Book Reviews

When Breath Becomes Air by Paul Kalanithi – Book Notes, Summary, and Review

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Rating: 10/10

Date of reading: 19th-28th of December, 2016

Description: It’s like watching Game of Thrones and your favorite character dying. You proclaim that they didn’t deserve it. The same thing applies to the autobiographical piece “When Breath Becomes Air.” A young neurosurgeon who had it all– his youth, a great and pregnant wife, an amazing career.  And then he finds out he has a stage four lung cancer as a non-smoker. 

My notes:




live with. I knew a lot about back pain—its anatomy, its physiology, the different words patients used to describe different kinds of pain—but I didn’t know what it felt like. Maybe that’s all this was. Maybe.

A young nurse, one I hadn’t met, poked her head in. “The doctor will be in soon.” And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.


In Perfect Health I Begin


Kingman, Arizona, which we grew to cherish, but how he ever convinced my mother to join him there. They had eloped, in love, across the world, from southern India to New York City (he a Christian, she a Hindu, their marriage was condemned on both sides, and led to years of familial rifts—my mother’s mother never acknowledged my name, Paul, instead insisting I be called by my middle name, Sudhir)

Conrad, for his hypertuned sense of how miscommunication between people can so profoundly impact their lives. Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection. My brief forays into the formal ethics of analytic philosophy felt dry as a bone, missing the messiness and weight of real human life.

remarked that finding a community for myself in the literary world would be difficult, because most English PhDs reacted to science, as he put it, “like apes to fire, with sheer terror.” I wasn’t sure where my life was headed. My thesis—“Whitman and the Medicalization of Personality”—was well-received, but it was unorthodox, including as much history of psychiatry and neuroscience as literary criticism. It didn’t quite fit in an English department. I didn’t quite fit in an English department.

moral opinions about them. Words began to feel as weightless as the breath that carried them. Stepping back, I realized that I was merely confirming what I already knew: I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action. I finished my degree and headed back to the States. I was going to Yale for medical school.

it should be noted, entirely reasonable. Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that’s the point. Putting lifestyle first is how you find a job—not a calling.)

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?

2. A pathologist, dying of pneumonia, wheezing her death rattle before heading down to be autopsied —her final trip to the pathology lab, where she had spent so many years of her life.

Any major illness transforms a patient’s—really, an entire family’s—life.

V maintained that our only obligation was to be authentic to the scientific story and to tell it uncompromisingly. I’d never met someone so successful who was also so committed to goodness. V was an actual paragon.

my clinical duties in the hospital. His hair had thinned and whitened, and the spark in his eyes had dulled. During our final weekly chat, he turned to me and said, You know, today is the first day it all seems worth it. I mean, obviously, I would’ve gone through anything for my kids, but today is the first day that all the suffering seems worth it.” How little do doctors understand the hells through which we put patients.

If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed. Two hours could feel like a minute.

“It’s Jeff. He killed himself.”
Jeff was finishing his surgical fellowship in the Midwest, and we were both so punishingly busy…we’d lost touch. I tried to recall our last conversation and couldn’t.
“He, uh—he apparently had a difficult complication, and his patient died. Last night he climbed onto the roof of a building and jumped off. I don’t really know anything else.”
I searched for a question to bring understanding. None was forthcoming. 

onerous yoke, that of mortal responsibility. Our patients’ lives and identities may e in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.


Cease Not till Death


transition, I found myself the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-shattering.

Yes, all cancer patients are unlucky, but there’s cancer, and then there’s CANCER, and you have to be really unlucky to have the latter.

How else did I make life-and-death decisions? Then I recalled the times I had been wrong: the time I had counseled a family to withdraw life support for their son, only for the parents to appear two years later, showing me a YouTube video of him playing piano, and delivering cupcakes in thanks for saving his life.

Like my own patients, I had to face my mortality and try to understand what made my life worth living—and I needed Emma’s help to do so. Torn between being a doctor and being a patient, delving into medical science and turning back to literature for answers, I struggled, while facing my own death, to rebuild my old life—or perhaps find a new one.

thing exemplifying the second law of thermodynamics (all order tends toward entropy, decay, etc.).

Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving. Describing life otherwise was like painting a tiger without stripes. After so many years of living with death, I’d come to understand that the easiest death wasn’t necessarily the best. We talked it over. Our families gave their blessing. We decided to have a child. We would carry on living, instead of dying.

terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward. And so it was literature that brought me back to life during his time.

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.”

(People often ask if it is a calling, and my answer is always yes. You can’t see it as a job, because if it’s a job, it’s one of the worst jobs there is.)

But the truth was, it was joyless. The visceral pleasure I’d once found in operating was gone, replaced by an iron focus on overcoming the nausea, the pain, the fatigue.

The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. It felt like someone had taken away my credit card and I was having to learn how to budget. You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently. Two months after that, you may want to learn to play the saxophone or devote yourself to the church. Death may be a one time event, but living with terminal illness is a process.

In February, I flew to Wisconsin for a job interview. They were offering everything I wanted millions of dollars to start a neuroscience lab, head of my own clinical service, flexibility if I needed it for my health, a tenure-track professorship, appealing job options for Lucy, high salary, beautiful scenery, idyllic town, the perfect boss. “I understand about your health, and you probably have a strong connection with your oncologist,” the department chairman told me. “So if you want to keep your care there, we can fly you back and forth—though we do have a top-notch cancer center here, if you want to explore it. Is there anything else I can do to make this job more attractive?”

I didn’t know. But if I did not know what I wanted, I had learned something, something not found in Hippocrates, Maimonides, or Osler: 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.

God from the world but also love, hate, meaning—to consider a world that is self-evidently not the world we live in.

compelling. There is a tension in the Bible between justice and mercy, between the Old Testament and the New Testament. And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it. The main message of Jesus, I believed, is that mercy trumps justice every time.

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 pearl 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 reading,

“Okay,” she said. “That’s fine. You can stop neurosurgery if, say, you want to focus on something that matters more to you. But not because you are sick. You aren’t any sicker than you were a week ago. This is a bump in the road, but you can keep your current trajectory. Neurosurgery was important to you.”

I could drink enough by mouth. That evening, I was admitted to a hospital room. But when the nurse reviewed my medication list, I noticed Tarceva was not on it. I asked her to call the resident to correct the oversight. These things happen. I was taking a dozen medications, after all. Keeping track was not easy.

“Anyway, Tarceva is a special drug, and it requires a fellow or attending to sign off on it. Do you really want me to wake someone up for this? Can’t it wait till morning?”

“I usually take it at five A.M.,” I said. “And you know as well as I do that ‘waiting till morning’ means letting someone deal with it after morning rounds, which will be more like the afternoon.
“Okay, fine,” he said, and left the room.
When morning arrived, I discovered that he had not ordered the medication.

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.




Sunday evening, Paul’s condition worsened abruptly. He sat on the edge of our bed, struggling to breathe—a startling change. I called an ambulance. When we reentered the emergency room, Paul on a gurney this time, his parents close behind us, he turned toward me and whispered, “This might be how it ends.”
“I’m here with you,” I said.

Warm rays of evening light began to slant through the northwest-facing window of the room as Paul’s breaths grew more quiet. Cady rubbed her eyes with chubby fists as her bedtime approached, and a family friend arrived to take her home. I held her cheek to Paul’s, tufts of their matching dark hair similarly askew, his face serene, hers quizzical but calm, his beloved baby never suspecting that this moment was a farewell. Softly I sang Cady’s bedtime song, to her, to both of them, and then released her.

What happened to Paul was tragic, but he was not a tragedy.

On page 115 of this book, he wrote, “You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” It was arduous, bruising work, and he never faltered. This was the life he was given, and this is what he made of it. When Breath Becomes Air is complete, just as it is.

Check out more book notes at How I Read 90 Books In The Past 2 Years By Reading 20 Pages A Day

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