When Breath Becomes Air
By Paul Kalanithi
Read Oct 2020
This book was published posthumously after the author succumbed to cancer a mere twenty-two months after diagnosis with Stage IV Lung Cancer. It has received several awards and spent over a year on the best seller lists. The author had been struck down quickly and completely just as he was finishing his neurosurgery residency and just before he had originally hoped to launch a scientist/surgeon career and have a “normal” life with his wife, also a medical doctor. The author wrote this book during the time between diagnosis and death.
These aspects this reader knew when she started reading the book.
This reader posed some questions: Was the hype surrounding this book associated mainly with the tragedy of the loss of a young medical superstar long before his time? Did the book itself have elements that could drive it to endure as a book of great substance after the early hype had faded?
In Part 1: In Perfect Health, the author gives us a sense of his journey leading to becoming a neurosurgery resident. His father and uncles are doctors and he knew before graduating from high school that he didn’t want to become a doctor, especially as he saw little of his father while growing up He had decided “if that [little time with family] was the price of medicine, it was simply too high”. He takes a BS in English and Biology at Stanford and then continues at Stanford for a MA in English. After spending so much time with literature and words and his continuing interest in the biological aspect of identity, he decides to go to medical school. He spends a year taking all the classes needed as prerequisites and during the year that his medical school applications are being considered, he completes a yearlong program at Cambridge in the History and Philosophy of Science. That program confirms to him that words aren’t enough. “I found myself increasingly often arguing that direct experience of life and death questions was essential [to him] to generalizing substantial moral opinions about them.” “Moral speculation was puny compared to moral action.”
So the author is off to Yale Medical School where he soon meets Lucy who will eventually become his wife (whom he discusses very little in the book). When it is time to choose a path for residency, he chooses away from “lifestyle” specialties—those with more humane hours, higher salaries, and lower pressures. So after choosing away from medicine before he entered college, he chooses neurosurgery because it “works in the crucible of identity” and it was the most demanding path. Could he become a member of the ranks of the “polymaths”. He now sought a career path that would be all consuming.
While in his sixth year of residency, after he became chief resident, he begins experiencing a lot of pain in his back. About six months later he finally submits to appropriate tests and scans and his feared diagnosis of lung cancer is made.
In Part II: Cease Not Until Death, the author charts his progression through various treatments and through his evolution of the patient-doctor relationship. Initially he is a clear partner with his oncologist in choosing his treatment course. Although Paul initially doesn’t see the possibility of returning to surgery, his oncologist picks a treatment course that will be least damaging to his hands. He does eventually return to residency, initially focused only on the surgery piece and later on the whole experiences of patient care as well after he learns his program may not find him worthy of graduation from residency if he doesn’t. If ever there was a person motivated to be the best, Paul was certainly one, although he never actually says this. He loses out on a Stanford surgeon/scientist position for which he was contending prior to his diagnosis but is later offered a similar position in Wisconsin which he decides he cannot accept. His runway is no longer twenty years and the position required that in his view. Through this period he understands that his oncologist has provided him the space to determine what’s most important to him so that the treatment course can be directed to support that.
The patient-doctor relationship takes another turn just as he is about to graduate from residency abd just weeks before Lucy’s due date. His disease begins to overpower him, preventing him from attending the graduation ceremony and shortly thereafter he releases himself from needing to be a doctor on his case. He then fully devotes himself to writing this book.
By considering the topics he spends significant time discussing, it’s possible to follow the author’s evolution on several paths: what questions are important to him; what path should be pursued to answer those questions; what career path in medicine should be followed to allow driving as close to the asymptote of excellence he expects from himself. A fundamental question he pursues throughout his life is what enables the essence of the identity? Words can describe identity. Biology must somehow define identity. Neurosurgery can enable reclaiming the identity when the body is diseased. But science is imperfect in answering some of these fundamental questions. He comes to a wonderful conclusion: Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and it is never complete. And Truth comes somewhere above all of them…”
Lucy Kalanithi, Paul’s wife, provides a thirty page Epilogue that gives pictures from the last eight months of his Paul’s life: his determination to write this book despite increasing pain including his fingers; the warm times they spend together with family and friends; the final days and hours of his life; the memorial service. She attests she was a witness to his ability to face death with integrity.
While the initial hype about this book was likely in part due to the tragedy of such a promising doctor being struck down at an early age, the book should remain recognized as a book of substance. The author notes that dying of this type of cancer at such an early age is unlikely but dying at some point isn’t. We all have to face death at some point. His chosen vocation was to not only technically help his patients but also guide them in deciding paths of treatment—which might include no treatment. He lived this situation from both sides of the patient/doctor relationship and it made him a stronger doctor. In sharing his story the author the reader might choose to consider asking themselves a question he poised for himself—what gives a life meaning—which he learns is different than what gives a life purpose.