Book Review - When Breath Becomes Air by Paul Kalanithi
Book Review
When Breath Becomes Air is the unfinished autobiography of neurosurgeon, Paul Kalanithi, who was completing his medical residency when he was diagnosed with metastasized cancer, throughout multiple organ systems. This book is a beautiful, exhilarating, and captivating account of, and from, a man with a relatable love and desire for life, particularly that that is sparked by the threat of its end. In all the best ways, this story makes the reader crave the joys and bear the misery of life, right along with Paul. Paul reminds that, although his story is unfortunate, it is not uncommon. This path is one that many will walk, either themselves or alongside loved ones. An excerpt from the epilogue reveals Paul’s intentions, “[I want the reader to] get into these shoes, walk a bit, and say, ‘So that’s what it looks like from here… sooner or later I’ll be back here in my own shoes.’ That’s what I’m aiming for, I think. Not the sensationalism of dying, and not the exhortations to gather rosebuds, but: Here’s what lies up ahead on the road.” I do believe that Paul’s message was received, not just by myself, but by the millions of readers that it touched, as a New York Times bestseller.
I almost exclusively reside in fantasy/dystopian worlds and away from contemporary novels or nonfiction, when it comes to my reading habits. However, I wanted to reach out of my comfort zone, and I’m glad that I did. This book really takes the reader on an experience like none other. The prose flows so well, weaving stuttered thoughts into layers, while remaining smooth, understandable, and thought provoking. Paul’s deep love for both science and literature gave him a very unique perspective on the world. Although he was involved in some of the most clinically exhaustive and scientific of career paths, he drew much of his human experience from written works. He believed that, “Literature not only illuminated another’s experience, it provided…the richest material for moral reflection.”
Paul tells the reader stories that shaped his identity and his ideas about life. One such story depicts a visit to a home for people with severe brain injuries, when Paul was deeply offended at someone for insinuating that some of these lives may not be worth living, instantiating a point for the growth of his own understanding of life worth. This story, and those like it, make the reader feel as though they are watching this beautiful life in its building stages. We realize meaning right alongside Paul, particularly when he settles into the gravity of being a neurosurgeon and notes, “Brains give rise to our ability to form relationships and make life meaningful. Sometimes, they break.” Paul introduces us to the reality that we all know, but don’t want to accept, that more often than not, death is not peaceful.
Nonetheless, Paul does not focus on morbidity, and the autobiography is often quite funny. For example, Paul paints the uncomfortable situation of cutting up cadavers while craving a burrito (as formaldehyde can be a powerful appetite stimulant). Paul extends a hand to the scientifically inclined, using metaphors. At one point during a tough part of his cancer treatment he notes, “If time dilates when one moves at high speeds, does it contract when one moves barely at all? It must: the days have shortened considerably.” Paul reminds us that although things like brain surgery are glorified, it comes down to the person in the chair and the person hovering above, with the knife. "When the electrode sends current into a critical piece of cortex, it disrupts the patient's speech: ‘A B C D E guh guh guh rrr...F G H I...’ The brain and the tumor are thus mapped to determine what can be resected safely.” This is Paul’s “normal” before his life gets turned upside down.
Throughout the book, the reader walks through Paul’s journey through life. However, potentially more substantially, they get to see the changes to what Paul perceives life is and should be. He describes life not as some journey upward or forward, as is typical philosophy. Instead, he gives the reader words to think upon; “I don’t believe in the wisdom of children, nor the wisdom of the old. There is a moment, a cusp, when the sum of gathered experience is worn down by the details of living. We are never so wise as when we live in this moment.” Unfortunately, such poetic thoughts present themselves in dire circumstances. Yet, they probably would not have as much resonance outside of them.
I read this book mostly during my breaks at work. However, I became so absorbed in it that, oftentimes, I would find myself startled when interrupted. I lived a part of Paul’s life with him and I was both invigorated and frightened to see life this way – to imagine myself in Paul’s shoe’s. It was like being submerged in a pool for a few seconds past comfortable and gasping for air while emerging. The energy inherent to this book is mesmerizing. Emotions aren’t just read, they’re effortlessly felt. The reader oozes resentment, giddy joy, or solace ten times over what the words say on the page. Considering this, I would very much recommend this book.
