Paul wrote in an early part of his book about how quickly the medical students changed and that the, “Cadavers reverse the polarity. The mannequins you pretend are real; the cadavers you pretend are fake… to take one good look at our cadaver’s face and then to leave it covered; it makes the work easier.” (Kalanithi, 45) It’s facelessness quickly allowed what was once a person in whom life dwelled, a person who may have loved deeply and been deeply loved, to become instead pieces of a body. Although in this paper we look at Paul’s life as he approaches death to understand what has been learned both about living and the process of dying, let us not forget that Paul was real and his loss was deep. Loved by his wife, family and friends, he also left behind a future in his words, the lives he impacted and his young daughter newly created. It is in his words to his daughter, who will remember him only through others, that we see the title of our class captured so clearly:
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 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. (Kalanithi, 199)
This kind of response to one’s own death might seem extraordinary to many, but it was sculpted by a lifetime of influences. His Christian father and Hindu mother had eloped from the south of India to New York City where he had been raised for a while before being moved to Arizona with his family. His mother’s concern about his education caused her to emphasize reading heavily at a very young age. Meanwhile, his father was deeply committed to his medical practice which meant that he was not frequently around, making Paul view the personal cost of medicine as too high early on in his life. However, these things would remain important threads throughout the story of Paul.
“Brave New World founded my nascent moral philosophy and became the subject of my college admissions essay, in which I argued happiness was not the point of life.” (Kalanithi, 27) After starting college he consumed literature courses in a search for human meaning but soon began to look into biology to understand the mechanisms that made creatures creators, ultimately moving over to the pursuit of a medical degree. And yet literature continued to shape how he tried to understand his patient’s experiences and, ultimately his own. “Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining life and death… being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun.” (Kalanithi, 81) The medical culture he was now immersing himself in caused him to struggle to respond as a person dying instead of as a doctor and yet his lifetime of seeking served him well in expressing his experience through the book he ended up writing and scoping out his purpose towards the end.
“It is the differences in meaning, far more than mere differences in vocabulary, that isolate cultures and that cause them to regard each other as strange or even barbaric. It is not too surprising that many cultures refer to themselves as “The People,” relegating all other human beings to a subhuman form of life.” (Barland, 39) This division by culture is easily identified when there are language barriers, differences in dress, or other ethnic markers that turn a comparison between people into a study in contrasts. Maybe it is just as likely that cultural misunderstandings occur when we are almost the same. There is so much to relate to Paul on that when I struggle to understand him, it is hard to remind myself of the cultural nuances. For instance, in a culture that requires 100 hours a week when you’re dedicating yourself to the care of other’s, perhaps a reduction of empathy is a means of survival whereas I, having never had such demands put on me, see only callousness. Paul, upon hearing that a friend died from a car accident after an attempt to save her life, wrote: “In that moment, all my occasions of failed empathy came rushing back to me: the times I had pushed discharges over patient worries, ignored patients’ pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged in various diagnoses…” (Kalanithi, 85)
Additionally, I wonder if I would have chosen to have a child before I died, leaving my spouse with a permanent reminder of myself and the possible burden of being both in mourning and a single parent simultaneously. His wife also asked him, “Don’t you think saying goodbye to your child will make your death more painful?” (Kalanithi, 143) It wouldn’t only be hard on her; they both struggled with the decision. It’s clear as you read that family is a strong value for him from the very beginning. If I had been his wife I think I would have wanted to have the baby. He writes in reply to her question regarding it being more painful, “’Wouldn’t it be great if it did?’ I said. Lucy and I both felt that life wasn’t about avoiding suffering.” (Kalanithi, 143) Indeed, loss is the cost of our commitment to one another sometimes; the price we pay for love. If loving someone more deeply was what made this death harder, perhaps that is the best way one could exit this world.
