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But as far as I can tell, the Paul Kalanthi described in the book would want me to write an honest critique of his work, and I can’t be 100% positive. I have no problem with the lofty philosophical bits, but many other prospective readers will. Kalanithi seems to think that his decision to study medicine is deeply interesting (he studied literature first, and first bristled at the thought since there were doctors in the family). But I didn’t care so much – who among us hasn’t changed their college major or master’s program once or thrice? Depending on your existing worldview, you’ll either find Kalanithi’s ultimate choice of neurosurgery as either inspired or eye-rollingly hubristic.
Kalanthi is interested in the mind-body problem, and I know that he would have studied it specifically. But, disappointingly, he can’t muster much more to say about it than platitudinous rhetorical questions (“There must be a way, I thought, that the language of life as experienced – of passion, of hunger, of love – bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats.”)
For someone who decided (years ago, as a student) that “human relationality” “undergirds meaning,” it’s a little rich that Kalanithi had become estranged from his wife prior to his diagnosis and then barely mentions her pregnancy in passing. I do believe it’s noble that Kalanithi tried to relate to his patients on a human level, especially seeing as how he operates on what he takes to be the seat of their souls. But readers are just as likely to feel alienated by Kalanithi’s focus on strangers to the detriment of those close by. It’s like an overdone character in a book: doctor too busy caring for patients to care for his own wife, oops! The very last paragraphs Paul wrote are about his infant daughter Cady, and the joy she brought him as he died. But that’s why those bits seem a little surprising. Perhaps, due to Kalanithi’s increasing frailty, the part of the journey that turned him from arrogant doctor into sated family man simply went mostly unwritten.
To be clear, producing a single book that encapsulates everything someone with a full professional and personal life might want to say is a totally Herculean task (especially to undertake while already critically/terminally ill). It’s certainly no surprise that When Breath Becomes Air isn’t completely satisfactory in that regard. You don’t have to be a perfect person to write a good book, either. But since this is a book review…
The highlight reel of Kalanithi’s life doesn’t make you feel especially connected to him, but you feel obligated to preemptively develop some empathy because you know what’s coming next. His experiences training as a doctor are sort of depressing and cliched: start ambitious, end desensitized. His experiences as a student shouldn’t have to be that significant. But because his life is turning out to be rather short and he was a student for most of it, they become forced into significance. I don’t know exactly what I’d want anyone, dying or not, to say about “human relationality” vis a vis meaning in life (personally, I don’t think there’s any such meaning to be had, but the question comes up often enough that there has to be something to say).
Throughout, Kalanithi’s writing is alternately beautiful and cringe-worthily heavy-handed (“in taking up another’s cross, one must sometimes get crushed by the weight”). It’s clear that he’s trying to find a comfortable writing voice (while also grappling with the weightiest possible subject matter), and under such pressure. What a shame that he got only an ill-fated Titanic crack at writing a book. If this material had spanned a few decades instead, who knows how it could have come out.
I did especially enjoy (???) the section on glioblastoma, from a neurosurgeon’s point of view. It helped me to more fully envision the events that unfolded around my family member’s recent diagnosis. The epilogue, by Paul’s widow Lucy Kalanithi, is quite beautiful (a number of Amazon reviewers like it better than the rest of the book). It helps to drive home that Paul is gone, his life’s previous work (doctoring), new work (writing), and would-have-been-future-work (parenting) all left unfinished. She too must find her voice for this task under immense pressure, kudos for that. I have only begun to dip a toe into the mental fog of grief and it’s enough to make you forget how to brush your teeth, let alone how to write something huge numbers of strangers would want to read.
All of the above notwithstanding, I read the book very quickly and definitely cried at the end.
Read this book if you’re interested in how a doctor thinks about his own death and if you don’t mind stories without silver linings.
Don’t read this book if you’re very put off by arrogance or intellectualism.
When Breath Becomes Air details Dr. Kalanithi's life as a neurosurgeon and his fight against advanced lung cancer. Even in his short life he achieved noteworthy recognition as a scholar, a surgeon, a scientist and now - posthumously - as a writer. The book is a tale of tribulations and frank reflections. Ultimately there's not much triumph in it in the traditional sense but there is a dogged, quiet resilience and a frank earthiness that endures long after the last word appears. The tribulations occur in both Dr. Kalanithi's stellar career and his refusal to give in to the illness which ultimately consumed him.
