Time. We all have 24 hours in a day, 365 days in a year (366 if a leap year). We all have a finite number of years in a life (though depending on one’s belief in reincarnation, we may have multiple lives). But how we spend those hours, days, and years varies by person, and often for the same person at different stages of his/her life.
Regardless of how much or little time you have left in your day, your life, please find a few hours to read Paul Kalanithi’s When Breath Becomes Air. And if you have only a few minutes, kindly read this review of a vital book. And if all you can spare are a precious few seconds, I request that you skim through the quotes below transformed by line breaks into poems.
Kalanithi’s slender memoir on living and dying was written in the final months of the author’s brief, but fully-lived, time. As his wife, Lucy, writes in the book’s epilogue, “During the last year of his life, Paul wrote relentlessly, fueled by purpose, motivated by a ticking clock.”
Fueled by purpose,
A ticking clock.
If it seems odd to begin a review with a poetized quote from the book’s epilogue, please know that the intent here is a frame-break, to invert your sense of time as linear, to urge a sense of urgency, to have you believing that “I must read this important book. And I must read it now!”
But if you are more invested in the author’s words than those of his widowed spouse, first read the last paragraph that Kalanithi wrote and reverse the illusion of forward time.
As Abraham Verghese encourages in the book’s foreword, “read it aloud.” Read the paragraph in a church, a temple, a park. Read it to someone you love in a kitchen, a study, a bed. The paragraph is meant to be read aloud, each syllable to be given life with each breath. Though the author is no more, When Breath Becomes Air assures him an immortality through readers who care enough to make time to connect with the life of a writer-physician-patient-scientist, a father-son-husband-friend, who sought to make sense of death through his own life.
Perhaps this book is not meant to only be read; perhaps it is meant to also be lived, like life itself—a precious gift. In considering this gift, Verghese, who like Kalanithi is a writer-physician, became aware not only of the author’s mortality, but also his own. Perhaps Verghese was looking in the mirror when he wrote about Kalanithi’s dream of writing a book: “One day. He thought he had time, and why not? And yet now time was the very thing he had so little of.”
He had time,
So little of.
Squeezed between the foreword and the epilogue is Kalanithi’s life: Prologue, Part I: In Perfect Health I Begin, and Part II: Cease Not till Death.
With the prologue, it is all there at entry. One is about to read a literary memoir of a dying man—a young, observant, and caring neurosurgeon whose mortality is self-evident. There is no mystery as to how this book will end; indeed it is right there in the opening paragraph: “I flipped through the CT scan images, the diagnosis obvious … Cancer, widely disseminated … I’d examined scores of such scans … But this scan was different: it was my own.” The power in reading Kalanithi’s narrative is to appreciatively learn about the life that he has lived and empathetically understand how he will live out his days.
What Makes Life Meaningful?
This reader did indeed appreciate learning about the immigrant’s life in Arizona that Kalanithi and his family experienced after being twice displaced—first from India and subsequently from New York. Young Paul had a childhood of books in the desert; he was a precocious reader for whom “books became [his] closest confidantes, finely ground lenses providing new views of the world.” As a Stanford undergraduate, having earnestly questioned “what makes life meaningful,” Kalanathi was at a fork in the road: pursue literature for the “best account of the life of the mind” or study neuroscience to understand the “rules of the brain.”
Under the tutelage of the philosopher Richard Rorty, Kalanithi came to recognize that a multidisciplinary approach suited him best, and yet the intersection of biology, morality, literature, and philosophy still left him pondering the meaning of it all. It was during his time at Yale Medical School—time with donor-cadavers that taught much more than anatomy and living-patients who taught much more than diagnosis—that Kalanithi would better understand that it was in “human relationality” that he could understand the meaning of life and death. And practicing medicine would be his path to further build human relationships. Because Kalanithi elected to specialize in neurosurgery, he found himself researching the brain, “the crucible of identity,” recognizing that the “question is not simply whether to live or die but what kind of life is worth living.”
