Deconstruction of Binaries and Role Reversal in Kalanithi’s When Breath Becomes Air

Physicians‟ stories of their illness attempt to bridge the divide between a professional doctor and a patient‟s narrative by combining both the versions. This research paper undertakes a narratological analysis of latest illness narrative written by a physician-turned-patient Paul Kalanithi in his When Breath Becomes Air . The present study also finds out the role reversal happening between a clinician, patient and writer. It further aims to analyze Paul Kalanithi‟s autobiographical memoir as a literary narrative of his last stage fatal lung cancer. The paper highlights the link between literature and the medical world and in this way generates a better understanding of the present interdisciplinary relation of both the disciplines i.e. literature and medicine. This research is qualitative and descriptive while textual analysis has been used as a research method. This study ends with the findings and recommendations for further research.


Introduction
A rising number of physicians and surgeons have ventured to pen down their numerous stories of medical experiences, and this act paves the way for a different insight into their personalities and their feelings as doctors, human beings and writers. Similarly, Paul Kalanithi's memoir When Breath Becomes Air falls in this very genre that narrates his own tale of illness and his constant struggle against the fatal disease. Memoir is derived from "mémoire"; a French word that means "reminiscence" or "memory" and it refers to a subjective account of someone's life. It is a literary technique that narrates the experiences with respect to either a specific theme or a particular part of somebody's life. Memoir, in fiction, differs from a regular fictional narrative on the basis that former refers to external reality while later is based on imaginative and creative stories. Despite the link with the reality that exists outside the text, it cannot be stated that every detail narrated in a memoir corresponds exactly to a preceding reality. However, Kalanithi"s personal narrative about his own life also reflects the creative, imaginative and translated perceptions, fantasies and realities. According to Alberti, these memoirs do exhibit certain aspects, occasions, memories to link the relation of their author"s lives with the outside events. She states, "What does the autobiography author do, if not to imprint discontinuities to his life, pinpointing "significant" episodes that fit to the text"s structure, in order to elaborate (in the text, and about himself) a synthesis (something conceived)?" (cited in Guerra et al. (2017).
Paul Sudhir Arul Kalanithi was born on April 1 st 1977, and he died at young age of 36 years on 9 th of March 2015. He was an Indo-American neurosurgeon and besides that he also had a degree in English literature. He published various essays in The New Yorker, The New York Times and some other leading magazines. He delivered various lectures to the students at the University of Stanford. Moreover he had also given detailed interviews about his medical career, experiences and most importantly about his fatal illness. He suffered from stage IV metastatic lung cancer that took his life later on. His book entitled When Breath Becomes Air is a memoir that is based on the narration of all the significant events happened in his life during illness. It also reflects on his struggle against the battling stage IV of metastatic lung cancer. Initially it starts when he experiences certain negative changes regarding his health during his neurosurgical residency at Stanford University. His sudden weight loss, extreme back pain alarms him and his wife Dr Lucy. Kalanithi doubts that this rapid decline in health might be due to cancer that is though a rare case for people of his age. However, his initial X-ray reports turn out to be normal and he and his physician attribute the alarming symptoms to workload and aging. Later on, he remains determined to finish the last year of his residency and he ignores his recurring symptoms. However, his symptoms start growing stronger than ever and, at this point of time, there comes a brief gap in his marital life because his wife Lucy feels that he is not taking her in confidence regarding his health.
During his meeting with his friend Mike, Kalanithi doubtfully announces his cancer on the basis of the symptoms. After he returns to San Francisco, his physician calls him and informs him about his stage-four-lung cancer. On the very next day, he goes to the same hospital where earlier he used to examine his patients, seeing them die or recovered, but now he himself comes as a patient. As he undergoes cancer treatment, he keeps on writing and sharing his reflections on his experiences as a doctor and as a patient. His memoir reveals that his symptoms gets normal after receiving the treatment by Dr. Hayward, and he starts feeling better. After few weeks, his CT scan shows visible reduced number of tumors in his lungs and he decides to return to the operation theater to treat his patients. But he remains unable to finish a surgery due to his severe back pain. However, he gains strength by thinking about his graduation and the baby. Unfortunately, his second CT scan shows a big tumor in his lungs and he decides to get retirement from surgery operations that he strongly wished to do as a doctor. He writes about his painful experience of chemotherapy that deteriorates his health and forces him to ignore his own graduation. Finally, chemotherapy treatment fails and his condition becomes serious again to such an extent that even his doctor, Dr. Hayward, becomes hopeless and he announces Kalanithi"s short life. Later on, one day he dies in the ICU of his hospital due to his fatal lung cancer.
