Tuesday, January 26, 2016

Paul Kalanithi: A Well Ended Life Triumphs Death. 'Death, Be Not Proud'

'Do not seek death. Death will find you. But seek the road which makes death a fulfillment'  wrote Dag Hammarskjold. Paul Kalanithi died on March 9th 2015, aged 37, two years after he had been diagnosed with lung cancer. He wrote to his friend about diagnosis, "good news is I've outlived two Brontes, Keats and Crane. Bad news is that I haven't written anything". Kalanithi then penned "When breath becomes air" which has been critically acclaimed and is now a bestseller. Kalanithi, by writing this book, has triumphed death. The book carries a special meaning for me since my dad passed away last August due to cancer and he too, like Kalanithi, was a surgeon and a Christian for whom faith was central to his life.

Will Durant's quote from Robert Browning, "life has a meaning. Finding it is my meat and drink", aptly sums up Kalanithi's raison de etre.

Paul Kalanithi became famous when he penned an oped in New York Times, "How long have I got left" where he wrote about being diagnosed with lung cancer. He died less than 2 years of the diagnosis. Couple of weeks back he roared back into the limelight when New York Times book reviewer Janet Maslin wrote a fulsome praise of "When breath becomes air", a book Kalanithi wrote as life ebbed away.

Paul and Lucy Kalanithi with daughter Cady - Image courtesy www.paulkalanithi.com 
Kalanithi was born into a family of doctors and chose to stay away from pursuing what had practically become a family vocation. He pursued graduating in literature from Stanford but a brush with a 'low-brow' book provided an epiphany for him. He realized that "literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it". Utilizing the flexibility in choosing coursework that American universities uniquely provide Kalanithi enrolled in biology and neuroscience classes as well. Ready to graduate he felt he was "driven less by achievement than by trying to understand, in earnest: What makes human life meaningful?" In his sophomore year he chose to intern as a chef at a camp. A visit to a center for patients with severe brain injuries, mostly children, in his final year, made him realize "brains give rise to our ability to form relationships and make life meaningful. Sometimes, they break".'As graduation loomed', he realized that he had a "nagging sense" that he "wasn't done studying". Between Walt Whitman who taught him that "only the physician could truly understand 'the physiological-spiritual Man'" and a teacher of philosopher who told him that unlike most graduates of literature he was at home with science Kalanithi decided to become a doctor.

Unlike Indian school students who rush into medical school after rudimentary physics and chemistry in 12th grade Kalanithi, like American students, enrolled in pre-med classes to bone up on those two critical subjects. While he waited to apply for medical schools the Stanford literature and biology graduate went to Cambridge and pursued a course in history and philosophy of science and medicine. The course work convinced him that "it was only in practicing medicine" he "could pursue a serious biological philosophy". Kalanithi returned to US and joined Yale Medical school.

When Kalanithi joined Yale the legendary surgeon-philosopher, a tribe unique to western academia, Sherwin Nuland was a lecturer. Nuland's "How we die" is a classic that taught millions of what Kalanithi calls medicine's "twinned mysteries of death, its experiential and biological manifestations:at once deeply personal and utterly impersonal". Referring to Nuland's narration of an attempt to revive a patient by cutting open his chest and pumping the heart Kalanithi sums up the mission of what it is to be a doctor, "the heroic spirit of responsibility amid blood and failure". My dad would've underlined those words had he read the book.

Would knowledge alone suffice for a doctor? In lines reminiscent of T.S. Eliot Kalanithi, after performing an emergency C-section to deliver preemies that later inevitably died, rues the 'judgment call' and muses "intelligence wasn't enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too".

Doctors are human beings too. Kalanithi recounts how a tired oncologist silently rejoiced that a pancreatic cancer patient did not require further surgery after the initial cut and inspection which revealed extensive metastases. Then realizing the guilt and shamed she needed to be consoled.

"Neurosurgery, with its unforgiving call to perfection" and the realization that "neurosurgeons work in the crucible of identity" drove Kalanithi to become one. I think back to the reason Ayn Rand chose to depict the evils of socialism in medicine using not just any doctor but a neurosurgeon. A millimeter here or a millimeter there would make all the difference between a patient losing the ability to learn words or use them. A tumor excised too much has the probability of injuring a millimeter of another faculty and rendering a patient paralytic. I mused on the rationale for affirmative action which argues for jobs on the basis of "he needs it". In another passage that is strikingly similar to Ayn Rand's language Kalanithi writes "technical excellence was a moral requirement. Good intentions were not enough", "when the difference between triumph and tragedy was defined by one or two millimeters". I sadly thought of the hundreds of doctors in India who have purchased their way to a degree.

