— Hippocrates, Aphorisms
There are two facts that haunt When Breath Becomes Air, the memoir of the late neurosurgeon Dr. Paul Kalanithi: he died very, very young, and very, very recently. The two worlds — the one in which Kalanithi is alive, hot blooded, and vigorous, and the one we inhabit, which has persisted traitorously without him — lie side by side, so close that we may reach across the seam with scarcely a stretch. To spend a few hours in the company of a narrator like Kalanithi, such an urgent, pulsing presence on the page, you can hardly believe he is gone.
But When Breath Becomes Air is, at heart, a book about being gone. Paul Kalanithi was diagnosed with stage IV lung cancer at age 36 in his final year of neurosurgery residency at Stanford University, on the cusp of reaping the rewards, personal and professional, of a decade of preparatory toil. A mere 22 months separated his initial diagnosis and his passing, just over one year ago, in March 2015. The wound of his loss has not even begun to scar over; he is still very much man, hardly at all myth. (You can, if you are so inclined, find his Twitter feed, his online residency profile, those uncanny memorials to modern life.)
When Breath Becomes Air is another kind of memorial, built with a great deal of care by a dying man in his final years, detailing his childhood, career, and struggle with cancer. Like any memoir of terminal illness, it is saturated with the author’s awareness that this is it, his last chance to make himself known to those he loves and those who will only ever experience him on the page. For Kalanithi, the heartbreaking intersection of these two kinds of readers takes the form of his baby daughter Cady, who was only eight months old when he died, and to whom the book is dedicated. Those two little words after the front matter — “For Cady” — cast a long shadow over the rest of the text. Though Cady herself does not enter the picture until two-thirds of the way through the narrative, the possibility of her existence occurs to Kalanithi and his wife Lucy only a couple of months after his diagnosis. Their subsequent conversation about whether to become parents crystallizes Kalanithi’s approach to living face to face with his own mortality. Ever sensitive, ever the realist, Lucy asks, “Don’t you think saying goodbye to your child will make your death more painful?” His response: “Wouldn’t it be great if it did?” This is Paul Kalanithi in a sentence: leaning into meaning-making, reaching for a life lived at its highest pitch, stretching himself to the outermost limit of his capacities, and then one inch beyond.
Kalanithi’s disposition toward deep engagement with the world asserts itself powerfully during his illness; in his short time he not only writes his memoir, but also finishes a grueling surgical residency and, indeed, has a child, all the while racked by the cancer eating away at his vitality. But even as a younger person, Kalanithi bears a seriousness that prefigures his later intensity. A good part of the narrative of When Breath Becomes Air is devoted to his early life, first in Bronxville, New York, and then Kingman, Arizona, where his father, also a physician, moves the family in order to establish a cardiology practice. Paul’s mother, worried by the district’s subpar public school system, assigns Paul and his brothers a “college prep reading list,” which kindles an early love of literature in him — convinces him, in fact, that he ought to become a writer.
Pursuing this life of the mind, Kalanithi chooses to major in English literature at Stanford. But soon he conceives a fascination with the physical basis of understanding, and by extension, the anatomical home of cognition: the brain. He tacks on an additional, parallel course of study: human biology. After college, still grasping for a connection between his dual passions — the studies of mind and body, respectively — Kalanithi undertakes graduate work in English under the tutelage of the philosopher Richard Rorty, who helps him to see each discipline as “a set of tools for understanding human life in a particular way.”
Ultimately, Kalanithi finds he doesn’t fit into the milieu of the academic humanities. His roving intellect feels constrained by the theoretical orthodoxies of the field, especially those of an anti-science bent, as well as its political in-fighting. Kalanithi’s description of the reasoning that leads him from a graduate degree in English toward the practice of medicine represents some of the strongest writing and most important thematic discussion of the book — for it typifies his courage, rare versatility of mind, and determination to chase down answers to the existential questions that dog his waking hours.
Where did biology, morality, literature, and philosophy intersect? […] Augustine’s voice in the garden commanded, “Take up and read,” but the voice I heard commanded the opposite: “Set aside the books and practice medicine.” Suddenly, it all seemed obvious. […] [Medicine] would mean setting aside literature. But it would allow me a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay.
The next day, Kalanithi begins the journey to and through medical school, and a brief but distinguished career in neurosurgery.
The significance of this swerve for writer and reader alike cannot be overstated. After all, how many among us can imagine abandoning everything we know solely to sink our fingers into the messy business of figuring out what matters most? In remembering Kalanithi the physician, we must not forget that he was first and always Kalanithi the wonderer — not an inveterate science wonk, but a reader who followed his curiosity to an atypical end. If it seems inconceivable that an abiding book lover like him — like you and me — chose medicine over the formal study of literature, then that is a failure of imagination on the part of the disbeliever, who ought to open her mind to different ways of knowing and seeing, to the multiplicity of paths toward truth and beauty.
Indeed, Kalanithi makes his narrative of development fresh for readers of all backgrounds, in part by recounting discoveries of the philosophical complexities woven into the practice of medicine, first as a medical student and then as a resident. Dissecting cadavers in anatomy lab teaches him that the human body is both sacred territory and merely flesh; patient encounters show him that the physician’s most important task is not to treat, but to bear witness to suffering. Kalanithi learns early on that effective and compassionate care is rooted not in intellectual mastery, but in being-with — offering a stable, attentive presence amid crisis and confusion. This kind of attentiveness, as it happens, is also the key to a meaningful life. Good medicine and good living both come from a place of relationship.
