Nothing Becomes Something

Thomas Laqueur

  • When Breath Becomes Air by Paul Kalanithi
    Bodley Head, 228 pp, £12.99, February 2016, ISBN 978 1 84792 367 7

We live in the golden age of pathography. Before the middle of the 20th century there was very little writing devoted to the experience of living with illness. There were many reports of bodily ills in the letters and diaries of 18th-century men and women but no sustained narratives of disease. Autobiographies in the shadow of death were rare and brief. In David Hume’s six-page-long account of his life there are four sentences about his impending end: ‘I was struck with a disorder in my bowels which at first gave me no alarm, but has since, as I apprehend it, become mortal and incurable. I now reckon upon a speedy dissolution.’ Despite his physical decline, he continues,‘I possess the same ardour as ever in study, and the same gaiety in company. I consider, besides, that a man of 65, by dying, cuts off only a few years of infirmities.’ If he could choose to live a period of his life over again he might choose this one, the last. For Hume, nothing more needed to be said about waiting for death, a subject that we moderns have turned into a veritable genre.

The 19th century brought a few memoirs of invalidism, like Harriet Martineau’s Life in the Sickroom, which reports on her five-year-long retreat from an active life. And there were occasional diaries of illness: Alphonse Daudet’s In the Land of Pain, written between 1887 and 1895, two years before he died in agony from tertiary syphilis, foreshadows the rise of disease as a kind of character, an antagonist to be faced and reckoned with (‘the first moves of an illness that’s sounding me out, choosing its ground’). At about the same time, Tolstoy was creating in fiction pathography’s foundational narrative form. Memoirs of illness and dying almost always begin, as The Death of Ivan Ilyich does, at the moment when nothing – the little ache, the ordinary vagaries of living in a body – turns out to be something. Ivan bumped his side as he fell while adjusting a curtain; it hurt a bit but he continued in good health that day and the next; then one day he wasn’t. He understood now that the trite syllogism in his school logic textbook did not apply exclusively to Caius or to humans in general but to him in particular. ‘All men are mortal; Caius is a man; therefore Caius is mortal.’ Ivan tried to get back to his old self – the one that existed before universal truth became personal – but could not. Tolstoy defines the moment – the crossing of a border into the land or the dimension of mortality – that is at the heart of all subsequent writing about disease. It is an odd moment. All of us can easily look up how long the actuaries with their well-wrought life tables expect us to live. But once the disease that is the agent of our demise declares itself, it transforms everything in our world. Tolstoy also describes the great gap Ivan feels between his physicians – for whom death and disease are the substance of their profession – and himself, the dying man for whom it is everything. All the stuff of modern disease narratives is here already in the 1880s: disputes of diagnosis and treatment among the doctors; well-meaning condescension. ‘What sort of night have you had?’ his doctor asks. Ivan looks at him, ‘as much as to say: “Are you really never ashamed of lying?”’

For almost a hundred years Ivan Ilyich had few literary followers. Forty years on, in 1926, Virginia Woolf noted how astonishing it was that ‘illness has not taken its place with love and battle and jealousy among the prime themes of literature’. What could be more weighty? In illness ‘we go down in the pit of death and feel the waters of annihilation close above our heads’; ‘when the lights of health go down’, ‘undiscovered countries’ come into view. And yet, for the next fifty years there were few reports on these seemingly uncharted lands. John Gunther’s bestselling 1949 memoir, Death Be Not Proud, about the death from cancer of his brilliant 17-year-old son, is a notable exception. Then, by the end of the 20th century, book-length accounts of illness were suddenly everywhere: more than thirty accounts of Aids and more than a hundred of cancer alone were published in the United States between 1988 and 1992. Their numbers keep growing and their scope expanding. Now there is even beginning to be a serious literature on the illness and death of pets, especially dogs, through which the emotional and ethical issues around the end of life, theirs and ours, can be newly imagined.[*] The proliferation is so noticeable that writers despair of rising above cliché. In Jenny Diski’s first dispatches to the LRB from the ‘Cancer World’ that she had just entered she despairs of being able to say anything new: ‘I was handed my script, though all the lines were known already and the moves were paced out. There were no novel responses possible. Absolutely none that I could think of.’ But, as she reminds herself, she is a writer and writing is what writers do. ‘Now, cancer is what I do, too.’ And so: ‘A fucking cancer diary? Another fucking cancer diary.’[†]