While the desert, college, and medical studies are either mildly entertaining or intellectually fascinating, it is the foreshadowing of Paul’s deeply personal response to the question “What kind of life is worth living?” that captivates and inspires the reader. There is the simile of the two premature purple babies: “like tiny birds fallen too soon from a nest.” And there is Kalanithi invoking Samuel Beckett’s metaphor: “the light gleams an instant, then it’s night once more.”
The Doctor and Patient
Kalanithi ends Part I of his book with what appears to be guidance to young physicians: “You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” But these words can be—should be—guideposts to all who strive for meaningful lives.
“Ceaselessly striving” captures perfectly how Kalanithi lived his life, how the author wrote this book. Indeed, Part II of the book is titled “Cease Not till Death.” At the tipping point of his residency, when he began to reap all that he had sowed, the 36-year-old neurosurgeon-scientist was confronted by the sense that with cancer, all that he had been building toward would now become unrealized potential. The doctor had also become a patient.
And as he had counseled so many of his own patients, Dr. Kalanithi “had to face [his] mortality and try to understand what made [his] life worth living.”
He was blessed to have a supportive family and to have an oncologist, Emma Hayward, who would guide him through this last stage of ceaseless striving to rebuild his old life or find a new one. Hearing Emma’s facilitator’s voice (“You have to figure out what’s most important to you.”), Kalanithi as a patient internalized what he had long known as a doctor: “the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”
When Emma helpfully tells Kalanithi that he has to figure out what’s important to him, he responds, “If I had some sense of how much time I have left, it’d be easier. If I had two years, I’d write. If I had ten, I’d get back to surgery and science.” Reclaiming ambitions without the “surety of time” is at first overwhelming. Indeed, this reader himself had so internalized the author’s dilemma that he was overwhelmed by a twinned paradox of frantic action and paralyzing uncertainty; and this reader was inspired by how Kalanithi “felt that life wasn’t about avoiding suffering” and “would carry on living, instead of dying.”
The New York Times columnist David Brooks recently wrote that “when one is inspired, time disappears or alters its pace.” He defined inspiration as coming “from the Latin inspirare, meaning ‘to breath into’.” Brooks continued, “the one who is inspired performs his own feats and inspires others.” To be sure, When Breath Becomes Air has already inspired and will continue to inspire countless medical professionals, chronically ill patients, and lay readers who have only a glancing relationship with healthcare. The audience for this important book is vast, for it is anyone invested in living a full and meaningful life. So, yes, dear reader, this memoir is written for you.
But as his time disappeared during his months of inspired writing, I imagine that if Paul Kalanithi could have had only one reader, he would have aspired to breathe his wise words into his infant daughter, Cady: “I hope I’ll live long enough that she has some memory of me. Words have a longevity I do not.”
In her moving epilogue, Lucy Kalanithi tells the reader that her husband died on March 9, 2015, surrounded by family, cradling Cady, “his face serene, hers quizzical but calm, his beloved baby never suspecting that this moment was a farewell.” Echoing Atul Gawande’s influential book Being Mortal, the epilogue is a compassionate primer on the medical fact of death. Just as Gawande asked the reader to consider how to approach the final stage of life, the Kalanithi family was confronted with whether to resuscitate Paul if the only intervention remaining was a ventilator. Lucy expressed to the rest of the family and to the medical professionals that “if [Paul] doesn’t have a chance of meaningful time, he wants to take the mask off and hold Cady.” When Paul said, “I’m ready,” the reader understands that by “ready, he meant, to remove the breathing support, to start morphine, to die.”
When Breath Becomes Air
The mask off
For Karishma (RCO’s niece who, with her MPH, first recommended this book to him), for Avinash and Amisha (the Oza Family’s aspiring MDs), and for the real and metaphoric book(s) we all aspire to write, to give life.