On "When Breath Becomes Air" by Paul Kalanithi

When Breath Becomes Air is a powerful and heart-wrenching semi-autobiographical novel detailing the life of neurosurgeon Paul Kalanithi. The book was published posthumously by Lucy Kalanithi, Paul’s wife, after Paul tragically dies of Lung Cancer. A moving, powerful celebration of life and love, this was one of my all time favorite reads.

Paul’s two pronged background is a perfect case study to analyze topics of death, mortality and meaning in life. On the one hand, he is a renowned neurosurgeon who has spent 10+ years training and studying - giving him the ability to write in detail about the biological aspects of his condition. At the same time however, his masters degree in English and Literature gives him the undergirding to write eloquently about death from a philosophical perspective. By the end of the novel, Paul has traversed the full spectrum of the doctor patient relationship - uncovering certain truths about death as it is viewed by a doctor and patient.

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. (131)

Paul’s story is made tragic by the fact that his diagnosis aligned with the point in time when he was at a career inflection point. He had just graduated from his residency program, had a baby girl, and was fielding lucrative offers from hospitals across the nation to continue his practice. The tragedy of seemingly wasted potential, the tragedy of not being able to traverse the trajectory of life he had so carefully been planning over the last decade and a half.

His diagnosis stripped these aspects of identity from him, being a doctor, earning millions of dollars a year, achieving the epitome of social status; None of that mattered to him anymore. During his final days, it was really about love, family and companionship, I think this will be true for all of us as well.

As Lucy Kalanithi describes in the book’s afterword, the book, was cut short abruptly by Paul’s worsening condition. The cruelty of time’s ceaseless march. But the book’s unfinished state is symbolic to the tragedy of a life cut short: Paul’s life.

“You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” It was arduous, bruising work, and he never faltered. This was the life he was given, and this is what he made of it. (224)

Despite the circumstances, Paul’s writing is clear and to-the-point. It has a the style of deeply poetic prose, while also being straight and brutally honest. Paul didn’t believe in Pollyanna optimism, he believed in facing the road ahead with the facts and statistics, and preparing himself and those around him for life after he was gone.

Death comes for all of us. For us, for our patients: it is our fate as living, breathing, metabolizing organisms. Most lives are lived with passivity toward death—it’s something that happens to you and those around you. But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. 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. (114)

Despite his diagnosis, Lucy and Paul decide to have a child, Cady. The juxtaposition at the end of the novel is beautiful and tragic. The scene of a growing child, still too young to grasp she is saying goodbye to her father for the last time, lying next to Paul as he takes his final breaths.

Feeling her weight in one arm, and gripping Lucy’s hand with the other, the possibilities of life emanated before us. The cancer cells in my body would still be dying, or they’d start growing again. Looking out over the expanse ahead I saw not an empty wasteland but something simpler: a blank page on which I would go on (195)

The book brings to light the incredible apathy the ever-marching force of entropy has toward human feelings of love, and kinship. It is a reminder to love our family and friends now, because the future really is uncertain. Despite all the fancy and science and math humans have invented during our short stay on earth, we really are at mercy to the laws governing randomness and uncertainty, who lives, who dies, and when.

Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation. (70)

Paul leaves one final message to his daughter to close the book.

When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing. (199)