I don’t mean to claim that the forty-year-old form that is now so familiar came from nowhere or from Tolstoy’s imagination. It is to some extent an expansion of those accounts of last moments and last words to which people in most literate cultures have been attracted for millennia. I think sometimes of the great French historian Marc Bloch on the brink of death: the teenage boy to whom he was handcuffed as the two were about to be executed by the SS in the summer of 1944 was terrified. ‘This will hurt,’ the boy cried. ‘No, my boy, it won’t hurt,’ Bloch is reported to have assured him. He was, in general, wrong. People have known for thousands of years that a meaningful, thoughtful, painless and even conscious death is largely the luck of the physiological draw at its most capricious. Yet we pay attention to how others have died in the hope of something better or for assurance that, since others have managed, so will we. Last words and behaviour seem irresistibly exemplary and consequential, a testimony to the truth or falseness of what we believe or live by. Dying – and last moments in particular – bears witness to what really matters. At stake in what we might think of as the ancestor of the pathography – the deathbed account – are the answers to big questions: can one die at peace without God, for example. The matter has been debated since the Enlightenment, reached a peak of public attention in battles between believers and free-thinkers in the 19th century, and remains alive in some circles today. There are many, many more obstacles to dying peacefully than an absence of faith, but, as Christopher Hitchens noted with some pleasure, there was a website that invited ‘potential punters’ to place bets on whether he would repudiate his atheism before he died or ‘take its hellish consequences’. He died an atheist.

The recent accounts of mortal illness attract readers for some of the same reasons as the old deathbed accounts. Nevertheless, pathography as a genre is new and offers something different. In the first place, it is not so much about dying, or death, as about life in extremis. It is a genre born of changes in how and when we actually die. Our ancestors succumbed mostly to infectious diseases: hence the relatively brief scenes in novels and diaries of acute anxiety, the wait for the crisis – the moment in which the sufferer moves in the direction of either recovery or death. Today most of us in the West die later and of chronic diseases or diseases of old age. We are three times as likely to die of cancer now as we were a hundred years ago. And because of advances in medicine and technology we now live longer and better with fatal illnesses. The temporal space for today’s cancer pathography, the dominant subgenre, and its narrative tension – the possibility of cure or remission as well as of the amelioration of symptoms – are the products of scientific advances made in the last forty or fifty years. And the same goes for other diseases. Before the invention and spread of positive pressure ventilation in the early 1980s those who suffered from motor neurone disease, known in the US as ALS, died much sooner after its onset than they do now. In short, pathography came into existence to explore a new stage of life: the greatly extended time between the moment when nothing has become something and the dénouement of that something at the end.

So the stage of life during which we live with serious illnesses has expanded. But it has also undergone a conceptual transformation that allows us to think of ourselves as sojourners in the land of illness, hoping to return to the land of the well, fearing and preparing for death. The first question – the universal cliché – that everyone diagnosed with cancer or any other serious illness asks is: ‘How long do I have?’ In the old days no one would have expected a precise answer and to a large extent that precision is still illusory. Then, someone was simply ‘mortally ill’. Today we want more. But prognostication is notoriously difficult – indeed impossible – in any individual case. (See on this Stephen Jay Gould’s unpacking of the eight months’ ‘median survival’ that he had been promised for his abdominal mesothelioma in his 1985 essay ‘The Median Isn’t the Message’.) For all sorts of reason – genuine agnosticism, the acknowledged importance of hope in the face of hopelessness, and other technical and ethical issues (truth-telling is a major issue in medical ethics and prognostication is a much studied muddle unto itself) – doctors are reluctant to make predictions based either on statistics or clinical experience. Patients and their families find it hard to hear and assimilate what they are told. Weighing comparative treatment options in the face of such uncertainty adds a layer of terror.

