When Breath Becomes Air

by Paul Kalanithi

Date: Feb 10, 2019

A Bit Of A Back Story

I can't seem to recollect how I first heard about Paul Kalanithi's heart-rending memoir When Breath Becomes Air. In hindsight, the whole experience of choosing this book feels surreal to me. All I knew (back then) was that it was a book written by a dying man. I made a mental note to read it later and just moved on. But the story doesn't end there. It somehow came back to find me at the right moment in my life. If I've learned anything in 2018, it's that timing is everything. Off late, I've been struggling to find meaning in life. Things that used to give me a strong sense of purpose no longer do. Atleast, they aren't enough to be sated. Unbeknownst to me, life had moved the goal posts already. What made me tick a year back doesn't work anymore. I need to reinvent myself and redefine the things that make my life worth living. It's almost impossible to talk about life and meaning without thinking about death. Nothing is more certain than death. Depending on your perspective, it could make life meaningful/meaningless. I haven't read/experienced enough to make a strong argument supporting either claim. But I do know that finitude (a word I learned from Paul Kalanithi) enhances meaning in life.

"The dying are the ones who have the most to teach us about life..." These words kept echoing in my mind as I rolled under the blanket, musing about a life well lived. I didn't know where I had read/heard that phrase, but I couldn't get it out of my head. I was experiencing the earworm reverberation. Finally, I had to google the phrase and et voila, I came across Paul Kalanithi, a great man whose life ended way too soon. A man who'd forever remain an inspiration to countless men and women including yours truly. A man who didn't avert his gaze when the grim reaper came knocking on his door. A man who's authenticity and integrity took my breath away. Quoting Lucy Kalanithi, "What happened to Paul was tragic, but he was not a tragedy."

Preparing Yourself Mentally To Read This Book

Ecclesiasticus 6:33

If thou love to hear, thou shalt receive understanding: and if thou bow thine ear, thou shalt be wise,

King James Version (KJV)

This book has a lot of wonderful things to say. Question is are you prepared to listen? Some books are meant to be skimmed through in a rapid pace. There are a select few with which you take your time, carefully weighing each word, reading and re-reading portions you cherish. This book is just a little over 200 pages. I should've been done with it in less than 3 hrs. But it took me over 24hrs overall. Why? Simple. I was hanging on to every single word. I would sometimes read it out loud and let it ruminate for a bit. This book isn't meant to be a monologue. Give yourself some time to let Paul's words sink in. Listen to the voices in your head. They're all responding to Paul's beautiful prose-poem style of writing. It'd force you to dig deeper. A quick read to get a summary is a waste of your time. It's not a soap you watch to kill time. It's the tragic story you watch with your eyes wide open, unable to avert your gaze, experiencing a motley of emotions until something fundamentally changes in your moral core. Abraham Verghese nailed it in the foreword:

Be ready. Be seated. See what courage sounds like. See how brave it is to reveal yourself in this way. But above all, see what it is to still live, to profoundly influence the lives of others after you are gone, by your words. In a world of asynchronous communication, where we are so often buried in our screens, our gaze rooted to the rectangular objects buzzing in our hands, our attention consumed by ephemera, stop and experience this dialogue with my young departed colleague, now ageless and extant in memory. Listen to Paul. In the silences between his words, listen to what you have to say back. There in lies his message. I got it. I hope you experience it, too. It is a gift. Let me not stand between you and Paul.

I highly recommend reading the following articles written by Paul first. Think of them as pre-requisites for his book. It mentally prepares you for the journey:

  1. How Long Have I Got Left?
  2. Before I go - Time warps for a young surgeon with metastatic lung cancer

What Happens To Your Identity & Sense Of Purpose When All Your Grand Plans Are Shot To Hell?

It's been a while since a book made me cry. Paul Kalanithi was no ordinary man. He confronted death - as a scholar, as a surgeon, and finally as stage 4 cancer patient. He might have died too soon, but he did not go gently into that good night. He's achieved more in 37 years than most people ever will in their lifetimes. What most people fail to understand is that he's competing on an entirely different level. It's an unending pursuit of perfection and self-realization that gives deeper meaning to life.

My brother Jeevan had arrived at my bedside. “You’ve accomplished so much,” he said. “You know that, don’t you?”

I sighed. He meant well, but the words rang hollow. My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close. I was physically debilitated, my imagined future and my personal identity collapsed, and I faced the same existential quandaries my patients faced. The lung cancer was confirmed. My carefully planned and hard-won future no longer existed.

A Life Well Lived

As a neurosurgical resident, Kalanithi was well aware of the difference between living and merely surviving, the paradox and the interplay between the tough medical choices he's made and the things that give his patient's lives meaning.

While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact…At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability – or your mother’s – to talk for a few extra months of mute life? The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?