The first part of the book could almost stand separately as an outstanding account of the coming of age of a neurosurgeon and writer. Dr. Kalanithi talks about his upbringing as the child of hardworking Indian immigrant parents and his tenacious and passionate espousal of medicine and literature. He speaks lovingly of his relationship with his remarkable wife - also a doctor - who he met in medical school and who played an outsized role in supporting him through everything he went through. He had a stunning and multifaceted career, studying biology and literature at Stanford, then history and philosophy of medicine at Cambridge, and finally neurosurgery at Yale.
Along the way he became not just a neurosurgeon who worked grueling hours and tried to glimpse the very soul of his discipline, but also an eloquent writer. The mark of a man of letters is evident everywhere in the book, and quotes from Eliot, Beckett, Pope and Shakespeare make frequent appearances. Accounts of how Dr. Kalanithi wrested with walking the line between objective medicine and compassionate humanity when it came to treating his patients give us an inside view of medicine as practiced at its most intimate level. Metaphors abound and the prose often soars: When describing how important it is to develop good surgical technique, he tells us that "Technical excellence was a moral requirement"; meanwhile, the overwhelming stress of late night shifts, hundred hour weeks and patients with acute trauma made him occasionally feel like he was "trapped in an endless jungle summer, wet with sweat, the rain of tears of the dying pouring down". This is writing that comes not from the brain or from the heart, but from the gut. When we lost Dr. Kalanithi we lost not only a great doctor but a great writer spun from the same cloth as Oliver Sacks and Atul Gawande.
It is in the second part of the book that the devastating tide of disease and death creeps in, even as Dr. Kalanithi is suddenly transformed from a doctor into a patient. It must be slightly bizarre to be on the other side of the mirror and intimately know everything that is happening to your body and Dr. Kalanithi is brutally frank in communicating his disbelief, his tears, his hope and his understanding of his fatal disease. It's worth noting that this candid recognition permeates the entire account. Science mingles with emotion as compassionate doctors, family and a battery of medications and tests become a mainstay of life. The painful uncertainty which he documents - in particular the tyranny of statistics which makes it impossible to predict how a specific individual will react to cancer therapy - must sadly be familiar to anyone who has had experience with the disease. As he says, "One has a very different relationship with statistics when one becomes one". There are heartbreaking descriptions of how at one point the cancer seemed to have almost disappeared and how, after Dr. Kalanithi had again cautiously made plans for a hopeful future with his wife, it returned with a vengeance and he had to finally stop working. There is no bravado in the story; as he says, the tumor was what it was and you simply experienced the feelings it brought to your mind and heart.
What makes the book so valuable is this ready admission of what terminal disease feels like, especially an admission that is nonetheless infused with wise acceptance, hope and a tenacious desire to live, work and love normally. In spite of the diagnosis Dr. Kalanithi tries very hard - and succeeds admirably - to live a normal life. He returns to his surgery, he spends time with his family and most importantly, he decides to have a child with his wife. In his everyday struggles is seen a chronicle of the struggles that we will all face in some regard, and which thousands of people face on a daily basis. His constant partner in this struggle is his exemplary wife Lucy, whose epilogue is almost as eloquent as his own writing; I really hope that she picks up the baton where he left off.
As Lucy tells us in the epilogue, this is not some simple tale of a man who somehow "beats" a disease by refusing to give up. It's certainly that, but it's much more because it's a very human tale of failure and fear, of uncertainty and despair, of cynicism and anger. And yes, it is also a tale of scientific understanding, of battling a disease even in the face of uncertainty, of poetry and philosophy, of love and family, and of bequeathing a legacy to a two year old daughter who will soon understand the kind of man her father was and the heritage he left behind. It's as good a testament to Dr. Kalanithi's favorite Beckett quote as anything I can think of: "I can't go on. I will go on".
Read this book; it's devastating and heartbreaking, inspiring and edifying. Most importantly, it's real.
Top reviews from other countries
Paul Kalanithi was the second of three sons of an Indian couple settled in America. He had everything going for him. A comfortable life with family, marrying the love of his life, pursuing a career as special and as advanced as neurosurgery, reputation that could have landed him a plump career as soon as his training ended. But he also had something else too – lung cancer of an advanced stage. All his plans for the future suddenly vanished like mirage. With a life now cut short due to illness, Paul launched deeply into questions of existential nature, questions he had felt even while he was riding the crest of the tide.