But none of this uncertainty has slowed the elaboration of mortal illness as a new temporally defined category of life, with cost-benefit analysis as one of its chief features: how much pain, how much treatment for how much more life of some assumed quality. Public authorities, clinicians and researchers of all sorts have played a large part in the conceptual shift I’m describing, giving us the language for narrating the phases of this period of our lives. In the United States for the past several decades there has been a bureaucratically mandated definition of terminal illness: Medicare eligibility for hospice care requires that the beneficiary will die within six months. Answers to ‘How long do I have?’ and ‘Which treatment would give me the best chance and at what costs?’ depend, however precariously, on statistical techniques developed between the late 1950s and early 1970s. They make it possible to calculate survival probabilities – the number surviving divided by the number at risk – for a given population over a given time interval under specified risk conditions or different treatment regimes. (Before Cox’s proportional Hazards Regression model came along in 1972 the tools used were Kaplan-Meier estimators, developed in 1958 after Edward Kaplan, working at Bell Labs on the problem of vacuum tube survival in transatlantic telephone cable repeaters, was put in touch with Paul Meier, who was working on cancer survival using a similar method.) The use of these techniques in medicine and in the world of cancer is ubiquitous, and they have done a great deal to create the new temporal world of pathography.

These statistical techniques are fed by vast new streams of ever more refined data. The systematic collection of statistics on cancer specifically began haphazardly in the early 20th century and accelerated dramatically worldwide in the postwar period. It came into its own at about the same time as modern pathography. The United States created the National Cancer Registry in 1971; the NHS Reform Act of 1966 was the critical moment in the UK. At the same time researchers developed standardised classificatory categories: stages of the disease that comported with chances of survival. In the 1960s Donald Gleason, a pathologist working for the US Veterans Administration developed the eponymous Gleason five-stage scale for assessing prostate cancer; it’s now one of hundreds of similar systems based on pathological and genetic analysis. A gigantic web of knowledge of all sorts is part of what has enabled the rise of pathography. Its language has become familiar. No one much used the dread word ‘metastasis’ a hundred years ago; now it is commonplace.

But the genre’s popularity is also of a piece with our increasing appetite for memoirs and reminiscences more generally. And personal experience in the foreign country of potentially fatal illness is stranger and more interesting than ever. The languages, laws, customs, clothing and hierarchies of the modern hospital, and modern medicine generally, makes ethnographers of us all. Even the doctor, fluent in the language and customs of the place, finds herself a stranger in the land of backless gowns, plastic bracelets and helplessness when she becomes a patient. The world of illness in the late 20th and 21st century is exotic, and it is also fraught with life and death decisions as never before in history. All this gives the pathography an inherently dramatic quality, but it also presents the form with something of a problem. We read autobiography for reflections on life, not just descriptions of it, and we might expect a pathography written in proximity to death to have even more depth and perspective than most autobiographies. And yet the ethnographic – purely descriptive – demands of the genre often predominate. This quandary seems especially apparent when pathographies describe the cancer province of this world. When one is encouraged to think of oneself as a warrior battling against an internal enemy, is there much energy left for existential reflection?

*

Paul Kalanithi’s When Breath Becomes Air was published in the US in January to critical and popular acclaim. There had already been ‘an overwhelming response, an outpouring from readers’, to an article Kalanithi published in the New York Times 14 months before he died, on 9 March 2015, and eight months after being diagnosed with lung cancer at the age of 36. That essay, ‘How Long Have I Got Left?’, Abraham Verghese writes in his foreword to this book, ‘was simply stunning. The prose was unforgettable.’ The book itself had much the same effect. ‘There was an honesty, a truth of writing, that took my breath away. Be ready. Be seated,’ Verghese warns. Janet Maslin wrote in the New York Times that ‘to read this book is to feel that Dr Kalanithi still lives, with enormous power to influence the lives of others though he is gone’. ‘Unmissable.’ The New Yorker called it ‘a manifesto for the genre’. Pathography seems to have reached its exemplary form and its public apotheosis.