There's a certain alien beauty in tragedy and suffering. I sound like a psychopath when I say it out loud. But it's true. Bear with me. The kindest people have endured some of the darkest moments in life. The unexpected kindness of strangers in the face of unending pain and suffering is one of the hallmarks of humanity. Reading this book is like watching a tragedy of epic proportions unfold. He slowly reels you in. You know how it ends. Yet you are unprepared. A man who's achievements and passion evoke camaraderie and understanding in my heart. I know what it takes to achieve in his level. In a moment of pure vanity, I thought I was like him. Truth be told, if I live to be half the man Paul was, I think that'd be a life well lived. Amidst a horde of "woke" people forever harping on and on about living every day it was your last, here's a man who says something sensible :)

Grand illnesses are supposed to be life-clarifying. Instead, I knew I was going to die – but I’d known that before. My state of knowledge was the same, but my ability to make lunch plans had been shot to hell. The way forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d go back to treating diseases. The truth that you live one day at a time didn’t help: What was I supposed to do with that day?

Struggle Toward The Capital-T Truth

I saw a few reviews mention that the book had nothing new to say. If you think Paul Kalanithi hasn't said anything that hasn't been said before (in terms of life lessons), you are right. But it also means that you haven't been paying attention. It's not what he said. It's the way he said it. The beauty truly lies in the eyes of the beholder. He's not the first person to talk about death, life and meaning; and he sure as hell won't be the last. For centuries we've had eastern and western philosophers discuss and debate about death and meaning. Personally, what struck me the most was Paul's unique perspective and undeniable authenticity. He was interested in discovering where “biology, morality, literature and philosophy intersect”. His whole life was built around those ideals.

Struggle toward the capital-T Truth, but recognize that the task is impossible - or that if a correct answer is possible, verification certainly is impossible. In the end, it cannot be doubted that each of us can see only a part of the picture. The doctor sees one, the patient another, the engineer a third, the economist a fourth, the pear diver a fifth, the alcoholic a sixth, the cable guy a seventh, the sheep farmer an eighth, the Indian beggar a ninth, the pastor a tenth. Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete. And Truth comes somewhere above all of them, where, as at the end of that Sunday's ready; the sower and reaper can rejoice together. For here the saying is verified that "One sows and another reaps." I sent you to reap what you have not worked for; others have done the work, and you are sharing the fruits of their work.”

An Impassioned Message For His Daughter That Brims My Heart With Love

He leaves behind this message for his daughter, Cady, eight months old at the time of his death.

When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.

Perfection Is A Never Ending Journey

He died trying to finish the book forever exemplifying his core value - strive for perfection knowing full well that you can never achieve it :)

You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.

In the immortal words of Samuel Beckett, "I Can’t Go On. I’ll Go On."

And so it was literature that brought me back to life during this time. The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action. I remember the moment my overwhelming unease yielded, when that seemingly impassable sea of uncertainty parted. I woke up in pain, facing another day – no project beyond breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over “I can’t go on. I’ll go on.”

Highlights & Comments About Lucy Kalanithi's Poignant Epilogue

Relying on his own strength and the support of his family and community, Paul faced each stage of his illness with grace — not with bravado or a misguided faith that he would “overcome” or “beat” cancer but with an authenticity that allowed him to grieve the loss of the future he had planned and forge a new one. He cried on the day he was diagnosed. He cried while looking at a drawing we kept on the bathroom mirror that said, “I want to spend all the rest of my days here with you.” He cried on his last day in the operating room. He let himself be open and vulnerable, let himself be comforted. Even while terminally ill, Paul was fully alive; despite physical collapse, he remained vigorous, open, full of hope not for an unlikely cure but for days that were full of purpose and meaning.

Paul’s voice in When Breath Becomes Air is strong and distinctive, but also somewhat solitary. Parallel to this story are the love and warmth and spaciousness and radical permission that surrounded him. We all inhabit different selves in space and time. Here he is as a doctor, as a patient, and within a doctor-patient relationship. He wrote with a clear voice, the voice of someone with limited time, a ceaseless striver, though there were other selves as well. Not fully captured in these pages are Paul’s sense of humor—he was wickedly funny—or his sweetness and tenderness, the value he placed on relationships with friends and family. But this is the book he wrote; this was his voice during this time; this was his message during this time; this was what he wrote when he needed to write it. Indeed, the version of Paul I miss most, more even than the robust, dazzling version with whom I first fell in love, is the beautiful, focused man he was in his last year, the Paul who wrote this book—frail but never weak.

The quote above is important for context. Throughout the book, we see a side of Paul Kalanithi that he chose to reveal to us - a voracious reader, a gifted writer, a high-achieving scientist-surgeon, a man in pursuit of meaning and perfection, a man who placed a lot of value in human relationships. But that is not the complete picture. Lucy Kalanithi wrote the epilogue that concludes the book. Her account of Paul's final days is heartbreaking to say the least. When I was reading her afterword, I had to frequently stop to close my eyes and fight the tears. Her last sentences struck a chord with me:

“For much of his life, Paul wondered about death – and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness.”
This book would remain close to my heart for a long, long time. I'm not who I want to be yet. Thanks to Paul Kalanithi, I atleast know that I'm headed in the right direction. Read this book. See what authenticity looks like. See what facing death with grace and integrity looks like. Listen to your inner voice when reading his immortal words. I promise, it'll make you a better person.