When Breath becomes Air remained on The New York Times non-fiction best seller list for several weeks. It also demonstrates the role of writing as a literary cathartic process and, in this way, it merges both the disciplines; literature and medicine. It describes that how Kalanithi kept on practicing neurosurgeon despite being ill and his profession rescued him from his painful experience. His dual interest in human biology and literature played a crucial role in his strong understanding of life and mortality. The present study also reflects the unique perspective of a physician, as a patient, in understanding his patient"s suffering and illness.

Significance of the Study
After doing a lot of research, it has been found that narratological anlaysis has not been sufficiently explored till date, and even if there are some studies they are still "weak precisely in that their authors fail to use adequate descriptive tool" (Bal, 1990). Many theoreticians and critics conducted analysis regarding structural-narratological perspectives rather than delving into a detailed textual analysis of a narrative text. Soultana Maglavera justifies the lack of narratological studies as she states, "Narratology has gone out of fashion, and may now seem antiquated, as research interests have moved as fast as lightening to gender studies, cultural studies, psychoanalytical or rhetorical approaches, and ideological and historical issues" (1994,6). Therefore, the current study endeavors to make the usefulness of narratology-in-use known to the readers and critics.

Research Objective
This study is based on the following objective: 1. To investigate the connection between medical autobiography and English literature through narratology

Research Questions
On the basis of the research objective, this study investigates the following questions: 1. How does When Breath Becomes Air bridge the gap between literature and medicine through deconstruction of binary oppositions? 2. To what extent the writer is successful in materializing his trauma through his autobiographical memoir?

Literature Review
Binary oppositions have been a characteristic of modern age that is related to the philosophy of Plato and Socrates, and it has been challenged in contemporary postmodern culture. These dichotomies exist as mind/body, doctor/patient, fiction/non-fiction, science/arts etc. and this dualistic thinking created a gap between both the divides. Similarly, doctors/patients binary supposes that physicians do stay healthy in order to treat the sick patients, and also because of their knowledge about disease and its control.
Amy E., Caruso Brown and Rebecca Garden in their research study analyze the deconstruction of binary oppositions in various medical narratives in order to explore the role reversal of doctors into patients. They assert, "Popular narratives like the 1991 movie The Doctor reflect our culture"s struggle with the effects of binary thinking in health care" (2017, 501). They are of the view that the protagonist of the movie transforms from a rude surgeon to a kind hearted doctor due to the diagnosis of his own throat cancer. He becomes sympathetic towards his patients" pain and behaves like a super-heroic physician. They further assert that this transformation molds his way of thinking, actions and even his own identity. Similarly, in Latin literature the narration of pain exists as in L'Ascension du haut mal i.e. a graphic novel, written by David B, pens down two brothers" experience related to one of them who suffers from epilepsy. His sickness has caused a great physical and mental shock for both; the patient as well as his entire family. This novel provides a detailed description of the emotional stages that come with the diagnosis and go to the extremely painful fits. During those fits, his brother"s body uses to get an abnormal posture and finally collapses causing Pierre Francis to feel strange. He gets terrified and avoids getting close to his brother, "Not only do the brothers live through a process of alienation, but also a similar progressive marginalization takes place on a social level: The uncontrollability of the epileptic fits largely excludes them from central domain of social life"(49). Jean Christophe"s disease changes his identity and he faces marginalization, passiveness and powerlessness, "His body is fragmented by medical examinations, a process that is directly visualized by David B" (49). David paints a picture of the society that excludes the patient due to lack of understanding and empathy with him and it causes serious results i.e. suicide etc. Similarly "The Disease-Subject as a Subject of Literature" is another research study that explores the overlapping of narration between literature and medicine. It states that: Becoming acquainted with literature"s capacity to create characters, modify narratives and depict life-stories in crisis, might sharpen physician"s hermeneutic acumen and make them more receptive to the quandaries of disease-subjects facing major medical and existential decisions in the wake of disruptive disease" (Kottow and Michael, 2007). The researchers regard that pain-narratives are significant as the knowledge about the past encounters with disease helps in devising innovative way of treating the disease. Secondly, the patients" tales lead towards a healing process as they say, "Let us understand in order to heal, for healing is a good thing, and literature"s power lies in its ability to call up and articulate feelings and evoke vicarious experience" (Kottow and Michael, 2007). They believe that literary narratives assist the doctors in understanding the role of literature as a scaffold for the patient"s transformed identity and it will also help them to understand the feelings of the patients associated with his/her disease.