One can see why the book has such appeal. The protagonist is a brilliant young neurosurgeon who was diagnosed with a rare form of lung cancer just as his career was beginning. He has, from childhood, done everything right. He has sacrificed living life fully for the sake of his professional future. ‘Medical training is … all about delayed gratification,’ he writes; finally he ‘reached the mountaintop’ and could ‘see the promised land, from Gilead to Jericho’. But instead of entering a promised land of still loftier prospects, ‘the future, instead of the ladder towards the goals of life, flattens out into a perpetual present.’ It is one thing, readers might appreciate, for God to keep Moses out of the Promised Land because – views vary – of his own sins or the sins of the Children of Israel. There is no such ambiguity in Kalanithi’s case: unruly, self-willed, capricious cells over which he had no control threatened his future before it could begin, before, that is, his life as he imagined it could fully begin.

Symptoms appeared near the end of his arduous training; he began to lose weight and to suffer severe back pain. It’s nothing, he thought: overwork. He didn’t have the time to have the problem checked out and dismissed the symptoms as the result of the inhumanely stressful life of an ambitious young neurosurgeon. In fact, he seems to have had very little time in his life for anything but work. His marriage to a fellow resident, Lucy, was in trouble. They had been in love since their first year in medical school but she felt they were connecting only halfway; she wasn’t sure that his isolation could be attributed to the pressures of residency. She needed some time off from their marriage. He went alone to visit friends on a trip that they had planned to take together, became acutely ill while on the East Coast, and returned to Palo Alto to the diagnosis that is the beginning of this book. Lucy and Paul were immediately reunited in adversity. ‘Cancer had helped save our marriage,’ he writes.

One wonders what would have happened had his backache and weight loss really been only the temporary consequences of overwork. But they weren’t. Lucy as wife and doctor ministered to his increasingly frail body and made it possible for him to write. They decided to have a child together (through IVF – they stored sperm before he began chemotherapy), even though he realised that this might make leaving life more difficult. The last paragraph of the book – Verghese suggests we read it aloud – is Kalanithi’s dying message to their daughter. ‘When you come to one of the many moments in life when you must give an account of yourself,’ he imagines telling her, ‘do not, I pray, discount 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 an epilogue, Lucy writes Paul’s deathbed story, worthy of a Victorian novel in its clinical detail and its poignant sentimentality. I can imagine having the Oscar Wilde response – ‘one must have a heart of stone’ to read it and not laugh – but I went for it.

The room, saturated with love, mirrored the many holidays and weekends we had all spent together over the years. I stroked Paul’s hair, whispering: ‘You’re a brave Paladin’ – my nickname for him – and singing quietly into his ear a favourite jingle we’d made up over the previous months, its core message being ‘thank you for loving me.’

He died in her arms. A love story brought full circle.

Between the discovery that what had seemed to be nothing was something and the dénouement there are two Bildungsromanen, first that of an earnest and gifted young man who becomes a surgeon and then that of the same protagonist under the sign of mortal illness who reflects on the meaning of his life as framed by his ethnographic experiences of the clinic. We learn in the first that Kalanithi had never wanted to be a doctor. His father was a cardiologist and seldom at home; a career in medicine seemed to imply absence. He was instead engaged from an early age with the question of ‘what makes human life meaningful’. At a summer camp he read a book called Death and Philosophy while others were having a good time. In college he studied philosophy and literature and went on to get an MA in English with a thesis entitled ‘Whitman and the Medicalisation of Personality’. But in his senior year of college he enrolled in a neuroscience class that took a field trip to a facility for severely brain-damaged people. He had the epiphany that brains are what allow us to form relationships and that only as a physician could he understand what Whitman had called ‘the physiological-spiritual man’. He went to medical school, where ‘the enormity of the moral mission of medicine’ lent his studies a ‘severe gravity’.

