News release

From: University of Sharjah

By Leon Barkho, University of Sharjah

A new study examining death-related conceptual metaphors employed by neurosurgeon Paul Kalanithi in his acclaimed memoir, When Breath Becomes Air, sheds light on how he depicted death after being diagnosed with stage IV lung cancer at the age of 36.

The memoir, published posthumously following Kalanithi’s death in 2015, received notable coverage and significant literary recognition. It was selected as a finalist for the 2017 Pulitzer Prize in Biography.

Led by researchers from the University of Sharjah, the study investigates how Kalanithi constructs the meaning of death through the use of metaphors. Drawing directly on textual evidence from the memoir, the authors identify and examine death-related metaphors in Kalanithi’s primary narrative and classify them into broad discursive frameworks.

The paper, published in the journal Language and Health, further explores the distribution and contextual functions of these metaphors within the distinctive genre of a medical literary autobiography, highlighting the unique blending of Kalanithi’s dual identities as a neurosurgeon-turned-terminally ill patient.

Using the Metaphor Identification Procedure Vrije Universiteit (MIPVU), a widely recognized method employed to identify metaphorical expressions in texts, the researchers found 211 instances of death discourse metaphors in the memoir. These were classified into five major metaphor frames and ten subordinate metaphor types.

The findings reveal that Kalanithi predominantly conceptualizes death in his memoir “as a transition or movement, followed by a negative presence, an overwhelming or obscuring force, a concluding performance, and a biomedical breakdown.”

“Furthermore, the results demonstrate how illness discourse, by its nature, blends medical discourse with personal and existential discourse and modifies conventional death metaphors,” the authors write.

Death and metaphorical mappings

Metaphors are fundamental to human cognition and communication. In When Breath Becomes Air, Kalanithi employs them not merely as stylistic embellishments but as powerful conceptual tools through which he understands and articulates a personal experience of dying. His metaphors show that death can be shared, narrated, and contemplated despite its abstract and intangible reality.

The authors argue that Kalanithi’s memoir offers a particularly rich site for examining death metaphors within a work of nonfiction that seamlessly intertwines literary narrative with medical discourse. They demonstrate that metaphorical representations of death arise not only from his expertise as a neurosurgeon but also from his deeply personal understanding of bodily decline as he confronted his own mortality.

Among the most compelling findings of the research is Kalanithi’s recurrent use of departure metaphors. Through these figurative constructions, death is conceptualized as the author leaving the world, moving away, or passing from one state of existence to another. One evening, while they were in bed, his wife, Dr. Lucy Kalanithi, asked him, “What are you most afraid or sad about?” His answer was simple yet profound: “Leaving you.”

The authors observe, “In Kalanithi’s memoir, departure metaphors convert death into a relational event: the dying person is imagined as leaving, while loved ones remain behind.” They further note that “the cultural work of the metaphor lies in making biological death narratable as separation, memory, and continuing influence.”

For Kalanithi, death was a lived experience, far more than an abstract existential concern or biological process. The researchers’ analysis reveals that, in addition to departure metaphors, he understood and expressed his impending mortality through what they describe as “coenesthetic metaphorical mappings.” They demonstrate how these metaphors conceptually and figuratively shape people’s experience of mortality and “frame their responses to death, mortuary practices, and their understanding of death itself.”

Death, metaphor, and meaning

Diagnosed with terminal cancer, Kalanithi came to recognize that the endpoint of his life had become painfully foreseeable. The authors analyze a range of metaphors that map the end of a journey onto death, constituting the basis for an alternative metaphorical conceptualization of death. Reflecting on his diagnosis, Kalanithi observes that before cancer he knew that “someday I would die, but I didn’t know when. After the diagnosis, I knew exactly when: when I had run out of life to give.”

In another metaphorical construction, Kalanithi casts himself as a runner likening his demanding medical career and his struggle with illness to a race whose endpoint is death. Death is implicitly situated at the finish line toward which his deteriorating body is moving: “Yes, I thought, and therein was the paradox: like a runner crossing the finish line only to collapse.”

Kalanithi’s transformation from neurosurgeon to patient is also metaphorically conceptualized through a shift in agency, from actor to one acted upon. In the text, the authors highlight figurative contrasts in his transition from a physician directing events to a patient increasingly controlled by illness. This change is poignantly expressed when he writes that he had “traversed the line from doctor to patient, from actor to acted upon, from subject to direct object.”

And despite his deadly cancer, Kalanithi resists the idea that the terminal disease is going to end his life: “This is not the end… Or even the beginning of the end. This is just the end of the beginning.” The figurative representation culminates in the following evocative comparison: “Like a candle in the wind, my life wavered, uncertain of when the gust would come to extinguish it.”

Kalanithi’s imagery of death at times evokes the traditional figure of the Grim Reaper, the silent force that ultimately claims every life. In these metaphors, death is presented not merely as a biological endpoint but as an inevitable presence drawing nearer. Yet, despite its certainty, Kalanithi refuses to allow death to dominate the life that remains for him. He acknowledges that the “curse of cancer created a strange and strained existence,” but emphasizes that he is “neither blind to, nor bound by, death’s approach.”

As the authors argue, “The contribution of the study is not merely the listing of metaphor labels. Rather, its significance lies in “showing how widely documented death metaphors are reorganized within the specific discourse of a medical memoir,” in which Kalanithi’s narrative “alternates between clinical expertise, patient vulnerability, literary reflection, and existential meaning-making.”

The study offers what appears to be the first systematic discursive exploration of death metaphors in When Breath Becomes Air, a memoir that occupies a distinctive place not only in medical science but also in literary craftsmanship. Its findings contribute to the fields of medical humanities, narrative medicine, and existential inquiry.

Additionally, the study is likely to resonate with universities where Kalanithi’s memoir is assigned as a core or supplementary text in courses on medical ethics, narrative non-fiction, journalism, literature, communication, and the humanities.