When Breath Becomes Air ~ Paul Kalanithi

This is a very sad book, but one well worth reading.

It’s written by Paul Kalanithi, a young and promising American neurosurgeon who was diagnosed with lung cancer at the age of 36. The cancer had already spread to other organs and was considered inoperable, though there was a chance chemotherapy and radiation could help extend his life.

In this book he recounts his diagnosis and his subsequent life up until the point where he was unable to keep on writing. A moving Epilogue by his widow continues the story up to and beyond his death.

But this is definitely not a depressing book. It’s sad, but it’s dense with thoughts about life and death and how we cope with the knowledge of our eventual demise.

The whole first part of the book is about Kalanithi’s life before this diagnosis, starting out with his strong love for literature. He thought after leaving school that he might become a writer or an academic in the liberal arts. He recounts his fascination by what gives life meaning; but then through that how he was drawn to the study of the brain.

I studied literature and philosophy to understand what makes life meaningful, studied neuroscience and working in an fMRI lab to understand how the brain could give rise to an organism capable of finding meaning in the world…

He begins to study medicine in earnest and eventually becomes an intern in a major hospital, on the way to becoming a neurosurgeon. It’s here that he has to confront issues of life and death close up, and begins to have to make profound decisions about his patients’ lives.

As a resident, my highest ideal was not saving lives — everyone dies eventually — but guiding a patient or family to an understanding of death or illness. When a patient comes in with a fatal head bleed, that first conversation with a neurosurgeon may forever color how the family remembers the death, from a peaceful letting go (“Maybe it was his time”) to an open sore of regret (“Those doctors didn’t listen! They didn’t even try to save him!”). When there’s no place for the scalpel, words are the surgeon’s only tool.

And again:

Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.

Kalanithi was a student of literature as well as a surgeon: his use of language in this book is beautiful and clear; he frequently invokes poets like T.S. Elliot, and in the Epilogue his wife recounts how he could quote passages from The Waste Land from memory.

The second half of the book is, of course, his diagnosis and how he manages to go on living with the knowledge of his imminent demise.

I began 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 it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.

The final paragraph in Kalanithi’s account, addressed to his daughter at some future time — she was only a toddler when he died — is both heartbreaking and inspiring. It’s not for me to quote it here out of context.

I read this book twice within a month, highlighting passage after passage. It’s a book I would want to read again if I knew that my own death was near.