Unmissable. Unforgettable. When Breath Becomes Air by Paul Kalanithi

When Breath Becomes Air is an unflinching account of what happens when a man with expertise that can save lives, is powerless to save his own life.

At the age of 36, on the verge of completing a decade’s training as a neurosurgeon, Paul Kalanithi was diagnosed with inoperable lung cancer. Overnight he underwent a transformation in his identity. One day he was a doctor in control of his patients’ destinies. The next he became the patient, forced to relinquish control over his treatment and to put his future into the hands of fellow professionals. Having aspired to be “the pastoral figure … I found myself the sheep, lost and confused”.

When Breath Becomes Air traces his life and the path he took to become a neurosurgeon fascinated by the most complex organ in the human body. The organ that not only controls all other organs it operates in the very core of human identity.

From Literature to Neurosurgery

He never set out to become a doctor. At university he studied English literature, gaining a postgraduate degree with a thesis on Walt Whitman. But he became increasingly interested in the metaphysical questions raised in literature but found books couldn’t provide him with answers. So he enrolled at medical school.

He chose to specialise in neurosurgery because of its “unforgiving call to perfection”. A two millimetre variation in the size of an incision would mark the difference between life for his patient or a living hell of “locked in syndrome.” His quest for excellence combined with the pressure of his job (100 hour weeks were not uncommon) almost cost him his marriage. He even persevered with his punishing surgical duties (including 36 hour stints in theatre) through excruciating back pain and severe fatigue.

What kind of surgeon would he have become if those pains and rapid weight loss hadn’t turned out to be a sign of lung cancer so rampant it had deformed his spine and obliterated one lobe of his liver? When Breath Becomes Air gives us a strong feeling that he would have become one of the foremost specialists in his field, an expert much sought after by university medical departments across the United States.

Questions of Mortality

But it was not to be.

Instead of contemplating that glittering career Paul Kalanithi instead turned to contemplating questions of life and death. They are questions his medical training has not equipped him to answer. The statistics of survival rates and probability of treatment effectiveness that are part and parcel of a medical practitioner’s world are meaningless to a patient he discovers. He comes to the conclusion that the question is not “how long will I live, but how well will I live”?

Not an easy question to answer when his sense of himself has been turned upside down. Robbed of his role as a surgeon he no longer knows who he is or what he wants. How important is it that his treatment plan preserves his manual dexterity, so leaving the door open for him to return to work? Should he and his wife have a child as they had always planned? Should he stay in Stanford and take up a much coveted post or go for a different job that would require a move to Wisconsin?

When Breath Becomes Air was written in the 22 months that elapsed between his diagnosis and his death. But though he wrote at every opportunity and with great determination, he died before he could finish the book. It lends the text added poignancy particularly since the last words he wrote were in the form of a direct address to his baby daughter, the child whose first birthday he would never see. I confess that listening to this passage in my car I was so overcome with emotion I had to pull over and stop.

There is of course a huge amount of emotion invested in this narrative. How could it not be, given the topic. But it’s never sentimentalised or gratuitous. Paul Kalanithi tells his story with delicacy and beauty. It makes the result a book that is inspiring and unforgettable.