‘When Breath Becomes Air’

Originally published: 12 January 2016

Author: Paul Kalanithi

Pages: 228

Paul Kalanithi was a neurosurgeon and a writer, he held degrees in English literature human biology, and history and philosophy of science and medicine from Stanford and Cambridge universities before graduating from Yale school of medicine, he also received the American Academy of Neurological surgery’s highest award for research. His reflection on doctoring and illness have been published in the New York Times, the Washington Post and the Paris Review Daily, Kalanithi died in March 2015, aged 37. He is survived by his wife, Lucy, and their daughter, Elizabeth Acadia.

This is a true story about his life and illness with stage IV metastatic cancer, Paul Kalanithi, just as he starts the life he has been training for over ten years. We see Paul transform from medical student, to neurosurgeon, to patient at the age of just 36.

This book is a chronicle, but it is different from the (manifold) other physician memoirs in a few important ways. Perhaps most significantly, the author died before the book saw final publication. Dr. Kalanithi was at the end of his residency in neurosurgery when he was diagnosed with metastatic lung cancer; he wrote the book knowing that he would not likely live much longer, and he passed away before the book became widely available. Thus, his story is not only tinged with sadness, but also a sense of triumph. By writing the book and knowing at the end that it would be published, Dr. Kalanithi was — in no small way — able to keep living beyond death.

The book is relatively short, but filled with incredible insights amidst a moving central narrative. The two halves are tellingly titled: “In Perfect Health I Began” and “Cease Not Till Death.” In the first, Dr. Kalanithi leads the patient through his life story: childhood, college, his decision to study medicine, medical school and residency. His short vignettes offer glimpses into his personhood, and it is clear that he has something to teach his readers. The uniting thread, both in the narrative and his life, is death. Dr. Kalanithi highlights many instances in which he sought to understand death and how patients deal with it. In fact, his decision to study medicine was a consequence of not just wanting to study theory and conceptual ideas of disease and death, but to learn firsthand about it. The unspoken message, of course, is that he never expected to learn about it as personally as he did.

In the second section, Kalanithi’s story moves to the period after he received his diagnosis. As anyone might expect, the diagnosis changes much of his perspective on life; indeed, it is both the stated and unstated impetus for his writing the memoir. He writes briefly, but eloquently, about many topics often associated with dying: discovering and reaffirming his core values, religion and his eventual return to God and trying to understand time and its effect on those acutely aware of their imminent death. He writes perhaps most powerfully about the tension faced by many people with diagnoses such as his: what do I do about it now? Do I go back to doing surgery, or quit my job to spend time with family? Though there is rarely an easy answer to questions such as these, he writes openly about the process of discovering his values at the end.

Dr. Kalanithi explores the profound idea that “[t]he angst of facing mortality has no remedy in probability,” meaning that accurate life expectancy statistics are a myth — none of us knows when our end will come. He offers this thought, both unsettling and comforting:

“I began to realise that coming in such close contact with my own mortality had changed both nothing and everything. Before my cancer was diagnosed, 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 know it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.”

When Breath Becomes Air is one of the most difficult books I have read, but not in terms of vocabulary or language. Despite never fulfilling his dream of becoming a prolific author, Dr. Kalanithi writes with the grace and ease of a seasoned writer. His voice is clear, the language crisp and the story deeply compelling. No, this book is difficult because of how real it is. His words are so understandable and relatable that it forces the reader to confront the obvious: we all must face death, and it very well might not be when we think it will be. Dr. Kalanithi, realizes this. What makes his diagnosis especially sad, at least at first, is that it comes at the end of a long, grueling journey. On the cusp of finishing residency and accomplishing his dreams, they are shattered by the unthinkable. This idea is haunting to all, but especially to the medical students and residents who read it and keep thinking this could be me. Any book which forces confrontation of hard truths and a subsequent shift in paradigm is worth reading, and this book fulfilled both for me.

By the end of the book, I felt that I had known the author a long time, which made the end that much harder, and the beautiful epilogue written by his wife. Although emotionally difficult, I recommend this book to all, but also patients and others not in the healthcare profession. His insights about medicine are worthwhile, but his insights about life and death are truly inspiring. When Breath Becomes Air is not only one of the best medical memoirs I have read, but also one of the best and most important books I have experienced.