When Paul Kalanithi sent his best friend an email in May 2013 revealing that he had terminal cancer, he wrote: “The good news is that I’ve already outlived two Brontës, Keats and Stephen Crane. The bad news is that I haven’t written anything.”
It was a jokey way of dealing with the unthinkable but also an indication of Kalanithi’s tremendous ambition. He had led a fascinating life and was not about to leave it unchronicled.
The bittersweet news is that in the 22 months left to him, Kalanithi, who died at 37, went on to write a great, indelible book, “When Breath Becomes Air,” that is as intimate and illuminating as Atul Gawande’s widely appealing “Being Mortal.” To paraphrase Abraham Verghese’s introduction, to read this book is to feel that Kalanithi still lives, with enormous power to influence the lives of others even though he is gone.
Verghese suggests not only reading “When Breath Becomes Air” but also listening to the overwhelming response it prompts in you. I guarantee that finishing this book and then forgetting about it is simply not an option.
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There is so much here that lingers, and not just about matters of life and death: One of the most poignant things about Kalanithi’s story is that he had postponed learning how to live while pursuing his career in neurosurgery. By the time he was ready to enjoy a life outside the operating room, what he needed to learn was how to die.
Kalanithi’s abiding and eclectic interest in serious literature serves him well throughout “When Breath Becomes Air.” Its hauntingly beautiful title is a paraphrase from the poem “Caelica 83,” part of a 17th-century sonnet series by Fulke Greville. It’s obscure but could not be more apt.
Kalanithi wrote his own book with great determination but also great difficulty, to the point of wearing silver-lined gloves to use the trackpad when his fingertips began to crack during chemotherapy. (In the epilogue and afterword by his wife, Lucy Kalanithi, also a doctor, she says that the manuscript had to be completed posthumously.) But the difficulty doesn’t show: Paul Kalanithi knows how to make a paragraph fly. And the book opens with a beauty, quoted here to show its swift economy and precision:
“I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.”
With those facts established, he is free to flash back through the lifetime of experiences that got him to this point: an unusual love-hate relationship with medicine as the thing that kept his father, a cardiologist, away from home at night but also struck him as a calling rather than a profession.
Once his family moved from Westchester, N.Y., to Arizona, he and his brothers became essentially home-schooled by a strict mother who had no idea what truly excited Paul, the neurosurgeon in waiting. She worried about her sons and drugs, “never suspecting that the most intoxicating thing I’d experienced, by far, was the volume of romantic poetry she’d handed me the previous week.”
With the seeker’s restlessness that seems not to have left him until his last breath, he went on to accrue two B.A.s and an M.A. in literature at Stanford, then a Master of Philosophy at Cambridge, before graduating cum laude from the Yale School of Medicine. He returned to Stanford for a residency in neurological surgery and a postdoctoral fellowship in neuroscience. His training was almost complete when the bad diagnosis hit.
In the first half of the book, Kalanithi provides a good set of anecdotes about how he goes from medical resident to seasoned doctor: first cadaver (formaldehyde stimulated his appetite), first births and deaths on the same day (which made him mindful of “Waiting for Godot,” with its line about “birth astride of a grave”). From the start, workaholic though he is, he understands patients’ needs better than most young doctors do.
And then everything changes. In a single moment of recognition, everything Kalanithi has imagined for himself and his wife evaporates, and a new future has to be imagined.
Should they have a child, or would that make it harder for him to die? (They do. The book is dedicated to their daughter, Cady.) A job at Stanford for which he was the prime candidate? Not happening. Another good job that would require the Kalanithis to move to Wisconsin? Too far from his oncologist. Long-term plans of any kind? Well, what does long-term mean now? Does he have a day, a month, a year, six years, what?
“When Breath Becomes Air” is gripping from the start. But it becomes even more so as Kalanithi tries to reinvent himself in various ways with no idea what will happen. He can’t gauge how much strength his body still has until he tests it, and sometimes the consequences are horrific.
He no longer knows who he is or what he wants. His whole sense of identity is shaken. And for a terrible period when his oncologist is away, he is treated as a problem and not a patient by an inept medical resident who nearly hastens his death by denying him one of the drugs he desperately needs.
Part of this book’s tremendous impact comes from the obvious fact that its author was such a brilliant polymath. And part comes from the way he conveys what happened to him — passionately working and striving, deferring gratification, waiting to live, learning to die — so well.
None of it is maudlin. Nothing is exaggerated. As he wrote to a friend: “It’s just tragic enough and just imaginable enough.” And just important enough to be unmissable.
“When Breath Becomes Air” by Paul Kalanithi (228 pages; Random House; $25)