This book is the answer to his questions about the meaning and purpose of human life. And, what an eloquent and poetic answer this has turned out to be! Published posthumously, this memoir recounts Paul’s early life in detail, telling us about what led to his decision to pursue a career in neuroscience, his early days as a resident surgeon and his ascent to glory. Then come the details of his illness, the various stages of cure that were tried and his frantic, determined quest to find the meaning for his life, whatever little was left of it. His wife Lucy’s epilogue is as fitting an end to the book as it could have been – beautiful, full of love and written more in a matter of fact manner than in a mawkish tone, just the same way in which Paul had written the whole book.
Life is a continuum and Death is a part of it, whether we like it or not. Death is in fact the only absolute certainty in the lives of everything, from the tiny sapling to the mightiest of stars. Just like the eyes ignore the nose that is in front of them, in order to give us an unhindered view of the world, our minds push that ineluctable reality behind so that we can plot our plans for decades until, of course, Death arrives calling, putting to waste our best-laid plans. The more we contemplate the meaning of our lives, the more we acknowledge what awaits us all in the end, and the more we chart the course of our lives accordingly, the easier it becomes for us to leave our mortal shells behind with dignity. Just the way Paul did.
Going through the book, I was often reminded of Viktor Frankl’s ‘Meaning Triangle’. According to him, a human being can add meaning to his/her life in one of these three ways – by creating something beautiful – a work of art, literature or something else similar, by being a beacon of love, filling the lives of others with love and joyful experiences or, finally, by showing a courageous attitude towards the travails that Life places on one’s path. According to me, Paul has done all the three and has really added a glowing meaning to his beautiful life, no matter however short it had been.
Done reading, I am leaving this book on my shelf, nestled between Viktor Frankl’s magnum opus ‘Man’s Search for Meaning’ and Anne Frank’s ‘The Diary of A Young Girl’, because I really feel that this book deserves its place up there!
I had absolutely loved Part 1. Everything Paul talked about enthralled me. His love for literature, his constant philosophical questioning as to what made life meaningful, his insights into the paradoxes of studying life to understand it vs experiencing it and building the relationships that gave it meaning, and his drive and fascination with biology and specifically neurology. He felt so alive in Part 1 as I read, his drive, his yearning to master this thing called life, his success mindset, I loved him. I felt so sad that he was dead and that I would never get to meet him. What a loss to the world. And it seemed so horribly unfair that a man who did so much to save the lives of others, should be deprived of life himself. Horribly unfair. Was that how we got rewarded in life for good deeds?
I gave myself a break before Part 2. A breather because I knew it was going to get heavy. Paul hadn't survived despite the upbeat voice of Part I. He had died. Others had warned me this was a book that would leave me in torrents of tears, so I gave myself some time to prepare for the emotional upheaval and brace myself.
Yet during that break, something nagged at me. A small voice at the back of my head told me something didn't sit quite right. Paul seemed too brilliant from the first part. Was that how he really was? Maybe he was saying some of things that so impressed me, because they came to light after he knew he was facing death. Maybe he was making himself sound better than he was...?
I made the mistake of googling the book so I could read some more about him. It was odd, I wasn't ready to face Part 2 yet, but I still wanted to stay connected to Paul and the book, so I found myself reading about him and his wife on the internet.
I discovered they'd had a baby! That shocked me. Why would he have a child when he knew he wasn't going to be around to bring it up?
And I read about his wife finding new love a couple of years after his death. Ironically, with a widower whose dead wife had also written and had a memoir published about her impending death.
I know it's totally wrong of me to feel this and judge, but I felt cross with her. I was still at the part in the book where Paul was alive, and here she was already with someone else. I lost love for her and my opinion of her became a little jaded. (I know, totally dumb and unfair. What can I say...)
When I finally got back to Part 2 then, I was already in lower spirits, but not because I knew Paul was going to die. Because I felt lost and didn't understand the decisions that he or his wife were making. I started to feel cross with him for having a baby when we wouldn't be there for her as she grew up. And when he returned to work full gusto after the first successful treatment, I was beyond flabbergasted. How could he do that. Knowing how ill he'd been? In fact, worse, how could he ignore all the pain that was returning and just use painkillers to mask it and go on? Why? Why would he do that? Why would anyone do that?
