Death Meets the Doctor

A review of When Breath Becomes Air

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Existential crises are by no means exclusive to students in the liberal arts (think the bearded Beat emanating a cloud of hand rolled tobacco smoke, nauseated by these two options: to drop out and hitchhike cross country or attend his Intro to Western Phil class). The burdens of years of scholarly toil, the substantial time in esoteric animal labs, the hypercompetitive pursuit of graduate study lead many students in the sciences to also question: What’s the point of it all? The rigors of the pursuit of knowledge as a means to a career in medicine weigh down too many bright young minds such that by the time the goal is met, the soul is bruised and weary.

Physicians have higher rates of burnout, career dissatisfaction, and suicidality than the general population. All this in the background of lower religiosity for practitioners that are at the frontlines of misery, pain, despair, and death. How does this anointed bestower of health appear to the frail and infirm? As Dr. Paul Kalanithi writes in his posthumously published memoir When Breath Becomes Air, he appears like “Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease — and utterly missing the larger human significance.” And how does the patient fare when her physician lacks the humanistic characteristics that mark the compassionate caregiver? Just ask anyone who’s complained about a bad doctor. The complaint is usually not due to an improper treatment applied, but rather the delivery of news in an unsympathetic tone, the absence of concern in the voice, the failure to be the guide through treacherous seas. The account of the life of Kalanithi proposes one way in which arbiters of health can enhance their humanity.

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 When Breath Becomes Air by Paul Kalanithi

 

Kalanithi, a neurosurgery resident in his mid-30s at Stanford University Medical Center, early on reveals that he is diagnosed with stage four lung cancer, metastatic to his bones and liver, just as he is near the culmination of years of toil that nearly wreck his marriage. He then backtracks and narrates his childhood in Kingman, Arizona, where his father is consumed by his cardiology practice and his mother frets that her boys won’t succeed in the poorly performing Kingman school district. She prescribes the Western literary canon to a ten-year-old Paul, aiming for the Ivies and gifting him his lifelong love of books.

As college approaches, he seems destined for the liberal arts for it is in literature that he finds “the best account of the mind” and “the richest material for moral reflection.” He argues in his college admission essay that “happiness is not the point of life,” sounding like a desert guru prepared to shed all the trappings of modernity to plumb the depths of meaning and existence. He thinks he’s captured the sublime in the setting of the Sierras as he observes “the Eastern sky slowly erasing the stars” and the “full moon pinned to the sky.” Here we see the philosopher-poet, one of many identities he comes to occupy in his short life.

Yet he hungers for more. Although his literary heroes instruct him on human desperation, suffering, even miscommunication, he coincidentally studies human biology in order to comprehend the Cartesian machine that constructs meaning in life. On a tour of a group home for largely abandoned patients with traumatic brain injury, he connects with a young patient sparse in words yet still grand in emotion to his discerning eye. His professor callously remarks that death is favorable to the trapped misery of these crippled lives. Kalanithi recoils as the hand of his moral compass shudders from his professor’s repugnancy. He decides he “could either study meaning or experience it” and thus shifts tack, a brave readjustment for someone seemingly destined for a life of literary scholarship. For him, the nexus of his many learned disciplines (biology, morality, literature, and philosophy) suddenly arrive at only one station: medical school.

It is in medical school that we fully note the subject-object duality which nakedly informs his thoughts and subsequently his worldview. In cadaver lab he confesses “we objectified the dead.” That singular assertion sparks the subject-object separation that becomes the framework for his view of the world and his place in it. The scaffold of dualism becomes a prerequisite for his conception of the “true image of a doctor” as one who takes on the “heroic spirit of responsibility amid blood and failure.” What we are privy to here is the elevation of the physician into the realm of demi-god, a heroic mythification that reinforces a paternalistic view of the doctor-patient relationship. When he delivers a healthy baby during his obstetrics rotation, he declares “I was a prophet returning from the mountaintop with news of a joyous covenant” as we picture him holding the infant above his head under hospital-grade fluorescent lighting. The language is surprisingly religious for someone who later affirms the distance he has kept from the church for most of his adult life.