The pages where Kalanithi sizzles is where he recounts learning to avoid becoming the "Tolstoy stereotype of a doctor" and care about patients. My dad used to recount his teacher's words that patients think a doctor has a magic wand to wave away their illnesses and how that implicit faith places upon the doctor a responsibility to care deeply for the patient. Faced with situations where surgery could be futile Kalanithi suggests that "when there's no place for the scalpel, words are the surgeon's only tool". Convincing a family to let a brain dead person die is the toughest job a doctor has to do. Kalanithi recounts in a sentence of profound candor that had he been more religious in his youth he might've become a pastor and he even realizes by hindsight that he had sought a 'pastoral role'. Faith was central to my dad's life as a man and as a doctor. He would've nodded approvingly at that observation.

Neurosurgeons, the American curriculums insist, must 'venture forth and excel in other fields as well'. In his 4th year during residency Kalanithi chose to enroll in a motor-neuroscience laboratory run by an Indian he only names as 'V' in the book. Kalanithi says that V, unlike the publish or perish breed of American academia who "connive to publish in the most prestigious journals and get their names out there", "maintained" that their "only obligation was to be authentic to the scientific story and tell it uncompromisingly". The character Max Gottlieb in Sinclair Lewis's Pulitzer winning novel Arrowsmith, an inspiration to legions of those who aspired to become doctors, comes to mind.

Atul Gawande in his bestseller "Being Mortal" recounts a profound conversation between his dad, a doctor himself, and his surgeon about a critical surgery that could possibly leave him debilitated. They go over what kind of functional loss would be tolerable and the question "what is important to you in your life" looms. To a neurosurgeon knowledge of what the patient holds dear is important says Kalanithi. Kalanithi sums up "their (neurosurgeon's) duty included learning what made that particular patient's life worth living, and planning to save those things if possible". Gawande in his book narrated how a surgeon at Harvard had no such patience toward his dad and how, in contrast, a Cleveland based surgeon was all about what was important to his dad.

Towards the end of his residency Kalanithi learns that he has terminal stage lung cancer. The debilitating disease and the proximity of death changes his life. Kalanithi's relationship with his wife until then was rocky and he confides that the cancer diagnosis brought them together. Paul and Lucy decide to even have a child despite his wife cautioning him that it'll be difficult for him to say 'goodbye'. In a touching epilogue Lucy adds that the "cancer diagnosis was like a nutcracker, getting us back into the soft, nourishing meat of our marriage".

A terminal illness radically alters not just the trajectory of one's life but even values as well. A class reunion reminds Kalanithi that while his peers will go on to have careers he faces death. The man who turned from literature to medicine in pursuit of finding life's meaning now took a turn back to literature and even religion to discover to what purpose can he use the meager remaining days.

A brief incident of a flippant resident doctor who forgets to include a critical medicine but is adamant, out  of laziness, not to correct it reminds Kalanithi yet again how important it is to be a human being as a doctor.

Racing against time Kalanithi, in luminous passages, ruminates on what is life, the cheer of his newborn child Cady and death.

Having seen my dad slip into the grip of death over an agonize 8 month period as his once corpulent body was wasted and thinned out by the spread of cancer I could visualize Paul Kalanithi's life move inexorably to its end. Though dad was afflicted by dementia for a brief period he did maintain a semblance of lucidity until the end. I've never stopped thinking what must have gone through his mind as he lay contemplating the arrival of the grim reaper. When a false alarm of his impending death arose in March of last my brother and I dashed down to India and held his arms telling him that he had run a good race and that he should depart in peace. I could not bear to read the passage of Kalanithi, who in his last hours seeing the end is near wanted to remove his face mask and hold Cady. Then he muttered the words "I'm ready", says Lucy. Lucy's narration of the final hours is moving, poignant and inevitably lachrymose.

The flap jacket on the book lists Kalanithi's academic credentials. He had a B.A and an M.A in English literature, a BA in human biology (all from Stanford), an MPhil in History and philosophy of science and medicine (Cambridge), graduated summa cum laude from Yale School of Medicine, Neurosurgery from Stanford and also won the highest award for research from American Academy of neurological research. He was 37 when he died.

