When Breath Becomes Air

by Paul Kalanithi

ISBN 978-1-4104-8785-8

“I was less driven by achievement than by trying to understand, in earnest: what makes human life meaningful? 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 ten years of medical education, Paul Kalanithi was on the verge of completing his training as a neurosurgeon when he became concerned about his own health. At first he blamed the rigours of residency, but a CT scan soon revealed the worst: cancer in the lungs, spine, and liver. Early in his university career, Kalanithi studied literature, dreaming of a career as a writer, but was driven to medicine by questions about mortality and meaning that he felt could not be answered by literature alone. Suddenly, those questions became urgent and personal, and the only time left to write a book and achieve that dream was now.

Kalanithi’s February 2014 New York Times op-ed “How Long Have I Got Left?” was a viral sensation. Two years later, Kalanithi is dead, but his book, When Breath Becomes Air, has been on the New York Times best-seller list for twenty-nine weeks as of this writing. It sits a few spots above Being Mortal, by fellow Indian-American doctor Atul Gawande, which has been on the list for eighty-one weeks. Clearly the theme of mortality has struck a nerve.

When Breath Becomes Air is both short (280 pages) and fast-paced. One moment Kalanithi and his wife are considering whether or not to get pregnant, and a couple pages later, she is three months along. At no point does he arrive at the moment he decided to start writing the book, though his connection to literature is evident and explored. The style, the sense of rushing, is literally characteristic of the state in which Kalanithi was living; the timeline he had expected suddenly sped up and warped beyond recognition. When Breath Becomes Air is, in a sense, unfinished, derailed by Kalanithi’s rapid decline. But that is an essential component of its truth, of the reality that he faced.

Up front, Kalanithi admits that he and his wife were struggling at the time of his diagnosis. The long hours of medical school and residency—his wife is also a doctor—had taken a toll on their connection. But I was moved by the fact that his illness reconnected them. I didn’t get the sense that Lucy stayed out of obligation, but rather that the diagnosis stripped away everything that had gotten between them over the years. To be honest, Lucy Kalanithi’s epilogue was the part of the book that affected me most. This is, perhaps, unfair. She had time; time to reflect, and time to polish, a luxury her husband did not enjoy.

Kalanithi’s concern with seeking the meaning of life is largely philosophical, and occasionally religious. He is able to approach his death theoretically and intellectually, in a manner that can almost seem cold, even as it is also obviously the fire that drove him into medicine in the first place. After getting two degrees in literature, Kalanithi put off his dream of being a writer to pursue the medical side of this question, imagining a literary career could wait until after he was an established neurosurgeon and researcher. He is idealistic, and even romantic, still finding his voice even as he loses it. When Breath Becomes Air is simultaneously reflective and rushed, because while Kalanithi is concerned with big, deep questions, he was left with little time to ponder them.

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Further reflections on life and death: Mortality by Christopher Hitchens