When Breath Becomes Air by Paul Kalanithi


I picked up this book yesterday whilst at layover in Changi airport, Singapore. There were many fine books as there often are at airport bookstores. I recognised this one as a best-seller in the Amazon medicine category. It was a handsome, white hardback with ruffled pages which are so nice to turn and with plenty of empty space on each page. It was the thought of having that book on my shelf for a lifetime that made me choose it rather than the Elon Musk biography or The 4-hour workweek.

The book is the story of an aspiring neurosurgeon who gets lung cancer shortly before he finishes his training, how his life is devastated by it and how he tries to put it back together.

“Now this is not the end. Or even the beginning of the end. This is just the end of the beginning”

Tragically the title doesn’t quite fit the book. However it is symbolic for what he hoped the book to be if he had a little more time and thus becomes itself a part of the experience.

Paul spent 10 years training to be a neurosurgeon. In his 30’s, shortly before attaining his final certification he got lung cancer which would be terminal.

He was incredibly ambitious. He wrote how many medical students would opt for “lifestyle” specialities such as dermatologist which had less demanding hours. I don’t fully understand why he chose Neurosurgery, which is perhaps the most demanding speciality. Even that was only part of his ambitions though. He also wanted to be a serious Neuroscientist and author as well. One is struck by the enormity of his expectations and I personally felt it raised the ceiling of expectations in general.

“The pain of failure had led me to believe that technical excellence was a moral requirement”

The book has two parts as well as a prologue and an epilogue. The first part is about his childhood and the development of his journey as he planned for a long, healthy life. The second part is about his short life after the revelation of lung cancer.

It’s crucial that he had everything planned out. He referred a lot to “identity” where others may refer to their personality or life in general, perhaps this is a neurosurgeon’s unique perspective. Finding a new identity, a new life seemed to be a key part of his process.

“Emma hadn’t given me back my old identity. She’d protected my ability to forge a new one. And, finally I knew I would have to”

In the first part of the book he would deal with patients who would often be facing their mortality. He wanted to do what ought to be done for them, or perhaps even more so to simply understand. Yet after reading the second part, one is left with the impression that he was somehow unsatisfied in his treatment of the dying. He understood it as being like a pastor.

Uncertainty about prognostications weighed heavily on his thinking. Achievement was a huge part of this man’s life and he needed to know how long he had left to make the right decisions. For example if he lived a month he would spend it with family, a year he would write a book, ten years he would return to neurosurgery. At one point the cancer stabilised and he did go back to surgery and eventually graduated and finally became fully certified as a neurosurgeon.

“I can’t go on, I’ll go on.” – Samuel Beckett

He and his wife had a baby less than a year before he died. His final message to the daughter at the close of the book was beautiful and heart-breaking. Perhaps the greatest literary achievement and the most honest part of the book which is saying a lot. His message to his infant daughter was essentially that if she ever wants to consider her worth in the world, to remember that once she was the singular, abiding happiness in his otherwise future-oriented and all-too-demanding life.

In the epilogue, the wife (an internist) writes about his last days and after he died. This adds yet another creative dimension to the work and deepens the impression of Paul even further.

“Bereavement is not the truncation of married love, but one of its regular phases – like the honeymoon. What we want is to live our marriage well and faithfully through that phase too” – C.S. Lewis



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