When Breath Becomes Air

Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. Paul Kalanithi

What makes life meaningful? Paul Kalanithi asks this question over and over in his memoir When Breath Becomes Air.

“As soon as the CT scan was done, I began reviewing the images. The diagnosis was immediate: Masses matting the lungs and deforming the spite. Cancer. In my neurosurgical training, I had reviewed hundreds of scan for fellow doctors to see if surgery offered any hope. I’d scribble in the chart “Widely metastatic disease—no role of surgery.” And move on. But this scan was different: it was my own.”

Kalanithi died March 9, 2015 at the age of thirty-seven, twenty-two months after he saw that CT scan. It was coming face to face with his own mortality that led him to try to understand what constitutes a meaningful life.

And it was before operating on his patients that he realized he must first understand the patient’s mind, their values, what makes their life worth living, and what makes it reasonable to let their life end.

Kalinithi was raised in Kingman, Arizona and had no interest in becoming a doctor, although both his parents were physicians. His mother, concerned about the dismal state of education in Kingman, gave Kalinithi and his brothers book after book to read, instead. Determined to be a writer, he received a BA and MA in English literature at Stanford, in addition to majoring in biology.

“I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.”

After a year in Cambridge studying the history and philosophy of science, he decided to enter medical school at Yale and choose a career in neurosurgery. When Breath Becomes Air describes the rigorous and lengthy training required in medical school. He returned to Stanford for an even more grueling residency in neurological surgery and a postdoctoral fellowship in neuroscience.

His eleven years of training were almost finished when the effects of lung cancer—weight loss, fevers, chest pain, night sweats, unremitting back pain, cough and the effects of chemotherapy-- made it impossible for him to continue.

Through it all he never stopped reading literature or hoping he would be able to write one day. He wrote, “Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection.” His tremendous ambition compelled his to begin work on his memoir which he almost finished before he died. His wife, Lucy, completed the manuscript in an Epilogue.

Moral reflection infuses the book. It challenged him to examine the meaning of life before operating on his patients, to confront his own mortality, and to ask the readers to do the same.

What makes your life meaningful?

“Everyone succumbs to finiitude… Most ambitions are either achieved or abandoned; either way they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.”

Kalanithi also frequently reflects on time. How much time do I have left? Am I spending too much time on this operation? How long has the patient been under anesthesia? What time am I getting out of the hospital tonight? When Breath Becomes Air “carries the urgency of racing against time.”

How much time do you have left?

Knowing that he did not have long to live, he and his wife decided to have a child. And in the end he came to understand that his relationships with his wife, large family, close friends, and above all his daughter, Cady, meant most to him.

He doubts that she will remember him, all he has are his words. The message he writes to her is simple.

“When you come to one of the many moments in life when 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.”

In the Epilogue Lucy Kalanithi says that the Paul wrestled with death as a physician and as a patient. “He wanted to help people understand death and face their morality.” When Breath Becomes Air certainly had that effect on me. I think you have to be of a certain age for that to happen and I suppose that is a good thing.