When Breath Becomes Air by Paul Kalanithi — A Review

Somewhere in the pages of his unforgettable memoir, Paul Kalanithi invokes the Greek concept of areté, the fulfilment of human faculties at their highest, to describe neurosurgery’s unforgiving demand for perfection. Here, the journey of a scalpel a millimetre up or down, right or left, through the labyrinths of the brain can separate the restoration of a human life from what he calls a “twilight existence of unconscious metabolism.” Long before we encounter the word areté itself, however, we sense something of that same exactitude in Kalanithi’s writing. The precision demanded of the neurosurgeon seems to have entered his prose: measured, lucid and intensely attentive to the weight of words.

The life behind these pages is as compelling as the prose that records it. Abraham Verghese, who, like most of us, came to know Kalanithi only after his death, wonders in his foreword whether Paul was Thomas Browne redux or, reversing the perspective of time, Thomas Browne was Paul Kalanithi redux. The comparison places Kalanithi in that rare tradition of physician-writers for whom literature and medicine illuminate the same human questions. But Verghese offers an even simpler invitation: “Listen to Paul. In the silences between his words, listen to what you have to say back. Therein lies his message.” It is in that conversation, between Kalanithi’s words and our own intimations of mortality, that the book begins to exert its extraordinary hold.

The dreaded diagnosis arrives at the outset of the book, though Kalanithi and his wife, Lucy, have suspected it for some time. He has been enduring bouts of severe back pain, losing weight and waking at night with his sheets drenched in sweat. The symptoms have begun to resemble a textbook case of cancer, and he has even been secretly looking up the incidence of the disease among non-smokers of his age. For a physician trained to read the body’s signs, the implications are difficult to ignore. Yet knowledge offers no protection against what the diagnosis means, and its timing could scarcely have been crueller.

“At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea. I could see a nice catamaran on that sea that Lucy, our hypothetical children, and I would take out on weekends.”

He is at the threshold of the life he has spent decades working towards when the future abruptly changes its meaning.

The reversal becomes stark when Kalanithi finds himself in his own hospital, no longer in a neurosurgeon’s scrubs but in a blue hospital gown, a plastic identification bracelet around his wrist. He is checked into the same room where he has seen hundreds of patients over the years, explained terminal diagnoses and complex operations, congratulated some on being cured and pronounced the deaths of others. Now a young nurse asks him to wait for the doctor. The physician who had spent years interpreting illness for others has crossed, almost imperceptibly, to the other side of the encounter. Medical knowledge remains his, but the distance it once afforded him has vanished. As Kalanithi writes, “And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.”

From the collapse of that imagined future, Kalanithi turns to the past. We glimpse his childhood in rural Arizona, in a house “just beyond the city limits, at the base of Cerbat Mountains, amid red-rock desert speckled with mesquite, tumbleweeds and paddle-shaped cacti.” It was a landscape where “dust devils swirled up from nothing, blurring your vision, then disappeared. Spaces stretched on, then fell away into distance.” We also meet his formidable mother, who had crossed the world to marry the man she loved but remained terrified of the desert snakes. Alarmed that the impoverished local school system might fail her children, she initiated them early into literature and poetry. She gave Kalanithi 1984 when he was ten. “I was scandalised by the sex, but it also instilled in me a deep love of, and care for, language.” Other books followed, some leaving deeper marks than others. Brave New World, he recalls, helped shape his nascent moral philosophy and prompted a college admissions essay in which he argued that happiness was not the point of life. Long before medicine entered the picture, the questions that would preoccupy Kalanithi had begun to take shape through literature.

Kalanithi did not initially know where this search would lead him, though writing a book remained somewhere in his imagination. Literature had taught him to pursue questions of meaning, life and death, but he increasingly felt that language alone could not answer them. His scientific leanings drew him towards medicine, where questions that had seemed philosophical acquired the urgency of lived experience. At Yale Medical School, an encounter with a paediatric neurosurgeon counselling the parents of a child with a large brain tumour helped crystallise that recognition. “And as I sat there, I realized that the questions intersecting life, death and meaning, questions that all people face at some point, usually arise in a medical context.” Neurosurgery would eventually become his chosen field: a place where biology, identity, mortality and meaning converged, and where the questions he had first encountered in books could no longer remain abstract.

When Breath Becomes Air is less a treatise on mortality than a meditation on the inextricability of life and death. Nor is it merely an elegy on life’s transience. Kalanithi’s deeper concern is how one continues to live when death ceases to be an abstraction and enters the room. The questions that had occupied him through literature and medicine now become fiercely personal: What gives life meaning when the future has suddenly contracted? What remains of ambition when time can no longer be taken for granted? His answer is neither heroic defiance nor easy consolation, but an attempt to find meaning within the limits that mortality imposes.

There is a clarity to these reflections and a lyrical quality to the prose that owes much to Kalanithi’s unusual habitation of both literature and science. He can move from the physical laws governing human organisms to the bewildering subjectivity of becoming a patient himself. “It occurred to me my relationship with statistics changed as soon as I became one.” Elsewhere, he captures with remarkable precision what terminal illness does to the very shape of time: “Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder towards the goals of life, flattens out into a perpetual present.” Such passages illuminate what the memoir does at its best: it brings the abstractions of mortality, time and meaning into the immediate experience of a life suddenly forced to reckon with all three.

Kalanithi’s lifelong intimacy with literature reveals itself also in the ease and precision of his allusions. The extract from T. S. Eliot’s Whispers of Immortality at the beginning of the book may acquire its full resonance only later, when Kalanithi reflects on his choice of neurosurgery: “I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking.” Literature, for him, is not an ornament laid over experience but one of the means by which experience is understood. It is fitting, then, that Kalanithi should find the title of his memoir in Fulke Greville’s Caelica 83, its transformation of breath into air distilling into a few words the passage between life and death that preoccupies the book from beginning to end.

When Breath Becomes Air could scarcely be complete without the epilogue by Lucy Kalanithi. Paul can write towards his death, but not beyond it; Lucy must carry the narrative across that final threshold. Her account offers a kind of closure, both for herself and for the reader, while reaffirming the coexistence of life and death that runs through the memoir. She establishes the note early: “As winter turned to spring, the saucer magnolias in our neighbourhood bloomed large and pink, but Paul’s health was declining rapidly.” The juxtaposition of flourishing and withering brings their coexistence sharply into focus. Towards the end of her tribute, Lucy writes of what Paul had come to understand and what she now carries “deep in my bones too: the inextricability of life and death, and the ability to cope, to find meaning despite this, because of this.” Her final distinction is perhaps the one with which the book deserves to be remembered: “What happened to Paul was tragic, but he was not a tragedy.”

When Breath Becomes Air begins with a physician confronting his own mortality, but it finally becomes a book about how to live in its presence. Kalanithi had pursued questions of life, death and meaning through literature, medicine and neurosurgery; illness stripped those questions of their abstraction and demanded that he answer them with his own remaining days. His answer lies not in triumph over death, which he knew to be impossible, but in continuing to seek meaning within life even as its limits close in. The book is dedicated to Cady. I will leave the reader to discover why, and perhaps to find there Kalanithi’s most tender answer of all.