Another perspective would be that having the child was a form a denial that death was as imminent as he was being told. In fact, he wrote, “We would carry on living, instead of dying.” (Kalanithi, 144) Paul manifested denial differently than many of us might. He could not intellectually deny that he had cancer, or that he understood to at least some extent the severity. He had become the patient for the very things he treated. He writes: “After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely.” (Kalanithi, 132) He undoubtedly felt it profoundly. But his denial was found in his actions. He stated that if he had a sense of the time he had left it would determine what he would do. Two years versus ten years mattered, but he knew she couldn’t give him what he was asking. It appears he was able to exist in a place where he was more acutely aware of his mortality while generally operating in denial until the birth of his daughter. “Yet there is a dynamism in our house. Day to day, week to week, Cady blossoms: a first grasp, a first smile, a first laugh… Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence-and eventually, death.” (Kalanithi, 196)
Paul writes that he believes he went through the five steps of grief in reverse; that because he knew he was going to die but at the time was unable to know the when, instead of experiencing denial first, he experienced it last. Due to his vast medical experience in the field, he saw the stage of acceptance as being at the very beginning because he understood his prognosis. I would say that while Paul and Lucy certainly experienced that stages of grief, acceptance for them was at the end. “One of the most important aspects of Nearing Death Awareness is the need for reconciliation. Dying people develop an awareness that they need to be at peace.” (Callanan, 137) Before his diagnosis, his marriage was in danger of ending. In a way, the cancer brought healing. “Our relationship was still deep in meaning, a shared and evolving vocabulary about what mattered. If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning.” (Kalanithi, 142) To that end, the other important part is legacy, that we have defeated death through our ability to continue on even after we have died. Paul and Lucy managed this aspect of their grief through their child and completing the book together.
These aren’t the only things that changed for Paul towards the end of his life. Voirst writes that “our dying may sometimes provide a new opportunity, that dying may sometime permit… growth and change, that dying may precipitate a further stage of emotional development that had – until now—been well beyond our capacities.” (Voirst, 318) At first he had thought that he could never do surgery again. In the end he realized that his doctor had done what he himself had strived to do with his patients: protect the attributes which they value and empower them to discover what they wanted to do with their remaining time. As he practiced surgery, he learned more about how his illness transformed him: “The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out… Death may be a one-time event, but living with terminal illness is a process.” (Kalanithi, 160-161) In other words, dying is a process that at its best has you discovering who you are until the very end.
We come at last to consider the role that religious beliefs played in how Paul dealt with both being diagnosed and dying. Although certainly approached in a scientific and academic manner, Paul was not devoid of a relationship with God; he wrote that if he had known God sooner he would have perhaps pursued a pastoral role instead of the one he ended up in. The fact that he saw no proof of God left him in a place where believing in God seemed unreasonable and so he didn’t. It wasn’t that he didn’t have the foundation; he was familiar with Scripture and his family raised him Christian. After searching through much of his twenties, he reached the following conclusion:
“The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning-to consider a world that is self-evidently not the world we live in. That’s not to say that if you believe in meaning you also believe in God. It is to say, though, that if you believe that science provides no basis for God, then you must also be obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any.” (Kalanithi, 169)
Paul reaches this conclusion and saw sacrifice, forgiveness and redemption as the foundational principles of Christianity. This was crucial to helping him deal with his situation, even if he doesn’t appear to lean on it very heavily. This is true also of his lens of seeing Jesus as delivering a message of mercy over justice. Christians understand that sacrifice is a part of their story; Paul responds to his loss of life, time and experience less with anger and more with a zeal to squeeze what he can out of what is left. While he strives, he is full of forgiveness and we see redemption is his relationships time and again.
Christian’s often define faith with language like “assurance of things hoped for, the evidence of things unseen,” similar to Hebrews 11:1. To this end, I don’t believe this is a struggle of Paul’s. The way he is built makes supernatural faith hard, but he sees evidence in the world around him that speaks to a Creator who wants our lives to have meaning and purpose. So while his faith might look different, that doesn’t make it any less deep. This is a man who, dying, chooses to create life. To write of his experience dying in order to help others. I do not see a struggle of faith in Paul; I see a man being faithful in his struggle, much like the man after which he was likely named.
Barlund, Dean. “Communication in a Global Village.” Basic Concepts of Intercultural Communication: Selected Readings (1998): 35-48. Print.
Callanan, Maggie and Kelley, Patricia. Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. New York: Simon & Schuster Paperbacks, 2012. Print.
Kalanithi, Paul. When Breath Becomes Air. New York: Random House, 2016. Print.
Viorst, Judith. “The ABC of Dying.” Necessary Losses (Unknown): 305-327. Print.