In my vanity and arrogance, I was so mad with Paul. He'd had a chance to live and he'd thrown it away in my opinion. He'd gone back to a job that had killed him. That's what it felt like for me.
And that oncologist! Why did she keep pushing him back to such a stressful unhealthy job?! There was no way in the world that a personality like Paul was going to go back to it part-time. A return to it was always going to almost certainly put critical strain on his body.
And emulating her question, he kept asking several times in the book, what do you value? What gives your life meaning?
Except, he never explicitly answered. In my arrogance, I judged the meaning of his actions and assumed that they revealed what gave him meaning: his job, achievement, becoming a high-flying consultant who was respected and adored by all.
I thought he was selfish. His marriage was on the rocks before his diagnosis, precisely because they weren't spending time together (my assumption) and there he was, having been given another chance, and he returned to the same crazy lifestyle. He valued success. He didn't value relationships or other people.
That was my original opinion. Harsh, judgmental and assuming.
It took a whole evening of discussion at Bookclub to really unlock this book and Paul Kalanithi's last days for me, and turn my opinion completely around. One of the members asked repeatedly, why did we think Paul wrote the book?
We didn't come to a common consensus right away. I felt he had wanted to leave a legacy. For selfish reasons. But others thought that the book was a way of him coming to terms with what was happening to him.
I now think that this is true, the book did give him opportunity to try to make some sense of his life and his impending early death. I think that anyone facing an early demise would find themselves trying to understand what was the point of it all.
I think he did also want to leave a legacy, but not truly for selfish reasons. Literature was a passion of his and he had always wanted to write. It was a dream, an ambition and he wanted to fulfil it before he died. There's even something noble in this. To leave something of value behind for others so that they might benefit from his sorrow and suffering.
When we noted that Paul never explicitly answered what he valued and what made his life meaningful, we considered that maybe he didn't actually know the answer to that question. And there was a searching for it in the book as he wrote it to some extent.
Someone noted that he'd repeatedly asked and needed to know, how long did he have? Because how long he had would impact how he chose to spend his remaining time. Did he have time to finish his training and graduate? Or was it less? If it was less, he would write his book. The same dilemma appeared again and again.
And he noted finally at one stage, the irony of his position. Before his diagnosis, he hadn't known how long he'd got left. And after, he hadn't known how long he'd got left.
My friends helped me to realise that Paul was a man that was really struggling even though he doesn't express it in emotional terms through his writing. What a horrible position to find yourself in. You've got cancer, you're definitely going to die. What do you do with your remaining days? What would you do?
For Paul, it made sense if he had more time to go back to work and complete the training he had invested virtually his whole life in. He was so close to the finish line. So close. It made sense to just go back and finish it and maybe even reclaim the future he had worked so hard and relentlessly to attain.
When the returning cancer started to make itself known through the excruciating back pains he started to experience again, he dumbed it down, ignored it, buried his head in the sand a little, or more accurately perhaps, stayed laser-focused on his goal. You don't become a neurosurgeon by being swayed or distracted by obstacles when they appear. That was not his way, and I can only assume that he was helpless to change this in himself.
I realised that for all the good that Paul Kalanithi did for others, how many lives he saved and how many people he redirected on the road back to health and self-care, ultimately he did not do the same for himself.
Did he realise this? That he had failed in his own self-care? He makes a point midway through Part 1 how some students had rallied to try and change the Hippocratic Oath equivalent that they were to swear to in the US, caveating that they should not put their own welfare behind their patients. Of course this was meant in a different context, but the irony strikes me hard in the face. I wish fervently that Paul Kalanithi had cared more about his own health and well-being, maybe then, maybe, he might even be here still to save more lives and see his wife smile and his little girl grow up.
Of course death comes to us all. It is our final master. The curtain that gives our performance meaning ultimately. And yet what I learnt from this book is that having Focus without Balance is a fatal mistake. Fatal to all projects, but in this case it feels like it may have been a key factor that claimed a life.
If Paul had not been so single-mindedly driven, would he have spotted those shadows in the scans before they became irreversible? Would he have chosen to make better choices about his hours (punishing 5am starts and such late finishes it was all he could do to collapse), about the food that he ate (a quick lunch of an ice-cream sandwich and coke was never going to be conducive to promoting good health in the body), about the emotions that he felt (there was such a desperate need/requirement to perform unreasonably consistently at an exceptionally high level for him)...