After graduation Kalanithi decided on neurosurgery, both because it seemed to address deep questions and because its sheer difficulty gave it moral exigency. ‘Any neurological problem,’ he writes, ‘forces a patient and family, ideally with a doctor as a guide, to answer this question: “What makes life meaningful enough to go on living?”’ Brain surgery ‘presents the most challenging and direct confrontation with meaning, identity and death’. He was drawn to its ‘unforgiving call to perfection’. He returns often to the moral and technical demands of his calling, to reminders of the devastation that the smallest mistake can wreck on a life: two millimetres, he tells us repeatedly, is beyond the margin of error. These burdens are what make medicine ‘holy and wholly impossible’. The meaning of life would be revealed in this, the most demanding of all professions. ‘In taking up another’s cross, one must sometimes get crushed by the weight,’ he tells himself – a shift from Moses to Jesus. He spent some time working in a motor neuroscience lab. His mentor there was not like other scientists he had known but was ‘soft-spoken and cared deeply about people’. He confessed that he wished he himself had been a surgeon. The encounter with ‘Dr V.’ inspired Kalanithi to begin imagining a life of research combined with clinical practice. ‘Morality, life and death were finally beginning to weave themselves into … a coherent worldview.’ He had assumed the onerous yoke of medicine, ‘that of mortal responsibility’; he came to realise, as he contemplated the death of a friend who committed suicide after making a fatal error, that ‘you can’t ever reach perfection, but you can believe in an asymptote towards which you are ceaselessly striving.’

With these words the first Bildungsroman ends and the pathography proper begins: a narrative of self-revelation told in the shadow of a potentially fatal disease. Kalanithi had ‘always imagined the doctor’s work as … connecting two pieces of railroad track, allowing for a smooth journey for the patient’, but it wasn’t so easy when it came down to it. He hadn’t expected his own mortality to be ‘so disorienting, so dislocating’ (I find this odd, but so he says). He is slowly compelled to revise his views on statistics and their relationship to hope, the survival curves with which he was initially so passionately engaged after his diagnosis: ‘It occurred to me that my relationship with statistics changed as soon as I became one.’ His oncologist, Emma, the medical hero of the book, slowly weans him from the notion that numbers could tell him how to live his life: ‘If I had two years, I’d write. If I had ten, I’d get back to surgery and science.’ ‘You know I can’t give you a number,’ Emma replies. He goes back to surgery despite not having a definitive answer because she convinces him to embrace what he loves in the life he has.

Kalanithi tells us that before he became ill he had mapped out a forty-year career for himself. (This used to be called hubris.) He would spend twenty years in neurosurgery and twenty as a writer. Now here he was in what seemed, at best, his last twenty and he was uncertain what to do. The future was receding; a life that ‘had been building potential’ was on the brink of extinction; the arch of promised success collapsed. A faculty position at Stanford for which he had been, he says, ‘heir apparent’, went to someone else while he was in treatment. He was crushed. Colleagues a few years ahead of him were getting promotions and early career awards. He was no longer on his planned trajectory. He couldn’t take up a good offer at a somewhat lesser medical school because he couldn’t be so far from his oncologist. Slowly he came to see himself in a new way: ‘while I knew that our identities derive not just from the brain, I was living its embodied nature.’ He came to realise what might have seemed obvious to a less cerebral young man: the body matters. One thinks of the beginning of Simone de Beauvoir’s materialist account of Sartre’s illness and death: ‘Death had closed its hand around me; it was no longer a metaphysical scandal, it was a quality of our arteries.’ Kalanithi was too sick to finish the last month of his neurosurgery residency – the ‘visceral pleasure’ of operating had gone – but was allowed to graduate as a fully qualified neurosurgeon. Brain metastasis made it difficult for him to finish his book – the early parts about his childhood, which he wrote last. And finally he began the last stage of his life: dying.

