Updated on March 5, 2016
Review: When Breath Becomes Air by Paul Kalanithi
To celebrate World Book Day, I’ve reviewed the brilliant new memoir “When Breath Becomes Air” by Paul Kalanithi
I don’t often read non-fiction books, or books about death, or books that are pretty much guaranteed to make me cry. So it came as some surprise to find myself eagerly awaiting the publication of When Breath Becomes Air – a book about mortality by a 37-year-old neurosurgeon with terminal cancer, Paul Kalanithi.
Some months earlier I had read an essay that Kalanithi had written for Stanford Medicine. It was stunning. In it, Kalanithi, a chief resident in neurological surgery, describes the warping of time inside the operating theatre and the necessity to work with both speed and precision as a matter of life and death. He contrasts this with the elastic quality that time assumes when you’re living with a terminal diagnosis – both in terms of his disassociation from the time of day or day of the week, and the sudden and brutal truncation of his hopes and expectations. The future, he writes, “instead of the ladder toward the goals of life, flattens out into a perpetual present”.
The essay was thought provoking and beautifully expressed, but it was the final paragraph that really caught my attention. I read it over and over again, not because its meaning was hard to grasp – it was utterly lucid – but because it contained such depth of feeling. Addressed to his baby daughter it was the epitome of “simple yet profound” – the final words of a man who had spent his life grappling with complex questions of life and death yet had a single, beautiful message to pass on to his child. Written in a lilting, rhythmic cadence it sounded effortless and natural, yet each word was chosen and placed with such care that, with lines breaks added, it could easily have been composed as a poetic stanza. The message itself was so straightforward yet so utterly heart wrenching that it immediately brought me to tears.
Kalanithi died a year ago, on 9 March 2015. But in the last year of his life he worked on a book, a memoir that detailed his decision to study medicine and become a neurosurgeon, followed by his experience as a patient at the other end of the stethoscope. It’s not something I would normally have been drawn to but, on the strength of that paragraph, I couldn’t wait to read it. When Breath Becomes Air was finally published in the UK last month and I finished it in a few sittings – only putting it down late at night when I could no longer keep my eyes open. And then I read it again. That essay promised much – sage-like insight, satisfying clarity of thought, wry humour, and elegant, eloquent writing – and the book delivered in spades.
It is, inevitably, a fairly compact book. Kalanithi had only months to write it – in her epilogue, his wife notes that he “drafted paragraphs in his oncologist’s waiting room, took phone calls from his editor while chemotherapy dripped into his veins, carried his silver laptop everywhere he went”. He didn’t know how much time he had left but knew it was an urgent task. And yet, even under such gruelling circumstances – and with, let’s face it, the mother of all deadlines ahead of him – his writing remained clear sighted, considered and compelling. The skills of a neurosurgeon – the intense focus, the quick thinking, the fluid yet methodical movement – are all evident here. I’ve heard it said that people with terminal illness often resent the assumption that, staring death in the face, they are suddenly blessed with a visionary wisdom, a spiritually enlightened insight into the meaning of life, an automatic mental reordering of its priorities. Kalanithi, however, the philosopher-physician, willingly took up this mantle.
In some ways it is a book that Kalanithi was always destined to write, even before his diagnosis. As a teenager, he pursued the meaning of life itself, devouring the great works of literature in search of answers, a task that “instilled in me a deep love of, and care for, language.” He was fascinated by questions of meaningfulness and the relationship between the brain – “an organ subject to all the laws of physics” – and the unique human consciousness that it enabled. At university he studied both English literature and biology, trying to find the place where moral reflection and neuroscience intersect. “There must be a way… that the language of life as experienced – of passion, of hunger, of love – bore some relationship, however convoluted, to the language of neurons, digestive tracts and heartbeats.” But the central question always remained: what makes life meaningful?
A masters in English literature at Stanford and an MPhil in the history and philosophy of science and medicine at Cambridge allowed more time for study. Ultimately, however, thought and speculation were no longer enough. Kalanithi realised that he wanted to experience the front line of life and death. Like his father, brother, uncle, and many family members before him, he needed to become a doctor.
