped – in part, certainly, by our fearful fascination with its subject matter, death- the imagination of so many readers in diverse stations of life. From matinee idols –Mohanlal was among the earliest in this category – to academics, millions have played ‘wedding guests’ to this counterpart in our day of Coleridge’s Ancient Mariner, whose tale leaves them ‘sadder and wiser.’

By April we shall know if he, or one among the remaining eleven in the list that includes the remarkably eclectic work by Siddhartha Mukherjee (The Gene: An Intimate History, May 2016)) is making the grade.

Paul’s promising medical career was cut short at 36 years of age on the threshold of a coveted professorship in neurosurgery in Stanford. Death comes to all. It is not tragic to die; even to die young. The most tragic loss is to live without vitality and to die as a stranger to oneself.

Hence the question of identity pops up again and again in this narrative, as Paul wrestles with this adversary whose reality he, as doctor, had taken for granted, and whose face he had not bothered to stop and read. The bloated corpse he anatomized, the fleshless skeleton he studied, the skull -smiling, as he says, with its lip-less mouth- that became a professional accessory: none of these imaged death as it truly is. Death is a profound thing. It is not death, but its brooding profundity, that terrifies.

Think of the title. Most spiritual traditions intuit the difference between breath and air. Paul himself understands breath as the presence, or the essence, of a being. Air is what breath was. In between this most mysterious of all transformations -that of breath becoming air- is the saga and struggle of life. Everything shall be what it was, before it became what it is. It is at once natural and inevitable, hence, that breath becomes air. But a whole universe indwells the interregnum between the two.

What we do with that indeterminate space –the theatre alike of our heroism and humiliation- is the issue. Air remains -and this is the heart of this rare narrative of life, death and hope- breath as long as it is inhaled by the spirit in hope and affirmation even in the teeth of death. He is immortal who manages to breathe eternity within time, rather than exhales his breath as no more than air. Air becomes breath in the alchemy of individuality. It is not death, but the meaningless of living that turns breath into air and voice into noise. Look at Paul’s death, through the eyes of his wife, Lucy: “Paul inhaled and then released one last, deep, final breath.”

Lucy alludes to the gulf between life and medical sciences. She endures the agony of making the momentous choice of disconnecting her young, dying husband from the machine assisting his breathing. The idea that a machine can breathe for a human being (or assist his breathing, in the lingo of docs) may belong to the hubris of science’s defiance of death.

But, given the person that Kalanithi was, machines are, strictly, the dispensers of air. They are alien to the mystery of breath. A distinction more crucial for safeguarding the humaneness of medical practice there cannot be.

Think for a moment, as a brief aside, of environmental pollution. Is it not, after all, the estrangement of air from breath? And is that not the death principle?

Why should anyone read this book by a neurosurgeon who happened to die young? Well, there are several compelling reasons.

First, it is not the doomed defiance of a talented neurosurgeon that this remarkable book chronicles. Paul was a poet at heart. This poet was also a philosopher and seeker. He embodied a humane and humanistic pursuit of excellence. One of the most relevant messages he continues to breathe into the conscience of our species in this age of super-specialization is the need to grow in an all-round fashion. This sets Paul Kalanithi apart as a doctor. Unlike stereotypical medical practitioners, he understands what the medical profession should mean and be. I can do no better than quote him:
A 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 (p 166)

Significantly, it is literature and philosophy, art and music, adventure and iconoclasm, the Promethean urge to be the very best, that sets him apart from the rest of the fraternity. Paul was far more than the most promising neurosurgeon in the US in his generation. He was wondrously rich in his humanness. You can’t be a great surgeon (or, great anything) without being rich in your humanity. This message is so very crucial to all professionals, at a time when technology and super-specialization tend to dwarf the human.

The lamentable consequence of this invasion of the physician-patient inter-space by technology, is the decline of communication skills in doctors. With this, the distinction between treating a human being (who needs to communicate) and an animal (which cannot) threatens to disappear! Paul is a refreshing and reassuring exemption; or, to use his own metaphor, he is a whiff of fresh breath in the medical world. When Breath Becomes Air is a fascinating illustration of the therapeutic value of communication. Writing this book did not save the young, ailing author from the killer-disease; but it healed him existentially. Intimate communication is half-healing.

Furthermore, what exactly is it that a doctor brings to bear on the healing process? Is it only his medical knowledge and surgical skills? Paul believed otherwise. The foremost resource for healing is the person of the doctor and -this is most important- the person of the patient. Healing is a person-to-person experience. Regimens and protocols have to be, hence, used with intuitive attention to this partnership. As persons, neither the doctor nor the patient should be a passive element. Both need to participate actively and communicate sincerely. What the practice of medicine needs to regain urgently is the restoration of this healing partnership, with communication as its animating breath.

That is so, because healing, in respect of humans, has a great deal to do with meaning. What is the deepest need of a terminally ill patient? Listen to Paul once more: “I was searching for a vocabulary with which to make sense of death.” (p 148). A doctor who opts out of that search is like a teacher who covers the syllabus by way of meeting the physical, quantitative requirements, but does not bother to uncover the universe towards which each of the texts he ‘deals with’ (but fails to teach) is but a tiny aperture.

The gripping feature of this book is its passionate -desperately passionate- celebration of life. For one thing, the ominous shadow of Paul’s impending death heals his beleaguered marriage. That’s not all. The most heroic thing a young couple can do is to choose to be parents, even as they stand on the brink of the abyss! Paul and Lucy adopt Cady a mere eight months before Paul’s death not as a protest against death, but as a celebration of life, as though Handel were to bellow the Hallelujah chorus with his last breath! Under the circumstances, it is splendid poetic justice that Paul’s breath -this man to whom poetry was more comforting than scripture and recited T. S. Eliot with his penultimate breath- lives on through little Cady. Paul’s last words, not surprisingly, are a hymn of love for Cady (p 199).

When Breath Becomes Air is a theodicy of life and is, to that extent, a profoundly spiritual narrative. Unlike air, breath communicates. Only that which is spoken has any reality in the public space. Life is an articulation of what, otherwise, is incommunicable. Death has an irreplaceable role within that scheme. The spiritual cycle remains incomplete, if experiences are not empowered to breathe. That is what this book addresses.

Even as breath becomes air, the air that for 36 years remained in a world of rich and rippling experiences, becomes breath. This book is that breath: Paul’s life-breath. If it seems to become air, it does so only in a manner, thanks to the greatness of the human spirit, that wills it back to breathe again. So it breathes over those who are, to borrow the words of a poet that Paul was never tired of quoting, “living and partly living” (Chorus in T. S. Eliot’s Murder in the Cathedral, 1935).

(Valson Thampu is former principal of St Stephen’s College, Delhi)

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