When Breath Becomes Air
by Paul Kalanithi
I read a lot of memoirs. A lot. My choices tend to skew on the sadder side of life and if it involves death or some tragedy, chances are it’s going on my must-read list. These are often the books I’m still thinking about weeks and months after I’ve finished them.
In The New York Times (1/6/2016), reviewer Janet Maslin writes that “finishing this book and then forgetting about it is simply not an option. There is so much here that lingers, and not just about matters of life and death.”
She’s absolutely right. Paul Kalanithi, a brilliant and compassionate neurosurgeon who, at 38, was diagnosed with lung cancer just as he was on the verge of completing a 10 year residency program, has much to teach us in his posthumously published memoir. When Breath Becomes Air is more than the journey towards one’s own lightbulb, a-ha, now-I-know-what-life-is-all-about moment of revelation that often accompanies a serious illness or tragic event. Indeed, many memoirs cover similar ground in inspiring ways — but this one is, somehow, very different.
It’s about what it means when everything you have worked toward and planned for 10 years vanishes at the precise moment when you are on the cusp of realizing all those dreams and aspirations.
“My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close. I was physically debilitated, my imagined future and my personal identity collapsed, and I faced the same existential quandaries my patients faced. The lung cancer diagnosis was confirmed. My carefully planned and hard-won future no longer existed. Death, so familiar to me in my work, was now paying a personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable. 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.” (pg. 121)
This examination of identity and purpose is, ironically, at the nucleus of Kalanithi’s calling as a neurologist.
“While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact…. Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and his family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?” (pg. 71)
“I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being: getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles … surely a kind of transcendence would be found there?” (pg. 81)
These are such powerful observations — ones that resonate so much with me lately, which is part of why I think I loved this book so much. It’s both reassuring and refreshing to know that there truly are doctors who think and feel so deeply. In my 47 years, I’ve been lucky to know a few doctors with this level of knowledge and sensitivity, but, sadly, there haven’t been many. A doctor with a phenomenal bedside manner is special, indeed.
“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.” (pg. 86-87)
Read that last line again. When there’s no place for the scalpel, words are the surgeon’s only tool.
And those words? They matter. They matter so goddamn much. They’re what we remember when we get the phone call, the test results, the diagnosis, the prognosis. That moment is weighted; everything that comes after hinges on how that news is conveyed.
The title When Breath Becomes Air comes from Baron Brooke Fulke Greville’s “”Caelica 83.” (In addition to a brilliant physican, Paul Kalanithi was a hell of a well-read guy.)
“You that seek what life is in death,
Now find it air that once was breath.
New names unknown, old names gone
Till time end bodies, but souls none.
Reader! then make time, while you be,
But steps to your eternity. “
We’re all mere steps to our eternities, Kalanithi writes.
“Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” (pg. 115)
So how do we go on with our lives in the midst of such uncertainty which can either propel us forward or paralyze us? Kalanithi offers his perspective.
“Maybe, in the absence of any certainty, we should just assume that we’re going to live a long time. Maybe that’s the only way forward.” (pg. 162)
Undoubtedly, Paul Kalanithi impacted many lives as a neurosurgeon. He would have — no, should have — had the opportunity to touch many more for many, many more years than the 38 he was given. And while he should still be here, enjoying his wife and young daughter and a successful career, his words will change countless lives.
Highly, highly recommended. 5 stars out of 5. This will likely be the best book I read all year.