Kalanithi was accepted into Yale School of Medicine, and thus began a decade of relentless, punishing training. Far from struggling, he seemed to relish both the challenge and the opportunity to continue his search for answers. Puzzled by the decision of many of his classmates to specialise in less demanding “lifestyle” areas, his choice was always neurosurgery: “with its unforgiving call to perfection… [it] seemed to present the most challenging and direct confrontation with meaning, identity and death… neurosurgeons were also masters of many fields: neurosurgery, ICU medicine, neurology, radiology… The idea was overwhelming and intoxicating: perhaps I, too, could join the ranks of these polymaths who strode into the densest thicket of emotional, scientific, and spiritual problems and found, or carved, ways out.”
Neurosurgery also gave new angles to the question of what made life meaningful. He was not only making decisions of life and death, but of quality of life. A risky procedure, an error of a hair’s breadth, could destroy someone’s ability to communicate, to understand, to control their mood, their appetites or their behaviour. It could eradicate their identity, wipe their memory or cause total loss of movement. At what point was life no longer worth living?
Kalanithi excelled at his work but, just over a year before the end of his residency, his health started to decline. He lost weight and experienced agonising back pain. A few months later the diagnosis was confirmed: stage IV lung cancer. Emerging therapies might, possibly, prolong his life for several years, but this was a rapidly fatal disease.
By this point, his career was on a seemingly unstoppable upward trajectory – he had won numerous prestigious national awards, authored more than 20 scientific publications and was gaining a stellar reputation not just as a gifted neurosurgeon but as a brilliant neuroscientist whose groundbreaking research had opened up exciting new avenues. Job offers were coming thick and fast and years of hard work were about to pay off – his next step would be a professorship, with a less demanding schedule that would allow him to spend more time with his wife, Lucy, also a doctor, and start the family they had always dreamed of.
Suddenly, this carefully mapped future was gone. The questions he had been asking all his life were brutally brought to bear on his own situation. What made life meaningful when you are staring death in the face? How should you spend your time when you don’t know how much time you have left?
Kalanithi explores these questions with a mix of the scientist’s rationale and the philosopher’s deep thought. There is no pretence at bravado and he admits that, having once considered himself a guide through the unfamiliar territory of life-changing illness, he found himself in a foreign land: “Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank… I’d no idea how hard it would be, how much terrain I would have to explore, map, settle… I hadn’t expected the prospect of facing my own mortality to be so disorienting, so dislocating.”
Yet there is a total lack of self pity. As a doctor he knew the answer to the often asked question “Why me?” was simply “Why not me?” He knew that statistically he had been extremely unlucky but “my relationship with statistics changed as soon as I became one”. Against a medical backdrop of gene mutations, toxicity and CT scans, he describes his struggle to plan his life against the crushing weight of mortality, to find strength, solace and some semblance of control over whatever time he had left.
This tale of vigorous determination to make life meaningful while death hovered in the wings – as it will, ultimately, for all of us – is extraordinary, gripping, moving, thought-provoking and surprisingly uplifting. I only cried (and I cry very easily) when I read the epilogue, beautifully written by his wife. She describes Kalanithi’s last days, his sudden and unexpected deterioration, and his peaceful death. She reflects on his legacy, on their life together, and on the challenges ahead of her. Weaving medical facts with personal detail, her writing is as eloquent and moving as her husband’s and I have to admit that I bawled throughout the entire chapter. Paul Kalanithi’s writing is so intimate and open that, to bear witness to his death, even on paper, was a hugely emotional experience.
So, back to that paragraph, written for Kalanithi’s beloved daughter, Cady, who was just eight months old when he died. It is also the final paragraph of the book but as it has already been widely published I don’t think it’s too much of a spoiler to reprint it here – his final message to her:
“When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, 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 this time, right now, that is an enormous thing.”