When Breath Becomes Air

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“I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumours, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own”.

It is with these words that we first meet Paul Kalanithi, Dr Paul Kalanithi. It is essential to mention that he was a doctor by profession, a remarkably talented doctor and it is this singular fact that allowed him to maintain a unique perspective on his illness and the challenges he faced.

When Dr Kalanithi sent his friend an email revealing his terminal diagnosis, he wrote: “The good news is that I’ve already outlived two Brontes, Keats and Stephen Crane. The bad news is that I haven’t written anything.” This probably seems like a simple way to dull the blow for his friend, but it also serves to show his brilliant ambition, the light in him which seemed to glow brighter when faced with his own mortality.

Therefore, in the brief twenty-two months that he had remaining, Dr Kalanithi not only set out to write a remarkable, magical and indelible book, but he did so while faithfully fulfilling his role as a doctor, a husband and a father to his new-born daughter.

While writing, Dr Kalanithi never thought he was creating an extraordinary legacy. He simply concentrated on delivering his reflections on his life onto paper. But in his humility lies the magic of the book, a simple narrative about the concerns and doubts of a wonderfully talented and intelligent man contending with the two eternal foes of man– time and death.

For that, I am ever grateful. I am grateful that Dr Kalanithi lived, and was able to share his story as both doctor and patient with us all. If he hadn’t, the world would have been all the lesser for it.

Belonging to a family of doctors, Dr Kalanithi’s entry into medicine was circuitous. A deeply idealistic man, he sought to rally against the injustices he witnessed in the world around him. Yet, but being a practical one as well, he dreamed of finding the biggest questions of life.

Unsure that a career in medicine would give him these much sought out answers, initially he pursued his BA and MA at Stanford University. But though he loved literature and the meaning it added to life, he couldn’t shake the feeling that formal analytic philosophy remained ‘dry as a bone’, and that the brain was the machine that enabled the addition of such value and meaning. Ultimately, he was drawn into enrolling in biology and neuroscience lectures while at Stanford, to understand the workings of the human brain.

Still unsatisfied with the superficial explanations this training offered, he later pursued History and Philosophy of Science at Darwin College, where again the hollow debates about life-and-death questions frustrated him, and he argued that experiencing these events was essential to have an opinion of them.

It was in search of that direct experience that he moved to Yale for his medical school, to finally and seriously pursue a veritable biological philosophy.

I enjoyed the singular privilege of reading ‘When Breath Becomes Air’ in my first year of medical school. What struck me then was the vivid detail in which he detailed dissecting a cadaver for the first time, how the sheer normality of it all felt a little jarring, how opening another man’s body, trespassing on the sacrosanct under the glare of white lights, on steel tables feels worryingly normal. Those are some of the most beautiful pages of medical writing I have read, rich with descriptive detail and philosophical analyses of the often desensitised behaviours of his teachers and colleagues.

This brief description of his education paints the portrait of a beautiful mind, one that questioned all that it was fed, and longed for the ‘truth’, the ultimate reconciliation of art, philosophy, morality and science. To better understand the human condition.

This ultimate guiding philosophy of his blossomed in the uncertainty foisted upon him and his family by his stage IV malignancy and his interest in literature served as an effective means for him to give birth to his thoughts.

Dr Kalanithi knows how to make a paragraph fly, the text dance in the reader’s mind, conjuring vivid, palpable images, with each sentence and page more poignant than the last. He reflects upon how his diagnosis, in a single moment, sweeps clean any future he and his wife had imagined.

Their only option was to live in the moment, and Paul knew how to find an eternity in each moment, trying to reconcile his identities as a patient, doctor, father, son and husband.

When Breath Becomes Air is a gripping book, it is a hauntingly beautiful title paraphrased from “Caelica 83”, a 17th-century sonnet by Fulke Greville. The impact of this book is undoubted because of the central questions of life, philosophy, morality and death that the author has raised, but it has more to do with the brilliant thinker, philosopher and writer Dr Kalanithi is.

To read this book is to know that Dr Kalanithi still lives, with the unimaginable power to influence the lives of millions and that every reader will come to know Paul Kalanithi most intimately when he has ceased to be. It is a book that breaks your heart in a very real way, without romanticising or vilifying his illness or exaggerating his doubts and philosophical perspectives. It is palpably and painfully real, but also beautifully so. The text is lyrical and poetic at times, it dances off the pages into the reader’s soul, stirring it and touching it with a precision that only a surgeon can manage.

Nothing is exaggerated, as he said, “It’s just tragic enough and just imaginable enough.”