Medicine & Lit, Working Together

Sir Luke Fildes, “The Doctor”

Friday

My daughter-in-law Betsy Bates alerted me to this article about Paul Kalanithi’s book When Breath Becomes Air, which I now know I must read. Kalanithi was an English major-turned-neurosurgeon who wrote about his dying, and in today’s post I share those excerpts from the book, quoted in the article, about the importance of literature in Kalanithi’s life. Consider today’s blog post to be a teaser as I fully expect to explore further how literature helped Kalinithi make sense of and cope with his dying.

Apparently it was literature that led to Kalinithi’s interest in neuroscience:

The throwaway assumption that the mind was simply the operation of the brain [was] an idea that struck me with force; it startled my naïve understanding of the world. Of course, it must be true — what were our brains doing, otherwise? Though we had free will, we were also biological organisms — the brain was an organ, subject to all the laws of physics, too! Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it. It seemed like magic. That night, in my room, I opened up my red Stanford course catalog, which I had read through dozens of times, and grabbed a highlighter. In addition to all the literature classes I had marked, I began looking in biology and neuroscience as well.

A few years later, I hadn’t thought much more about a career but had nearly completed degrees in English literature and human biology. I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain. Meaning, while a slippery concept, seemed inextricable from human relationships and moral values… Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection. My brief forays into the formal ethics of analytic philosophy felt dry as a bone, missing the messiness and weight of real human life.

Kalanithi would first go on to get an M.A. in English lit:

I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion. A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form. It was the relational aspect of humans — i.e., “human relationality” — that undergirded meaning. Yet somehow, this process existed in brains and bodies, subject to their own physiologic imperatives, prone to breaking and failing. There must be a way, I thought, that the language of life as experienced — of passion, of hunger, of love — bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats.

[…]

For my thesis, I studied the work of Walt Whitman, a poet who, a century before, was possessed by the same questions that haunted me, who wanted to find a way to understand and describe what he termed “the Physiological-Spiritual Man.”

Eventually Kalinithi concluded that he needed to engage in hands-on work with the brain to ground his exploration:

I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them. Words began to feel as weightless as the breath that carried them. Stepping back, I realized that I was merely confirming what I already knew: I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action. I finished my degree and headed back to the States. I was going to Yale for medical school.

 And further on:

I had spent so much time studying literature at Stanford and the history of medicine at Cambridge, in an attempt to better understand the particularities of death, only to come away feeling like they were still unknowable to me… Such things could be known only face-to-face. I was pursuing medicine to bear witness to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.

When Kalanithi began wrestling with his own dying, however, he found that science too was insufficient, and he returned to literature. At one point, when the cancer was in remission, he wrote,

No one asked about my plans, which was a relief, since I had none. While I could now walk without a cane, a paralytic uncertainty loomed: Who would I be, going forward, and for how long? Invalid, scientist, teacher? Bioethicist? Neurosurgeon once again…? Stay-at-home dad? Writer? Who could, or should, I be? As a doctor, I had had some sense of what patients with life-changing illnesses faced — and it was exactly these moments I had wanted to explore with them. Shouldn’t terminal illness, then, be the perfect gift to that young man who had wanted to understand death? What better way to understand it than to live it? But I’d had no idea how hard it would be, how much terrain I would have to explore, map, settle. I’d always imagined the doctor’s work as something like connecting two pieces of railroad track, allowing a smooth journey for the patient. I hadn’t expected the prospect of facing my own mortality to be so disorienting, so dislocating. I thought back to my younger self, who might’ve wanted to “forge in the smithy of my soul the uncreated conscience of my race”; looking into my own soul, I found the tools too brittle, the fire too weak, to forge even my own conscience.

And further:

It was literature that brought me back to life during this time. The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action. I remember the moment when my overwhelming unease yielded, when that seemingly impassable sea of uncertainty parted. I woke up in pain, facing another day — no project beyond breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.”

That morning, I made a decision: I would push myself to return to the OR. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.

And finally:

All life is lived in the shadow of its own finitude, of which we are always aware — an awareness we systematically blunt through the daily distraction of living. But when this finitude is made acutely imminent, one suddenly collides with awareness so acute that it leaves no choice but to fill the shadow with as much light as a human being can generate — the sort of inner illumination we call meaning: the meaning of life.

Amen.