As the myth calcifies in his mind, as the distance between doctor and patient protracts, he decides to pursue training in neurosurgery, one of the most rigorous fields of postgraduate education. Its severity is not for everyone as many of his classmates happily pursue so-called lifestyle specialties, but in Kalanithi’s conception, the suffering he endures is proportional to his excellence. Happiness has never been the point, after all, and in neurosurgery he finds work “in the crucible of identity” manipulating “the substance of ourselves.” It is here that we are reacquainted with the sublime, but instead of a harmonic vista of the Sierras, Kalanithi pursues “a different sort of sublime, to forge relationships with the suffering and to follow the question of what makes life meaningful even in the face of death and decay.”

In Edmund Burke’s treatise on the sublime, “the mind is so entirely filled with its object” when contemplating the sublime “that it cannot entertain any other.” A great deal of Western thought hinges on this dualism, the construct of self and other, subject and object, observer and observed. The Romantics, perched on cliffs capturing raw vistas, saw themselves as poet-prophets, arbiters of the divide between the contemplative human mind and an unspoiled world. It is then not hard to conceive that dualism is the essential framework for a sort of learned otherness taught in medical training whereby the physician is the subject and the patient the object. The myth of physician as prophet has its roots in Western medical education.

What does it mean for Kalanithi to pursue the sublime in the doctor-patient covenant? It means that he is conscious of the divide between subject and object and that he strives to bridge it. But it is no easy task, particularly in a grueling residency, as it requires a constant vigilance of the humanity of others. In tales of patient encounters, the myth of the physician-prophet begins to be pierced as Kalanithi pulsates between the systole of his intellect, empathy, and courage and the diastole of his callousness and exhaustion. For a physician bent on climbing to the mountaintop, it is remarkable that he so candidly confesses his mistakes: “I observed a lot of suffering; worse, I became inured to it.” The stress and misery prove overwhelming for a cheery colleague of his who leaps to his death when a case goes awry. The fields in which errors end the lives of both subject and object are thankfully too few.

It is here that the budding neurosurgeon-neuroscientist embraces what is classically referred to as the art of medicine. For Kalanithi, it is not sufficient to excel in the operating theater; he strives to excel outside of it, recalling his ideal and wielding that great tool he spent years mastering: language. Rudyard Kipling remarked that “words are, of course, the most powerful drug used by mankind.” In interacting with patients, he enacts a number of techniques that are increasingly recognized as central to physician encounters with patients: the use of simple language, a thorough assessment of the patient’s values, shared decision making, empathic listening, and a deeper understanding of the multifaceted layers of suffering beyond the corporal, namely existential, spiritual, and psychic. This is the applied morality he first sought in medicine manifest as the caring clinician, “human relationality … realized in the doctor-patient relationship.” It is an arduous feat, but modern practitioners of medicine must arrive where he has, as difficult as it may be to sustain this worldview in every patient encounter. This is the quiet beauty of Kalanithi’s prose: he provides a manual for physicians to improve their interactions with patients in the disguised narrative of his own fits and starts.

As is the case in such accounts, it is when the subject is at the cusp of something grander, his identity as a physician-scientist near fruition, that calamity strikes, here in the form of an army of wayward cells. (I use the martial metaphor half-heartedly as in fact what’s thankfully missing in Kalanithi’s memoir is the staid narrative envisioning cancer as an unwelcome invader, an improbable externality, an alien foe that must be trounced at the battle stations of hope, with the guided weaponry of optimism and advanced pharmaceuticals). The doctor is a realist, his cancer is well advanced at the time of diagnosis; there is no chance of cure, only therapies to extend his life to a finite horizon. Cancer is less an intruder than a novel component to his identity surreptitiously spliced into his own being.