Summary of Book Highlights
At the beginning of the book, Paul seems to have a good grasp on being a doctor, his philosophy relatively cemented. Paul had defining moments in his schooling, these moments were not mind-blowing lectures on the beauty of human anatomy, but rather the moments where social constructs were created or enforced. One such instance resonates; "Early on, when I made a long, quick cut through my donor's diaphragm in order to ease finding the splenic artery, our proctor was both livid and horrified. Not because I had destroyed an important structure or misunderstood a key concept or ruined a future dissection but because I had seemed so cavalier about it. The look on his face, his inability to vocalize his sadness, taught me more about medicine than any lecture I would ever attend." Paul was often faced with the question of "not simply whether to live or die but what kind of life is worth living."
Paul reminds the reader not to belittle situations of the mind and heart. He guides them to philosophically decide where the fine lines lie in terms of life worth. When it comes to brain surgery, "Would you trade your ability - or your mother's - to talk for a few extra months of mute life?....Your right hand's function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable?"
Paul introduces the reality of being a doctor and their relationship with mortality. Doctors are responsible for the outcome, whether good or bad. And, unfortunately, no one is perfect. Paul tells us that he "made mistakes. Rushing a patient to the OR to save only enough brain that his heart beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want..." Doctors may not know the specific person, their desires, motives, or feelings on life. And, yet, they are still responsible for making decisions when others can’t. "Some insist on this life and embrace its possibility, eyes open. But many do not, or cannot, and the neurosurgeon must learn to adjudicate." Paul reminds us repeatedly that neurosurgeons protect more than just life, they protect your identity, your soul.
Towards the seconds half of the book, Paul strays from focusing on his doctoring philosophy and talks more about his life philosophy. Paul comes to express his coming to terms with becoming a “statistic” and the ravenousness associated with this. He reminds the reader of the all too familiar feeling of googling symptoms online and jumping to the worst conclusions. But he recognizes this fallacy, "Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability." Paul has an especially difficult time transitioning between doctor to patient, an experience that he had not anticipated, considering his work.
He explains the helplessness of humanity and illness. He lets the reader know that, "the word patient simply meant ‘the object of an action’, and I felt like one. As a doctor, I was an agent, a cause; as a patient, I was merely something to which things happened...a thing exemplifying the second law of thermodynamics…But I'd had no idea how hard it would be, how much terrain I would have to explore, map, settle. I'd always imagined the doctor's work as something like connecting two pieces of railroad track, allowing a smooth journey for the patient. I hadn't expected the prospect of facing my own mortality to be so disorienting, so dislocating...[I'm] lost in a featureless wasteland of my own mortality."
However, Paul doesn’t live the rest of his life in this distress, he recognizes that he "would have to learn to live in a different way, seeing death as an imposing itinerant visit but knowing that even if I'm dying, until I actually die, I am still living."
Paul had a sweet take on love and family, opting to have a baby before his time ended. However, this wasn’t necessarily an easy decision, Paul spoke with his wife, Lucy: “‘Will having a newborn distract from the time we have together?’ [Lucy] asked. ‘Don't you think saying goodbye to your child will make your death more painful?’ ‘Wouldn't it be great if it did?’ I said. Lucy and I both felt that life wasn't about avoiding suffering."On marriage, he states, "Our relationship was still deep in meaning, a shared and evolving vocabulary about what mattered."
The unfinished book ends with an epilogue written by Paul’s widow, Lucy. Lucy gives the reader a look into how life ended for Paul, pain and gentility included. Paul ends with a message to his daughter, only 8 months old when he passed, a message that he probably didn't think the book would end on but a beautiful end nonetheless.
My Connection
As someone who experienced the passing of my parents as a teenager, I connected with this book. I’d seen death in those closest to me multiple times before I had turned 18 and found solace and understanding in this book.