As a one-time custodian of medicine land himself, husband of another custodian, and with many friends there, Kalanithi wasn’t spared the humiliations of his loss of privileged citizenship once he became a patient. He confronted the WICOS problem – Who Is Captain of This Ship? – as various specialists disagreed with one another about his care. He tried in moments of lucidity to be in charge – to straighten them out – but to little avail. He had a late-night quarrel with a junior resident who wanted to take him off a medicine because of what, he argued in response, were irrelevant liver function tests; the younger man rejoined, rightly, that since the half-life of the drug in the body was 36 hours there would be time to sort this out in the morning, when the consultant was on duty. Kalanithi lost: he was no longer a senior resident but a patient; he was outraged. All this – a mix of arrogance and vulnerability – shows how very difficult it is to be seriously ill even for those who understand all about illness and its rules.

It’s easy to understand why Kalanithi’s story has attracted so large and passionate a following: the pathos of a young person mowed down, a bright future in ruins. It is in some ways a very old and terrifying story. Social advantage – we would call it privilege – as well as brilliance, hard work, fine values and all the wonders of modern medicine don’t keep Death from grabbing Paul Kalanithi. Like a medieval Everyman going about his business he got the skeletal tap on the shoulder before a lifetime of deferred gratification could pay off. His life ended, as he writes, ‘just as our careers were peaking’. Many readers have been moved by this tragic theme. That’s the way Kalanithi sees it: he found himself caught up in an ancient world ‘where human action paled against superhuman forces’.

*

It’s time to confess the obvious: I wasn’t deeply moved by this book. But it isn’t so easy to explain why. The first thing that comes to mind is that I find the author pompous, and, whether a true or a faux naif, egomaniacally self-conscious in his search for meaning. But that can’t be all of it: Anatole Boyard and Christopher Hitchens are scarcely self-effacing or modest yet I was attracted to their memoirs of illness. A larger problem is that Kalanathi isn’t very good at writing. Having done so little of it, why should he be? As Julian Barnes wrote in his introduction to Daudet’s memoir, dying doesn’t make someone a better writer, or a worse one for that matter. Bad prose, muddled thinking and literary camouflage obscured for me the wisdom that others seem to have found in this book. Many sentences reach for a profundity beyond their grasp: ‘A tureen of tragedy was best allotted by the spoonful,’ Kalanithi pronounces as a way of saying that patients need to be told the prognosis of their illnesses with discretion and a feeling for what they can absorb. When as a young resident he is faced with patients’ deaths he feels ‘trapped in an endless jungle summer, wet with sweat, the rain of tears of the families of the dying pouring down’. In an air-conditioned hospital in Palo Alto.

There are sentences that are pointlessly tendentious: he introduces Emma the oncologist by observing that she is just a few years older than he is and yet has ‘hair long and dark, but as is common to all those who spend time with death, streaked with grey’. What evidence is there that those who spend time with death have more grey hair than plumbers or pilots? And there are other sentences that are simultaneously banal and obscure: ‘The fact of death is unsettling. Yet there is no other way to live.’