And in both arenas, it isn’t always easy. Kalanithi describes moments in his practice when he acted callously, when he failed to listen, when he thought of his needs before a patient’s. Lapses in care and communication on the part of providers can often be traced to the unique difficulties, physical and emotional, endemic to working in medicine. When Breath Becomes Air is, in large part, a love letter to these difficulties, and to the enormous reserves of empathy and patience required to meet them. Neurosurgery is widely considered the most taxing subspecialty, not only because of the long years of training and exhausting lifestyle it demands of its practitioners, but also because of its focus on the brain, the locus of the self, where all wires converge. Anyone who operates here is forced into a critical intimacy with issues of identity and personhood, of what makes us who we are. For Kalanithi, obsessive explorer of consciousness, it is the natural choice of vocation. He makes us understand that doctors, neurosurgeons especially, play the role not only of expert clinician, but also of perpetual crisis counselor, to patients contending with fundamental questions that arise at the junction of the physical and metaphysical. “[The] question is not simply whether to live or die but what kind of life is worth living,” he writes.
Would you trade your ability — or your mother’s? — to talk for a few extra months of mute life? The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? Because the brain mediates 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?
In our age, doctors occupy a strange, paradoxical place in the popular imagination. Knowing that medicine, as Kalanithi puts it, “trespasses into sacred spheres,” we revere its emissaries for their knowledge and authority, seemingly limitless; we are riveted by the pristine white coats and brisk jargon of their TV counterparts. Yet so, too, does common discourse revile doctors: for their supposed greed and materialism; their cold, insensitive manner with patients; and their elitism, forged by a lifetime of being told how smart they are. These characterizations are true and false to varying degrees, but more to the point, they miss the essential reality of what it is to be a doctor: a human, alone like every other, locked in a struggle to beat back injury and disease, which are as infinitely renewable as the passage of time. The stakes are sky high, and the standard for victory is nothing less than perfection; no mistake is acceptable. On top of all that, the battle is invariably a losing one, a series of stopgap measures against the end which comes for us all, and which haunts the corridors of medicine as surely as the smell of antiseptic. What a strange and impossible job our doctors do.
Kalanithi manages to capture these difficulties without complaint or self-righteousness. He is exhausted, always, even before he gets sick. The strains of residency almost end his marriage; he loses a friend, a fellow surgery resident, to suicide. When another friend, also a doctor, suffers a fatal car accident, Kalanithi cannot help but picture the grotesque, invasive measures that were probably taken to resuscitate her — for doctors live the curse of knowing too much, unblessed by the vast ignorance of bodily processes which the rest of us enjoy.
Knowing too much becomes a different kind of problem when Kalanithi is diagnosed with cancer — or rather, it becomes beside the point. He writes, “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, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.” He demands a prognosis from his oncologist, who declines to indulge him, and eventually he comes to the startling realization that, basically, nothing has changed: both before and after getting sick, he knew he would die someday, just not when. “You have to figure out what’s most important to you,” says his doctor, and she may as well be speaking to him pre-diagnosis, or for that matter, to any of us, at any time in our lives.
In this way, at least, Paul Kalanithi had a head start: he’d spent his whole life figuring out what was important to him, so that when he grew physically frail, he was able to lean on immense strength of character and sense of self. His legacy serves as benediction and warning: we all die in the thick of becoming, so we had better hone in on what counts. Despite the ravages wrought by his disease, Kalanithi stayed joyful, and funny, and wise. He died as he lived.
But the trouble with dying is that it always leaves someone behind. Dr. Lucy Kalanithi, Paul’s widow, has contributed a devastating epilogue to When Breath Becomes Air. It begins with an epigraph from Emily Dickinson:
You left me, sweet, two legacies, —
A legacy of love
A Heavenly Father would content,
Had He the offer of;
You left me boundaries of pain
Capacious as the sea,
Between eternity and time,
Your consciousness and me.
She goes on to describe Paul’s last weeks and days, as well as aspects of his person he glossed over: his sense of humor, for instance, and his devotion to his daughter in their short time together. Most important, Lucy conveys the overwhelming fact of her love for Paul, the truest expression of what we’ve been brought to feel for him ourselves. Like the good doctor we infer her to be, Lucy takes readers by the hand and sits with us in our grief, while letting us see a little of her own, deep and dark as Dickinson’s sea. And like her husband, she ultimately casts her gaze in the direction of wonder, noting that Paul lived and died surrounded by love, a love that makes us the best possible version of ourselves: vulnerable, grateful, truly alive. “At home in bed a few weeks before he died,” she writes, “I asked him, ‘Can you breathe okay with my head on your chest like this?’ His answer was ‘It’s the only way I know how to breathe.’”
What doctors and writers have in common is that every decision they make is a provisional answer to what life means, or ought to mean. That Paul Kalanithi succeeded in both realms comes as no surprise, I suspect, to anyone who knew him. Late in the book, he writes, “Most ambitions are either achieved or abandoned; either way, they belong to the past.” When Breath Becomes Air does what all great literature does: it allows a man whose life belongs to the past to endure, and to remind those who live after him that we are not, in the end, what we do, but whom we love. Kalanithi harbored an expansive love for humanity that suffused every aspect of his life. We are so fortunate, as readers, to share in its bounty.