Paul helped me do some of my own soul searching, helping me determine what is important in life. What will I have wished that I held onto when it is my time to go? What is most important to my short existence in this world? I recently got out of college, and although I have much time to figure out what I would like to do with me life, I still stress over the idea that I have ignored crucial life advice. I have let myself get too involved in stability and monetary indulgences, that I have ignored my passions and my desires. I don’t know how to let my predisposition toward comfort and status be superseded by my desire toward learning and helping. "This is how 99 percent of people select their jobs: pay, work environment, hours,” Paul wrote, “But that's the point. Putting lifestyle first is how you find a job - not a calling." I know there’s a calling for me, but I don’t yet completely know what that is. I am always a bit fearful that I’m wasting myself by not pursuing something more meaningful to my own psyche.
I’ve always been interested in medicine and working in the medical field. I even got one of my bachelor’s degrees in Biomedical Engineering. However, I’ve also been held back by the fear of not being good enough. Or rather, not wanting to know that my existence has hindered another somehow. In engineering, at least in my specific field right now, when something goes wrong, people say that it isn’t a big deal – that no one will die if I make a mistake. This is seen as something to be thankful for, there is never too much weight on your shoulders.
Still, I want the weight, I need to feel like my work is making a difference to humanity. But, would I be able to handle it? Paul goes through the same dilemma a few times in the book. It’s comforting to see the same desire, restraint, and understanding. It gives me hope and trust in my own capabilities.
Reading about Paul’s experiences made me rethink the bunches of childhood hospital visit. Doctors were heroes to me. Paul helps humanizes doctors, particularly those who have to make decisions between life and death, or, more horrifically, between the time to save one life over another.
Paul gave me comfort in the recognition that doctors aren’t different than other people. They are very educated and specialized in helping others. But also, they get sick, they get hungry, they get so overworked that they forget how to act normally. They worry about the sandwich that they haven’t put in the fridge. They can get into car accidents, they can get cancer, they don't need to grow ripe in their old age - they can die suddenly and horrifically - just like the rest of us. I often make invincible stars out of doctors - but the truth is they aren't - at least aren’t invincible. Doctors can have mental illnesses, the can be depressed, they can kill themselves out of guilt. They can have family problems, they can be absent parents or spouses, both physically and mentally. Oddly enough, I found this comforting. This gave an excuse to times where doctors seemed unempathetic, disinterested, or curt. And major props to all the times when they managed to be the rock that kept my family together.
Paul described that "That first conversation with a neurosurgeon may forever color how the family remembers the death, from a peaceful letting go (‘Maybe it was his time’) to an open sore of regret (‘Those doctors didn't listen! They didn't even try to save him!’)” - as someone who has spoken with doctors and even neurosurgeons in this context - I can completely agree. This book gave me the gift of empathy and forgiveness in this way.
This book made me think a lot about mortality and my specific relationship with it given my background. My parents had different views on life/death and medicine. My mother had this thirst for life, although she had been ill for most of it. She wanted to be hooked onto machines for as long as they would keep her, so long as there was even the slimmest of chances of recovery. My father on the other hand, albeit very tenacious in his own right - considered much the quality of life he would live. He didn't want to live hooked up to monitors - he wanted peace in life and in death - if it was his time, so be it. I don't know which I would choose - I suppose you never really know until you're put in that situation.
It was important to have confirmation that life is not about preparing for death - lots of people, including Paul and my dad, had their cancer stabilized or completely removed, at least for a time. What’s much more difficult to come to terms with is who you are and how you live your life. When your relationships change, your day to day activities change, your likes/dislikes, your feelings towards the world, the things that fill your day change - you change, even if you don't want to. Cancer is cruel in that it allows you the time to go through the little things in life. Although cancer is sudden, it's not quite as sudden as you want it to be. There leaves time to rethink your life and decisions, to gruel over the physical and emotional pains as well as the pain now present in relationships that helped define you.
When Paul saw the return of the cancer that was ultimately his demise. His experience with cancer was similar to that of my own family, Paul described" A new tumor, large, filling my right middle lobe....I was neither angry nor scared...it simply was." I believe most people with cancer eventually enter this mindset. It just is. You learn that life is not fair, it’s not generous, but it’s also not unfair nor ungracious. It just is. And to experience that, in the context of someone else gave validation to my own feelings.
Reading this book was painful, but it helped bring me some peace.
Disclaimer:
I am no book reviewer. This is my relatively stream of consciousness style review of the book. On another note, I hope you have a good day.