Reflections on “When Breath Becomes Air”, by Dr. Paul Kalanithi


2016 | 225 pages | Random House | Autobiography

When Breath Becomes Air is the biography of a neurosurgeon who gets lung cancer.   He dies with the same dignity and and respect for life he showed his patients.  Dr. Paul Kalanithi bravely reflects on the moment when breath becomes air, when “is” becomes “was”, when life becomes death.

Paul doesn’t give a lesson before dying; dying is the lesson.  In an email to a friend, Paul talks about his book’s purpose:

“The thing about lung cancer is that it’s not exotic.  The reader can get into these shoes, walk a bit, say, “So that’s what it looks like from here… sooner or later I’ll be back here in my own shoes.’  That’s what I’m aiming for.  I think.  Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here’s what lies ahead up the road.”

-page 215

When I found out this book lost the Pulitzer Prize in Biography to a surfing memoir (Barbarian Days: A Surfing Life, by William Finnegan), I felt outraged.  Then I considered the surfing biography may have better writing.  Kalanithi’s wife Lucy writes, “Paul was proud of this book, which was a culmination of his love for literature… and his ability to forge from his life a cogent, powerful tale of living with death.”  When Breath Becomes Air reads like something written by a lover of literature, not a master of it (although Kalanithi does have a master’s in English literature, from Stanford).  The book jacket and foreword promise “unforgettable prose” from a “brilliant writer”.  He’s pretty good.  I wouldn’t call his prose “unforgettable”.  You would probably enjoy his writing more if you, too, had a medical degree or a master’s in English.  When Breath Becomes Air includes lots of domain- specific vocabulary and literary references, some more accessible than others.  The title is my favorite quote.

Dr. Kalanithi wrote a beautiful book with many long sentences, but he also saved numerous lives, operated on hundreds of brains, sliced open countless spines, and understood a facet of life that requires decades of training.  The doctor- turned- patient perspective provides Paul’s true contribution to literate.

Kalanithi’s calling as a neurosurgeon gets strong focus. When Breath Becomes Air rarely leaves the sterile hospitals where Paul lived, worked and died.  Dr. Kalanithi emphasizes experiences with patients over personal relationships or experiences.  In Part I, titled “In Perfect Health I Begin”, Paul writes,

“At [those] critical junctures, the question is not simply whether to live or die but what kind of life is worth living.  Would you trade your ability- or your mother’s- to talk for a few extra months of life?  Your right hand’s function to stop seizures?  The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage?  How much neurologic suffering would you let your child endure before saying death is preferable?  Because the brain meditates our experience of the world, any neurosurgical problem 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?”

When Breath Becomes Air, page 71.

When Breath Becomes Air also details the grueling near- torture medical students endure.  Despite labor laws, medical students enslave themselves to patients and paperwork.  Paul describes exhausting hours and staggering work shifts.  We expect 36 hours of alertness from people who literally hold lives in their hands?  I’m not suggesting Paul got cancer at work, but I do think his work/ life imbalance compromised his immune system.  Another discrepancy: Paul calls his oncologist Emma.  Lucy calls Emma “the oncologist”.  It’s not the first hint of tension between Paul’s personal life and his devotion to medicine.

Paul provides a unique view of living with death.  Still, I couldn’t deny the privilege of a published, Ivy educated surgeon at the top of his game.  Paul says:  know you will die, get your values in order, and live according to those values.  Paul valued love.  He valued quality of life, both for his patients and for himself.  He filled his last days with love from family, including his baby daughter Cady.  When Breath Becomes Air doesn’t preach, but if Paul gave advice, he’d probably tell dying people to have a baby (health permitting).

I always find the religious views of dying people particularly interesting.  Paul describes his faith journey, from devout Christian Bible study to steadfast atheism to eventual return to Christianity.  Paul eventually landed here:

“To make science the arbiter of metaphysics is to banish not only God from the world but also love, hate meaning- to consider a world which is self- evidently not the world we live in.  That’s not to say that if you believe in meaning, you must also believe in God.  It is to say, though, that if you believe science provides no basis for God, you are obligated to conclude that science provides no basis for meaning and therefore, life doesn’t have any.”

When Breath Becomes Air, page 169

“Maybe the message of original sun isn’t ‘feel guilty all the time’.  Maybe it means ‘we all have a notion of what it means to be good, and we can’t live up to it all the time’.”

When Breath Becomes Air, page 171

You could read When Breath Becomes Air in one sitting.  It might particularly help people dealing with terminal illness.  When Breath Becomes Air feels hopeful and honest.  Face death bravely.  We all die.


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