Steven Kruger"s AIDS Narratives: Gender and Sexuality, Fiction and Science is another remarkable study in the existing literary scholarship with respect to disease stories. Kruger aims to present counter narrative against the scientific assumption of the essential relationship between homosexuality and AIDS and he "seeks to disengage queerness from death" (1996, viii). He is of the view that "Fictional writing about AIDS depends heavily upon these cultural narratives" (Kottow and Michael, 2007). He also regards that other than stereotypical endorsements "Novels about AIDS, however, also in many ways question, rewrite, and subvert the narrative structures upon which they thus depend" (Kottow and Michael, 2007). He refers to some AIDS fiction; Sarah Schulman's People in Trouble and John Weir"s The Irreversible decline of Eddie Socket, that represents as well as questions the stereotypical biased representation. Similarly, a review essay titled "Facing Death" states, "While denial of death was thought to be an American characteristic, this may be true no longer; or at least the public shows a strong interest in narratives about morality" (Miller, 2016).

Research Methodology
The present study is descriptive and qualitative. The data comprises of Breath Becomes Air; a memoir of Paul Kalanithi"s life and his strong struggle against cancer. This study evaluates the text as a renowned linguist M.A.K. Halliday defines "text" as "a semantic unit containing specific textual components, which makes it "internally cohesive" and functioning "as a whole as the relevant environment for the operation of the theme and information system" (1978,136). The current research applies textual analysis as a research method that focuses on the minutest details as well as it studies the text in different components like words, sentences, phrases and idioms. Alan McKee states, "When we perform textual analysis on a text, we make an educated guess at some of the most likely interpretations that might be made of that text" (2001,3). Norman Fairclough in Analysing Discourse: Textual Analysis for Social Research states, "Text analysis is seen as not only linguistic analysis; it also includes what I have called "interdiscursive analysis", that is, seeing texts in terms of the different discourses, genres and styles they draw upon and articulate together" (2003,3). Textual analysis is a research method that is used to describe, explain and interpret the texts. It extracts in-depth information with respect to a text ranging from its literal understanding to the conceptual through symbolism, subtext, values and assumptions. Depending on the research objectives, it connects the given text with its cultural, artistic, political and social contexts.
This research applies the theory of Narratology and "This is bound up with etymologically more closely related German Expressions Erzahler (narrator) and Erzahlung (narration). Thus narrative is the story that the narrator tells" (Fludernik, 2009). Narratological analysis consists of two dimensions i.e. temporal organization of the incidents that develop an overall coherent impact of the story, and mediacy in the form of selection, interpretation and presentation from a particular perspective. "A Dictionary of Narratology" defines: "The recounting of one or more real or fictitious EVENTS communicated by one, two, or several (more or less overt) NARRATORS to one, two or several (more or less overt) NARRATEES" (Prince, 2003). Similarly Mieke Bal comments on the theory of narratology as he states, "A theory is a systematic set of generalized statements about a particular segment of reality. Narratology is the ensemble of theories of narratives, narrative texts, images, spectacles, events; cultural artifacts that "tell a story" (1990,3).
