When breath becomes air

Brewing with a Chemex probably seems like a complicated, time-consuming ordeal, but once you get used to the process, it becomes a soothing ritual that's worth the effort every time.

A colleague gave me a book recently called “When breath becomes air” by Paul Kalanithi which is a true story, written in the first person as he comes to terms with his own death from cancer. He explores his relationship with death and meaning, first as an English literature student, then as a medical student and intern neurosurgeon and finally as a terminally ill cancer patient. He describes his journey beautifully and in a profoundly emotional way makes you feel the sorrow and awe that he, his colleagues and his loved ones feel as they bear witness and come to terms with the gruesome details of the author’s patients and eventually his own drawn out death.

My dad’s name is Paul and he died from malignant skin cancer slightly more than a year ago now, so this book hit very close to home (i.e. I cried a lot).

Reading this book has really reinforced my view that we need to defeat death. Although Paul (the author) doesn’t explicitly state whether he thinks death imparts meaning to life or not, I found his language around death and meaning to be helpful in clarifying my own thinking about it. My view on why we need to defeat death boils down to 4 things, each of which he touches on in his book:

1. We all have to eventually accept our own death and try to make the best out of our finite lifespans. But that acceptance is necessary for our emotional well-being — it does not vindicate death.

When something horrible happens to us that we have no control over, we have a choice in how we respond. We can either helplessly try to fight it and succumb to the awfulness or our situation, further increasing our suffering and despair. Or, we can accept it and optimistically try to find meaning and learning in it. The latter is always preferable to the former as it alleviates the suffering and limits one’s sense of hopelessness and depression. This is especially true about death. If I find out tomorrow that I have two weeks left to live due some illness, I will to the best of my ability try to convince myself that this is “meant to be” and that it imparts a special meaning on my remaining time on earth. But I will not try to convince myself of this because it is true. I will do it because the other options are just unthinkably bad in comparison.

I need to repeat this, because this is incredibly important: The fact that this is the better option does not make it true and we should not be making decisions based on whether people chose this way out or not. Children that are abused during childhood often create imagined narratives as a coping mechanism that make them forget or justify their abuse. Most sane people would be justifiably horrified if someone were to use these children’s imagined narratives as proof that child abuse is harmless or deserved — yet people commit the same error constantly when it comes to cancer patients and other people facing their own imminent death. The narratives are there to help overcome the anguish of an awful situation, but the underlying cause of those narratives is still unambiguously morally wrong.

One sentence in the book jumped out at me as describing the necessity of these imagined realities when facing death. In context, one of Paul’s patients believes against all odds that he can fight his illness and says something along the lines of “we’re gonna fight and beat this thing, Doc”. Paul’s reflection on this attitude aligns with my reflection on people’s desperate belief that death is meaningful: “…[that attitude] seems brittle, unrealistic optimism the only alternative to crushing despair”.

2. Our eventual death does not make us “live as if each day is our last”, and imminent death is not the only way to live this way

In his writing, it’s obvious that Paul’s concept of time changes. Towards the end he writes “The future, instead of a perpetual ladder towards the goals of life, flattens out into a perpetual present.” It’s unclear in the way he writes about this whether this is a positive thing for him or not — in the paragraph before and after he reflects on his suffering but without either complaining or celebrating it. However, generally, experiencing a perpetual present is something held in very high regard and I believe it to be the purest, most ecstatic way of living. All of my most blissful moments in life have been when I have through meditation, personal connection or physical activity managed to stay completely in the moment for a long period of time.

“Before my diagnosis, I knew that someday I would die, but I didn’t know when. After the diagnosis I knew that someday I would die, but I didn’t know when. But now I knew it acutely.”

Despite, as he says, that nothing in the general sense actually changed when he received his diagnosis (he was always going to die at some point), the urgency of his imminent death did change his perception of time. I believe this is common for people who are terminally ill or on death row — but this is my point: it is not death in general that brings people into the present, it is their imminent death. And there are alternatives: meditation, deep personal connection, creating art, helping others, advancing human knowledge, enjoying the sensations of our physical bodies.

Unless we impose a society where everyone is forced to face their imminent death daily (perhaps by mandatory Russian roulette after dinner every day?), we do not get the “appreciate the present” benefit of death throughout our currently expected ~80 years on this earth. For most of our lives, death is too distant to us, emotionally and temporally.

3. Our definition of how long a life should be has changed, is changing and will continue to change.

When my father died at the age of 63, a few family members and friends included in their remembrance speeches something along the lines “…he was taken from us at far too young an age” or “…far too early”. These words are seldom spoken at the funerals of 80 or 90 year olds because at our current average expected lifespan of about 80 years in most developed countries, living past that age is often considered to be “long enough”.

I would do nearly anything for my dad to still be here with me today, but the truth is that 100 years ago, people would not have said that he died “too young” for the same reason that they don’t say that today at the funerals of 100 year olds. We have changed our definition of what is “long enough” and we will continue to do so. This is a good thing and is a sign of the progress we have made and are continuing to make. In many ways I wish that both dad and I had been born in another 100 years time — by then we will probably have figured out a cure and dad could have lived longer with us.

Paul‘s wife Lucy alludes briefly on this progress in the epilogue: “Dying in one’s fourth decade is unusual now, but dying is not.”

We have nearly doubled our expected lifespans in the last 100 years, but have we halved the amount of meaning in our lives? And if so, is that really driven by the increase in our lifespans or by the thousands of other radical changes that have been made to every single other facet of our lives?

4. Deciding to vanquish death is not a childish act of running away from pain. It is an adult decision to take control and make our own deaths into mature, conscious choices rather than random afflictions.

As a species, humanity is fighting death on all fronts. We have armies of policemen, attorneys and judges to stop violence and murder. We have swathes of bureaucrats to enforce safety regulations in everything from junk food to traffic safety. We have hordes of doctors, nurses and researchers working on every single ailment, injury and disease that harms us and kills us. We run suicide hotlines, hold anti-war protests and tax or ban addictive but harmful substances such as cigarettes, alcohol and heroin. We value lifestyles that are “healthy” and we try to follow our doctors’ and WHO’s advice when they say we should work out more, eat less red meat and sit less. Even voluntary euthanasia under the most extreme circumstances is considered to be taboo and unethical in most parts of the world. But when asked whether our goal should be to “cure” or eliminate death, most people say something along the lines of “No! Death is a natural part of life and imparts meaning to our short time on this beautiful earth”.

As children grow up, they start taking responsibility for their actions and are expected to make conscious choices. This is what makes us adults. Maturity comes from understanding the consequences of our actions and taking responsibility for them. Deciding instead of reacting. Children are expected to go with the flow and do what they are told (albeit often complaining about it). Adults are expected to make up their own minds and take control of their lives.

I believe that deciding to eliminate death and doing so will bring about one of the final stages in humanity’s maturing process. Making the decision of when to die is probably the hardest choice a person can make. At the moment our collective decision is that this hardest of all choices should not be made in an adult, conscious way, but rather by random luck of the draw — spinning the cruel and horrible wheel of violence, disease and pain.

But, as Paul says: “The angst of facing mortality has no remedy in probability.”

We may not ever be able to properly “cure” death, but I hope that one day the only reason anyone dies is because it is their own choice. However futile this battle may be, in Paul’s words: “The secret is to know that the deck is stacked, that you will lose, that your hands or judgement will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote towards which you are ceaselessly striving.”