One wonders at how poorer the world is for the loss of such an intellect and a great human being. Rarely does fate bestow such gifts on a man only to snuff out his promising life at such a tender age. Maybe Kalanithi would've become another Dr. Marsh, a legendary British neurosurgeon and an author of equally acclaimed 'Do no harm'. But who knows maybe this book is a better gift for posterity than any surgical procedure Kalanithi may've invented.

In a brief book written under the most dire of circumstances Kalanithi shows us his literary acumen and brings to life, in a compact two chapter book, who he was in flesh and blood. Abraham Verghese, a doctor and bestselling author of 'My own country', in his foreword aptly points out that despite being acquainted with Kalanithi personally and having read his essays he had come to know him from the book: "it was only when I received the pages that you now hold in your hands, two months after Paul died, that I felt I had finally come to know him, to know him better than if i had been blessed to call him a friend".

I'd rate Kalanithi's book several notches higher than Randy Pausch's "Last lecture" because Kalanithi is far more literary in his writing and weaves more profundity in a narrative that pulses with life. The world may not have benefited from Kalanithi's genius as doctor given his untimely death but Kalanithi the literary person has left a legacy.

Two points for my fellow Indian brethren to ponder. Kalanithi's life is what I'd call 'an American life'. The career choices he made, pursuing literature and philosophy before turning to medicine, including an internship as chef, underscores the uniqueness of what is possible in American education. While not every American neurosurgeon is a Kalanithi I can safely say that a Kalanithi would not be possible in India. Second, Lucy's life as widow. Lucy, an American, defies the stereotype that Indians hold of American women and of American marriages in general. Lucy herself penned a very moving column in New York Times, 'My marriage didn't end when I became a widow'. Lucy would go to Paul's graveyard and lie on top of it and caress the grass nearby as if she was caressing the hair on Paul's head.

Towards the end of his 'Ode to the West Wind' Shelley beseeches the wind : "drive my dead thoughts over the universe, like withered leaves to quicken a new birth". This book will do for Kalanithi what Shelley asked of the West Wind. Kalanithi had chosen a quote from Montaigne to begin the chapter titled "Cease not till death", "he who should teach men to die would at the same time teach them to live". Lucy in her epilogue movingly records, "For much of his life Paul wondered about death- and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness".

Abraham Verghese closed his foreword with the following words: "Listen to Paul. In the silences between his words, listen to what you have to say back. Tehran lies his message. I got it. I hope you experience it, too. It is a gift. Let me not stand between you and Paul."

"Death, be not proud" by John Donne

Death, be not proud, though some have called thee 
Mighty and dreadful, for thou art not so; 
For those whom thou think'st thou dost overthrow 
Die not, poor Death, nor yet canst thou kill me. 
From rest and sleep, which but thy pictures be, 
Much pleasure; then from thee much more must flow, 
And soonest our best men with thee do go, 
Rest of their bones, and soul's delivery. 
Thou art slave to fate, chance, kings, and desperate men, 
And dost with poison, war, and sickness dwell, 
And poppy or charms can make us sleep as well 
And better than thy stroke; why swell'st thou then? 
One short sleep past, we wake eternally 
And death shall be no more; Death, thou shalt die.


  1. Paul Kalanithi's oped in New York Times "How Long Have I got Left"
  2. Lucy Kalanithi's oped in New York Times "My marriage did not end when I became a widow"
  3. Paul Kalanithi's article in New Yorker on his "Last day as a surgeon" (he could not perform any surgeries after that one)
  4. Paul Kalanithi's article for Stanford "Before I go"
  5. New York Time's Book Review of "When breath becomes air"
  6. Lucy Kalanithi's interview with New York Times "Keeping Dr. Paul Kalanithi's voice alive"
  7. My blog on Randy Pausch's 'Last Lecture'
  8. Dr. Paul Kalanithi's website www.paulkalanithi.com


Anonymous said...

You are a fantastic reviewer, writer, opinion-inducer and more than most other things a stunningly well-read man. There is no denying that I disagree partially and wholly as the case may be, in substance, with some of your writings but what I admire is your nuanced take on things, breadth and reasonable depth.

Continue to write mate, bouquets and brickbats notwithstanding. How does it matter in the larger scheme of things what folks think of you, your opinions or for that matter anything else.

Unknown said...

As a medical student in india,i sincerely applaud the way in which u've shown the difference between medicine in india and that in US.books by authors like kalanithi and articles by people like you help us in the attempt to bridge the discrepancy.