The current research applies Lotman"s narratological construct of syuzhet that proposes a critique of event/incident and boundary crossing with respect to binary opposition. The theoretical application explores the text, story, fabula, characters, event, time location, ordering of the events, and the focalization. This study does not aim to propose a limited perspective of the novel rather it suggests one dimension only due to the research constraints and brevity. There is a room for other exploratory angles to the selected data as McKee is of the view that "There is no such thing as a single, "correct" interpretation of any text. There are large numbers of possible interpretations, some of which will be more likely than others in particular circumstances" (4). The present research is organized systematically through divisions i.e. introduction, literature review, textual analysis, conclusion, findings and works cited.

Textual Analysis and Discussion
Kalanithi"s autobiography is about the beauty of life and its relation to traumatic tale of death that comes with misfortune, mourning and finally abandonment. The text is analyzed from different perspectives on the basis of narratology that asserts, "The reader wishing to analyze a text distinguishes different layers of a text in order to account for particular effects which the text has on its readers" (Bal, 1990). The text has the all essential narratological aspects like sequentiality, articulation, mediacy etc. that reflect the psychological, moral or personal nature of Kalanithi"s suffering. The current study analyzes the novel through the narration of significant incidents and their representation because "the relationship between happenings and presentations is one of the mutual dependency" (Hühn and Kiefer, 2011).
The narratological analysis finds that events happen to the main character/narrator of the novel i.e. Kalanithi while the change in his behavior reflects the presentation of the incidents. Therefore, the plot or story is a macro structure of presentation that is collected, ordered and arranged in order to provide a meaningful connection between the events. It reflects Kalanithi"s thoughts, perceptions, memories, feelings, desires and ideas, and it also forms his mental identity as well. His voice provides a direct linguistic representation of the events and this act of narration exposes his bitter experience of cancer treatment and, finally, his death. It was quite an unexpected turn in his life as he states: At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea. I could see a nice catamaran on that sea that Lucy, our hypothetical children, and I would take out on weekends. I could see the tension in my back unwinding as my work schedule eased and life became more manageable. I could see myself finally becoming the husband I"d promised to be" (88). During the narration, he seems to involve the reader to feel his struggle in his fight against deadly lung cancer; a real event that happens outside the text in the real world. As a result, his narration and the incidents happen at the same time in the novel that heightens the intensity of the story. On the level of mediating entities, the primary communication is carried out by Kalanithi (2016) as a producer of the text, the narrator/speaker and as a character/protagonist of the text thus deconstructing the binaries of producer/protagonist/narrator and doctor/patient. He speaks in first person voice, and through his fictional speech he expresses factual speech that is related to his biography. In this way, as a subject too, he seems to blur the boundaries between protagonist, speaker and the empirical author; he keeps on changing his role from teller/narrator to doer. He faces a mix of life situations such as unconditional love of his wife, respect as a neurosurgeon and at the unexpected confrontation with the fatal disease. Like his book itself, the story speaks to something powerful than a traditional tale and it reveals the general attitude toward the physical failings of bodies, experience of pain and death. He narrates the unusual body symptoms regarding his disease, he says: My back stiffened terribly during the flight, and by the time I made it to Grand Central to catch a train to my friends" place upstate, my body was rippling with pain. Over the past few months, I"d had back spasms of varying ferocity, from simple ignorable pain, to pain that made me forsake speech to grind my teeth, to pain so severe I curled up on the floor, screaming. This pain was toward the more severe end of the spectrum. I lay down on a hard bench in the waiting area, feeling my back muscles contort, breathing to control the pain -the ibuprofen wasn"t touching thisand naming each muscle as it spasmed to stave off tears: erector spinae, rhomboid, latissimus, piriformis…(110). The narration highlights that he is responsible for the stylistic, formal, tropical and rhetorical structure while his wife Lucy Kalanithi"s acts as an abstract or composing author who winds up the story by writing an epilogue after his death. Her perspective is based on second-order observation and it established as well as reliable to speak on the behalf of the primary author. The narratological analysis reveals that the speaker/protagonist i.e. Kalanithi is selfreflexive