I feel so sad for Paul now. This was a man who struggled desperately to do the right thing in the only way he was taught to and the only way he knew how. But he was not rewarded for it ultimately.
I think now, that what Paul maybe valued most of all, was maybe trifold - relationships in conjunction with giving value to others and achievement. When he returned to neurosurgery and he was only doing the surgeries, he had said that the job had started to feel empty and he’d stopped enjoying it. And that it was only when he returned to consulting with patients that it became meaningful again.
And at the very end of the book, his final letter to his daughter, he tells her that when she questions if her life has had meaning, to know that she gave a dying man joy such that all his desires were sated. Finally in death, he had stopped the chasing that had been set up in his childhood and persisted in this crazy world we live in permeating a job that he loved and had tremendous value. Finally he found value and found himself being valued by a child who was till a baby and asked nothing of him other than to love and adore him and be loved and adored back in return. No chasing, nothing about his past or his future, all she wanted and needed from him was his attention now, here, in the present.
I've realised that this book was actually his real gift to his daughter. In it she can learn everything that her father was, what he stood for and believed in, what he loved and what he struggled with. Within the pages if she looks closely enough, she will find a guiding compass as to what kind of questions to ask yourself in life so you can be proactive in making your life meaningful and valuable.
For me, Paul and our bookclub members have given me an immeasurable gift. I have realised that like Paul, I myself need to more actively prioritise my health. Maybe that is why I was so mad with Paul, because he did what I do myself so regularly. Sacrifice longevity for quick wins in the scheme of things.
And perhaps equally importantly, I've recalled that none of us know how long we have truly. And that if we live our life without prioritising what's really the most important thing in the world for us, regardless of how long we have left, then we can only win ultimately. We must find a way to balance the scenario where we might live for several decades more and yet today might be our last day too.
I think this is actually possible and achievable. But it requires us to stop and take a step back every now and then, so that we look deeply into how we our lives now. And consider what it would be like if everything was to phase out to black in the next moments, as death stole us away. What would be the urgent need in these final moments?
Paul's sweet wife, Lucy, says in the afterword that Paul's hope was that the book might prompt readers to walk in his shoes a moment and feel what it's like to facing a difficulty such as his, before stepping out of them again. It's definitely done this for me. What a tremendous profound gift.
I don't know what the book might have been if Paul had had an opportunity to complete it. But I feel that paradoxically, not achieving completion was his greatest achievement of all. He perfectly demonstrates the future that awaits us all, and gives a profoundly valuable opportunity to breathe more life into our remaining days and years as a result.
It's a 'must read', inspiring - LIFE CHANGING - book. Paul, it seems to me, was a genius but he wasn't a distant, aloof intellectual - he was a kind, gentle, giving, empathetic person. Humanity is all the poorer now that he has passed away but thanks to and via the legacy of his beautiful writing, his teachings, his lessons, he will continue to inspire and comfort all who come across his giant footprint.
I'm now an unofficial, self-appointed ambassador/promoter of this book and the words and teachings of Paul Kalanithi.
Paul Kalanithi was a brilliant brain surgeon when he was diagnosed with an aggressive lung cancer, which despite treatment, continued to spread and ultimately caused his premature death. Paul was also a brilliant and very gifted writer, who, in his long terms plans prior to a diagnosis was going to spend twenty years of his life post-medical career, dedicated to writing. His ability to write shines through in this book. He uses language beautifully and has an almost poetic turn of phrase while remaining brutally honest to the situation he is facing.
Ironically, I found this book to be more about life than death. Paul talks about his journey into medicine and the privilege of being allowed to change the course of a person's life through surgery. His own cancer journey is shown as something he deals with rather than being ruled by. He continues to work and plans to start a family with his wife, Lucy. He charts the difficult transition he needs to make from being the doctor to being the patient and how he is not always successful in doing this.
No philosopher can explain the sublime better than this, standing between day and night. It was as if this were the moment God said, “Let there be light!” You could not help but feel your specklike existence against the immensity of the mountain, the earth, the universe, and yet still feel your own two feet on the talus, reaffirming your presence amid the grandeur.”
― Paul Kalanithi, When Breath Becomes Air
He really writes very well..