When Breath Becomes Air by Paul Kalanithi - review

For all his admiration of literature — the title of the book is paraphrased from a sonnet by Jacobean poet Baron Fulke Greville —Kalanithi chose neurosurgery for its insights into how “biology, literature and philosophy intersect”. Working as a resident surgeon, he witnessed countless injuries and describes performing many operations, the mistakes and failures, as well as the successes, with death never far away. “I had started in this career, in part to pursue death: to grasp it, uncloak it, and see it eye to eye, unblinking.” He worried about his failure to empathise with his patients and their families. What he told them, and how he said it, mattered enormously. Yet he also thrilled at his superlative technical abilities. When he cut “the dark gray rotting tumour” cleanly out of “the fleshy peach convolutions” of the brain he’d mutter “Got you, you fucker”.

But technical excellence was also a moral requirement. He was devastated when he learned that having damaging the hypothalamus of a child by a millimetre while removing a brain tumour, the boy had had to be institutionalised a few years later, or that locked-in syndrome would have been the result of cutting just two millimetres further into a man’s damaged brain stem. As surgeons, “we had assumed an onerous yoke, that of mortal responsibility.”

He brought this clear thinking and intellectual curiosity to his own terminal diagnosis, which “had changed both nothing and everything.” His “carefully planned and hard-won future no longer existed,” so the question was, what would replace it, since there was no knowing how long he would live. But facing mortality meant trying to understand what had made his life worth living. He and his wife went ahead with having a baby, who was conceived through intrauterine insemination.

As he neared the end, typing in seamless, silver-lined gloves to protect his fingertips from fissures caused by chemotherapy, he perceived that time had slowed down and lost its meaning, while the future had flattened “into a perpetual present”. The exception to all this was his daughter, a burbling baby who filled his days with “a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied.” In her existence he truly found the meaning of his life.