throughout the text as he himself is the main theme of the novel. The story narrated can be understood as an embodiment of the external and physical conflict of Kalanithi"s suffering due to cancer, loss of body control, and the unexpected role reversal; doctor/patient to patient/doctor. He remains resilient during his struggle against lung cancer that reflects his problem solving nature as well. He has to deal with internal conflict as well because his struggle does not bring to him his wish-world. He remains unable to fight his approaching death in spite of having the best medical treatment. He admits that, during his medical career, he has seen so many patients dying, and he has observed that an easy death is not the ideal phenomenon. Therefore, he embraces his life without getting concerned seriously; rather he tries to live at his fullest. His disease and death serve more than just plot device as other than allowing the readers to feel the grief, Kalanithi"s death tale serves a moral purpose. It teaches many lessons, for instance, how valuable it is to live happily and fearlessly. It portrays turning points, moral transformation, identity formation, and play of family values and support system especially Lucy Kalanithi; being the loving wife of Kalanithi. She shows her profound grief for her dying husband and she provides solace to him. Together, they both decide to have a child of their own as death no more scares them because they readily accept it. This very act of bringing a child declares her of immense faith on Kalanithi that reflects the unconventional understanding of disease that stops the patient to take interest in such full of life activities. It also demonstrates his wish to keep on his legacy even after his death through their child and in this way he plans a future on the basis of his imagination. The narratological analysis of the novel reveals that Kalanithi"s disease liberates him from fears and he starts taking pleasure from every aspect of life in his limited time span on earth. It highlights that he is not rejected by his wife rather their love gets stronger in this testing time. The text reveals that even when he is diagnosed with metastases "His wife Lucy lies by his side on the hospital bed as the reality of terminal cancer dawns on both" (Mbizvo and Danielle, 2017). They, as a married couple, don"t think any more on sexual fulfillment but they behave fully focused towards worldly matters like treatment, x-rays, and screening etc. Though, the diagnosis came as a shock to them because they were enjoying the marital partnership and wanted to produce and raise the kids. "They had plans in the pipeline and dreams in their hearts, including that of starting their family. But with the diagnosis of Paul's illness, all their dreams and plans simply evaporated, just like breath that becomes air" (Bhatia, 2017).
He establishes a strong sense of selfhood towards the end but he also grapples with questions of identity at different points in the illness phase. The plot begins with an overview of Kalanithi"s childhood and later on his adulthood, and, in this part, the narrator emphasizes the important role of literature on his personality. He believes that "Literature provided a rich account of human meaning" (Kalanithi, 2016). As a young man, Kalanithi attempts to bridge his love of reading, inherited by his mother, with a strong fascination with neuroscience. It happens due to the novel that comprised of 500 pages and it attracted him for its literary quality, and inculcated in him a love for literature and medicine. His autobiography reflects his personal shift from a doctor to a writer who pens down his health challenges with respect to his terminal cancer. Though his strength to cope with the illness comes from his practice and his treatment of others who are ill, when he decides to write and articulate his life the importance of literature comes back in his life. His literary and professional identities get mixed up when he receives treatment as well as directions from another surgeon. For Kalanithi, this passive status from subject to object becomes hard to accept and he takes shelter in the act of writing. The text represents his confusion when he says, "Like my own patients, I had to face my mortality and try to understand what made my life worth living… Torn between being a doctor and a patient, delving into medical science and turning back to literature for answers, I struggled…" (139). His interaction with literature demonstrates that "identity can be shaped and stabilized during terminal illness" (De Muijnck, 2019). He, at times, feels the pain of having a tragic illness as he says, "Only 0.0012 percent of thirty-sixyear-olds get lung cancer" (133). He is unable to believe that he has developed an identity of a patient during the treatment of cancer as he thinks, "Eighteen months earlier, I"d been in the hospital with appendicitis. Then I"d been treated not as a patient but as a colleague, almost like a consultant on my own case. I expected the same here" (122). There were times when he thought that he is going to survive as he says, "My lungs, speckled with innumerable tumors before, were clear except for a one-centimeter nodule in the right upper lobe. There had been a clear, dramatic reduction in tumor burden" (146).