I understand that muddled thinking in philosophy, or in memoirs, doesn’t have the same consequences as an error in neurosurgery. But this is a man who makes much of the claim that ‘technical excellence’ is a ‘moral responsibility,’ that ‘moral duty has weight,’ that ‘things that have weight have gravity.’ When explaining why he and Lucy decided to have a child, he tells the reader that ‘years ago it had occurred to me that Darwin and Nietzsche agreed … [that the] defining characteristic of the organism is striving.’ From this he deduces that describing life otherwise than through striving is ‘like painting a tiger without stripes’. He then draws the conclusion that the easiest death isn’t necessarily the best one and comes to the decision to have a child. As self-reflection on one of the most momentous personal decisions of his life, this is implausibly abstract, and it doesn’t even have the virtue of understanding the great thinkers it invokes. It misses the point that Darwin and Nietzsche agree only that the tiger having stripes is not its telos but a purely contingent result of an uncaring cosmos. (Nietzsche never actually read Darwin but hated him because Herbert Spencer, whom he imagined spoke for him, insisted that life had a progressive trajectory.) There is no ‘defining characteristic of life’ for Darwin or Nietzsche that tells anyone how to live or die, or whether to have a child in the face of death. The real problem is that he elides rather than probes what is important – humanly – about the moment he describes. Getting the intellectual history wrong isn’t a big deal, but placing a thin philosophical veneer over a crucial episode totally flattens the experience.

It’s even more noticeable when Kalanithi turns to religion. He had been a churchgoer as a child; he says that he might in another life have become a pastor; he speaks of his transformation from clinician to patient as going from shepherd to sheep. Now, in his illness, he starts attending the Episcopal Church again. Something is going on here. What does church attendance or God do for him; why and how does God become important to a man of science facing death? Instead of answers or insights, readers get a series of non sequiturs: ‘to make science the arbiter of metaphysics is to banish not only God … but also love, hate, meaning.’ He protests that he doesn’t want to say that if you believe in meaning you have to believe in God, but, rather, that ‘if you believe that science provides no basis for God, then you are almost obliged to conclude that science provides no basis for meaning and therefore, life doesn’t have any. In other words, existential claims have no weight, all knowledge is scientific knowledge.’ It’s hard to know what this means in any rigorous sense. It doesn’t follow from the belief that science can’t provide a ‘basis for God’ that one must also think ‘all knowledge is scientific knowledge.’ He is probably trying to say that there is a meaning to life and that science alone doesn’t provide it. My irritation comes from the way this jumble of sentences hides the autobiography’s subject. Why does he, Kalanithi, really turn to the church?

At moments like this I wanted to demand that he be more like his hero Thomas Browne. (Kalanithi is buried with a copy of Religio Medici.) The great attraction of Browne’s text is that it – like Montaigne’s Essays – reveals worlds within the writer himself. ‘There are many pieces in this one Fabricke of Man,’ Browne said to justify his intense engagement with his inner self. And he comes clean on God and religion: ‘It is true because it is impossible.’ Kalanithi is clueless like Everyman, a callow young man. It might be said that I am merely blaming him for the youthfulness that others find so moving. Does my response rest on the complaint that death, like youth, is wasted on the young?

There is, I now feel, a pathos in how little he seems to learn about life in the course of his illness. In 1973 Oliver Sacks sent his friend Thom Gunn a copy of Awakenings. Gunn wrote back to say he remembered that in the 1960s Sacks had wanted to write a book that was both well written and scientifically sound. ‘You have certainly done it here.’ And then he expresses his pleasant surprise that the book was as good as it is:

I have also been thinking of the Great Diary you used to show me … I found you so talented, but so deficient in one quality – just the most important quality – call it humanity or sympathy or something like that. And frankly I despaired of your ever becoming a good writer … Your deficiency of sympathy made for a limitation of your observation.

But maybe, Gunn speculates, ‘the growth of sympathies is something frequently delayed till one’s thirties.’ The pathos of Paul Kalanithi is that he didn’t have time to develop sympathy for himself, to understand that meaning wasn’t to be found in snippets of literature, or in technical excellence, or in science. One would have wished for him an end more like that of David Hume or Oliver Sacks, who became able to see life from ‘a great altitude … with a deepening sense of the connections of all parts’.

[*] See Jessica Pierce’s The Last Walk: Reflections on Our Pets at the End of Their Lives (2012).

[†] These pieces were published in book form as In Gratitude (Bloomsbury, 256 pp., £16.99, April, 978 1 4088 7990 0).