Which, of course, thrusts the philosopher-scientist into an existential crisis. What does it mean when a CAT scan reveals a subject to be an object, the doctor now a patient, the observer observed, the shepherd now a sheep? Who is this new Paul Kalanithi? A career that surrounded him with suffering and death didn’t readily gird him for facing his own mortality at such a young age. He despairs, questions, reevaluates in the same vein of his patients. Fortunately, his oncologist is the sort of humanistic physician he aspires to be. She denies the easy math of numeric prognostication, insisting that what matters is not the amount of time he has left, but what he makes of that time. She builds his trust and he shares his values with her: he wishes to return to medicine, to complete his residency. His body responds remarkably to a directed therapy and he is goaded by Samuel Beckett (“I can’t go on, I’ll go on”) to return to work, to graduate, and even to begin interviewing for academic jobs.

Yet the existential pain remains. The terminal illness shadows his every conception of himself. But he persists, finding new identities not in spite of his cancer, but arguably as a result of it. He becomes a physician-writer, a more attuned husband, and eventually a father. Cancer, he admits, saves his marriage. What is remarkable about the memoir is that he offers a narrative of dying with few companions in the great body of western thought on death. Kalanithi does not shun his sorrow. He embraces his sorrow and allows it to enlarge his capacity for finding meaning in life. In his personal life, his wife wonders whether having a child would be bittersweet, to which he replies, “wouldn’t that be great?” In his professional life, he comes nearer to his vision of the humanistic doctor. “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 make sense of their own existence.” The search for meaning, in large part, is what makes life meaningful.

Why are the most caring doctors often the ones who’ve come nearest to death’s precipice themselves? Precisely because they’ve traipsed the divide, been objectified, and experienced being infirm first hand. Since they’ve not learnt it in their training, they learn it in their lives, when suffering and death become all too personal. Surely there must be another way to engender the sort of humanism in physicians that every patient deserves. This is where the liberal arts must intercede.

When we read literature and inhabit the life of a fictional character, we bridge the subject-object divide. We experience the full expanse of the character’s motivations and emotions, from suffering to salvation, from angst to certitude. As Kalanithi writes, literature offers a “vocabulary with which to make sense of death,” but more than that, it blooms in us the language of life. Literature heals: it expands our minds, anesthetizes our wounds, reckons our sorrows, suffuses us with humanity. It enlarges our worldview so that we may cross the chasm between observer and observed. This movement is the crux of that much-bandied term: empathy. This movement is the requisite condition of the moral healer.

The liberal arts can play a central role in the search for meaning within the field of medicine. The liberal arts can allow us to look beyond the medicalized patient and appreciate the suffering human in front of us. The liberal arts can help replace the caricature of the unfeeling doctor and realign us to the humanistic healer through lessons in communication and deep reading of our patients, through greater understanding of the many layers of suffering beyond the physical, the type of pain that requires a soothing touch, a good set of ears, and the right combination of words — not a prescription pad. We see this humanistic physician in Emma who probes Paul’s values and encourages his return to work when his health improves. We see this humanistic physician in Paul, who writes to reveal his victories and failures, his evolution to a compassionate, contemplative doctor, one who strives beyond the mechanistic treatment of disease to become a technician of the spirit. (In fact, even in the act of writing, Kalanithi shows an acute sensitivity for the reader as his grander mission is revealed. He offers an account of his life not to make us mourn his great mind, but to instruct us on how to regain our humanity. The caring doctor thus absolves us of our pity.)

The fact is patients and their families are eminently captivating: they are joyful, tearful, subversive, destructive, skeptical, hopeful, inspiring. In other words, they are sublime. Doctors are not adequately trained to embrace the mess of personality before them, to behold the sublime in all we care for, but literature may prepare us to be enthralled by their humanity by priming our minds to the varied manifestations of experience. The well-being of both doctors and patients is at stake. The crisis in medicine, at times the crisis in Kalanithi, is the sense that we have lost our calling, we have forgotten why we first pursued the healing arts. It was not just to treat the body, but to understand the human in front of us, meet them where they are, and guide them to a place where their full humanity is realized. •

Nikhil Barot, MD is Assistant Professor of Medicine at the UCLA David Geffen School of Medicine.
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