As a doctor, before his own diagnosis, he never fully understood the trauma of his patients or their families as he narrates an incident of a road accident that almost crushed a young boy"s brain. He was brought to the hospital, and Kalanithi, who was having his lunch at that time, was supposed to treat him. Therefore, he rushed to the boy and "A whirlwind of activity surrounded him: catheters were slipped into his femoral arteries, tubes shoved deep into his chest" (83). Unfortunately, he could not save the patient and he died. At that moment, Kalanithi was more concerned about his undone lunch as he says, "I slipped out of the trauma bay just as the family was brought in to view the body. Then I remembered: my Diet Coke, my sandwitch" (91). Later on, he develops a passion driven relationship with his patients as he narrates, "But now I started coming in earlier, staying later, fully caring for the patients again, adding another four hours to a twelve-hour day" (158). He was back with his patients and their treatment became his primary goal despite the extreme pain of his body and this transformation from doctor, patient and a father is stated as: What started as an individual search for meaning becomes the story of a community wherein members impact each other and the meaning of their lives. The last words of this book convey the author"s simple joy of holding his daughter in his arms. Vulnerability is the central feeling and value communicated at the end of the book, leaving the reader with an authentic experiencealbeit difficult, but also illuminating" (Smith, 2016). He gets an understanding of his profession where not only a patient is dependent on a doctor; rather the entire family suffers. He uses his all energies to uplift the patients" bad feelings as he regards that, "A physician"s words can ease the mind, just as the neurosurgeon"s scalpel can ease a disease of the brain" (166). A part of his transformation comes as a result of his firm belief in his religion as he admits, "Yet I returned to the central values of Christianity-sacrifice, redemption, forgiveness" (171) It seems that "Throughout his memoir, Kalanithi wrestles not only with the concept of time, death and meaning, but also with expectations, goals, and living. Markedly, Kalanithi ponders what makes life meaningful in the face of death and decay" (Martin, 2017).
The narratology consists of the relationship between the text and extra-linguistic situation that forms the context. Therefore, the current study explores Kalanithi"s behavior and actions from textual as well as a contextual point of view. The text reflects that he goes through intense emotional, mental and physical pain in different moments of his interaction with the hospital, such as, when his cancer gets worst; he calls the hospital and informs them about his condition. He says, "I called Victoria and told her I wouldn"t be in on Monday, or possibly ever again, and wouldn"t be setting the OR schedule" (179). As a neurosurgeon and as a literature student, Kalanithi mixes up his identities, for instance when he says, "I"hv been reading science and literature trying to find the right perspective, but I haven"t found it" (190). The novel further refers to various literary authors and poets like T.S.Eliot, Emily Dickinson and Samuel Beckett. These references reflect Kalanithi"s love for reading literature, such as, at one point he says, "It was a five-hundred-page novel called Satan:His Psychotherapy and Cure by the Unfortunate Dr.Kassler, by Jeremy Leven. I took it home and read it in a day" (30). His memior is full with medical terminology that adds into the readers" information regarding the treatment as well, such as, "The traditional chemotherapy combination, cisplatin, pemetrexed, possibly with Avastin too-has a high rate of peripheral neuropathy" (123).
Kalanithi refers to art of writing as a way to create and preserve the memories as he is hopeful that through his novel, he will be read and remembered by the readers. Kalanithi"s quest to explore an intersection of literature, art, philosophy, morality, and biology, philosophy, and morality is due to his mother"s passion. He writes, "She made me read 1984 when I was ten years old, and it also instilled in me a deep love of, and care for, language" (26). His love for literature and language was strengthened by his brother too as "We worked our way methodically down the list:

Conclusion
The study has found that Kalanithi"s autobiographical memoir When Breath Becomes Air deconstructs the binaries oppositions of medicine/literature, doctor/patient and writer/narrator. It is about illness that is narrated with the help of citations from English literature as any text is a new tissue of past work. It is Kalanithi"s masterwork that reflects duality of life and death as a coexisting phenomenon while referring to aliveness to be the maximum triumph of human potentiality. Textual analysis shows that this memoir is in a process of re-writing which foregrounds the bits of the texts that it both places and dis-places. It is unique that represents a distinct essential combination of medicine, mental illness, literature, poetry and music etc. Kalanithi narrates his tale of suffering with the help of different quotations, metaphoric presence, and a strong characterization. This study finds out that the story demonstrates his love of medicine as a neurosurgeon with a strong liking towards literature as a human being with active aesthetics, and writing as a medium to express joy and pain as a patient.