When Breath Becomes Air is among the most beautiful books I’ve ever read.
Though it was published in the early weeks of 2016, its author, neurosurgeon Paul Kalathani, died almost exactly a year ago, on March 9th, of metastatic lung cancer, at the age of 37.
It is, in part, the author’s recounting of the last months of his life. His dying.
It’s also a compelling, uplifting and moving work of literature. I started it just a few days ago and always put it down with reluctance.
I’ve finished it, and miss it already. The space I inhabited while I read Kalanithi’s story was sad, certainly, but never depressing. Rather, it was transcendent and truthful. It connected me to something deep inside myself, yet also much greater than myself.
Who was Paul Kalanithi, and how did he become such a luminous human being?
On the back flap of the book’s dust jacket, we learn that:
“ He grew up in Kingman, Arizona, and graduated from Stanford University with a B.A. and M.A. in English literature and a BA in human biology. He earned an MPhil in history and philosophy of science and medicine from the University of Cambridge and graduated cum laude from the Yale School of Medicine, where he was inducted into the Alpha Omega Alpha national medical honor society. He returned to Stanford to complete his residency training in neurological surgery and postdoctoral fellowship in neuroscience, during which he received the American Academy of Neurological Surgery’s highest award for research. “
This was a man so exceptional as to seem unreal: a beautiful, enlightened mind; a man of enormous talents, both literary and scientific. His life was filled with such promise.
Writing his memoir was anything but an act of hubris. I think that it was, instead, an act of reconciliation. The culmination of a life spent trying to bring together the contrasting parts of himself: the lover of literature, language and writing, and the questioning medical mind—both searching for the deeper meaning of life.
The opening sentence of the first part of his book reads: “I knew with certainty that I would never be a doctor.” And it does seem understandable that the son and nephew of doctors (his father is a cardiologist) would first seek elsewhere the answers to the precociously profound and difficult questions he was asking.
During the last part of his life, many of Kalanithi’s certainties would be reexamined.
It has always felt true, to me, that literature—especially fiction—is the place where truth can be most convincingly expressed, and so I was touched to find Paul Kalanithi looking there first.
Still in his early twenties, he had come to the realization that it’s where life brushes up against death—that place where our very identity, our consciousness is threatened—that its meaning is clearest. Who we truly are and what matters most to us is clarified by the prism of our mortality.
But the study of literature wasn’t providing a sufficient understanding of the subject; the particularities of death were still unknowable. Kalanithi became convinced that: “ […] such things could be known only face-to-face.”
And so, he embarked on the decade-long path to neurosurgery because it “seemed to present the most challenging and direct confrontation with meaning, identity and death.”
This part of the book is fascinating, and filled with honest, insightful and unsparing descriptions of dissecting cadavers in anatomy class, and his years of study and practical training.
It was more difficult for me to follow along as he described the years of surgical residency when he was working sixteen hour days (and more), six days a week, because of course he was already sick, though he hadn’t yet been diagnosed. Those passages about his self-neglect and the exacting life-and-death nature of his neurosurgical practice bothered me; they seemed to be too heavy a burden to carry. They seemed self-sacrificial.
In fact, the end of his surgical residency coincided with the end of his life.
But this part of his life was also filled with the love and joy of his family, friends and of Lucy, his wife, also a medical doctor, who is the heart of his story and, I think, his rock.
The second part of the book, titled “Cease Not Till Death”, is about what followed the diagnosis of his metastatic lung cancer, and includes descriptions of the three phases of his treatment—each less hopeful than the previous—as well as his gradual redefinition of time.
“ I had begun to realize 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 knew this accutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.”
For Paul Kalanithi, the most essential preoccupation had always been to live a life of utmost meaning, in which every minute, if possible, was part of a coherent personal, moral and ethical system. But, just like the rest of us, he had mapped out the course of his life according to a linear sense of time—a map that included a horizon.
We all do.
Without a clear sense of the future, Kalanithi was:
“Lost in the featureless wasteland of my own mortality, and finding no traction in the realms of scientific studies, intracellular molecular pathways, and endless curves of survival statistics, I began reading literature again: Solzhenitsyn’s Cancer Ward, B.S. Johnson’s The Unfortunates, Tolstoy’s Ivan Ilych, Nagel’s Mind and Cosmos, Woolf, Kafka, Montaigne, Frost, Greville, memoirs of cancer patients—anything by anyone who had ever written about mortality. I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to translate them back into language. Hemingway described this process in similar terms: acquiring rich experiences, the retreating to cogitate and write about them. I needed words to go forward.”
Words, including those of his oncologist, Emma, urging him, always, to find his values, saying: “You have to figure out what’s most important to you.”
Hers was a different and very humane approach to cancer treatment, certainly, and precious to her patient.
It’s during this period that he wrote When Breath Becomes Life, and also when he and Lucy made the decision to have a child : Elizabeth Acadia, or Cady to her papa. She was eight months old when he died.
There are photos and video footage which show Paul, in the last months of his life, with Cady resting on his lap, her tiny hands in his. He is aglow with joy.
These cause me terrible pangs of sadness and I invariably cry.
But mostly, while reading the book, I felt, as Paul Kalanithi did, that time, no longer linear, had become a space that I happily inhabited.
Note: The ending paragraph of When Breath Becomes Air is a message to his infant daughter Cady:
“ There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.
The message is simple:
When you come to one of the many moments in life where 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, that is an enormous thing.”