When Breath Becomes Air

“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.”

Kalanithi makes the distinction between knowledge and experience quite early on in the book. This is a thread that will continue throughout, even precluding his cancer. In this scene, he is simply the object of another person’s perception; he is breaking a rule. On top of it, he’s still trying to decide whether or not he is terminally ill or is experiencing the daily pains that most humans suffer.

“From my desert plateau, I could see our house, just beyond the city limits, at the base of the Cerbat Mountains, amid red-rock desert speckled with mesquite, tumbleweeds, and paddle-shaped cacti.”

Paul explores Arizona after moving there at the age of ten. Kalanithi creates image-rich, rhythmic prose in order to draw attention to the importance of this childhood setting. The small house is dwarfed by the landscape, something Paul will experience again when he works at summer camp. His observations for and love of the world relay a curiosity that becomes central to his character.

“Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it.”

After reading Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S., by Jeremy Leven, Paul becomes interested in the mechanics of the body and mind. The idea that we are tethered to our biological processes while retaining our free will is a paradox that Paul hopes to explore as he proceeds with college. That Paul derives meaning from a book that is not “high culture” is a testament to his understanding of literature.

“No philosopher can explain the sublime better than this, standing between day and night.”

As Paul enjoys moments of solitude in the Eldorado National Forest, he experiences a beauty of the world that supplements his search for meaning in life. The childlike wonder of young Paul is juxtaposed against the mature, philosophical thought of the older version of him.

“I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion.”

What is being described here is what elevates writing to art. Paul is beginning to appreciate the rhetorical devices that provide layers of subtext in literature. These invisible spaces, where the reader must make sense of the words on the page and identify with someone like or unlike him or herself, provide opportunities for empathy. This is what draws Paul to study literature in the first place.

“In our rare, reflective moments, we were all silently apologizing to our cadavers, not because we sensed the transgression but because we did not.”

At medical school, the students’ reactions to cadavers turn from shock to apathy. They become more practiced and learn what to expect. It is an early taste of how easily the art of medicine can become, simply, a job. This is the attitude that Paul tirelessly works to combat, as he moves up the scale of neurosurgery. Though this quotation is not necessarily apologetic, it acknowledges the truth of an experienced eye.

“The neatness of medical diagrams did nothing to represent Nature, red not only in tooth and claw but in birth as well.”

Paul’s first hands-on experience in the hospital is in the labor and delivery ward. He is beginning to realize that no amount of studying and test-taking can prepare him for work in the operating room. The goriness of birth distracts him from remembering the proper actions to take. Like with the cadaver dissection, it is only experience that can propel Paul into mastery of form. The language here used to “represent Nature” feels elevated, which is a device Kalanithi uses consistently to overlap literature and medicine.

“Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.”

This epiphany is related to the particular event that made Paul decide to concentrate on neurosurgery. A surgeon is telling a set of parents that their young child has brain cancer. Paul realizes that the surgeon has the opportunity to bring the world into focus for people who feel it has fallen apart. Cancer is a targetable disease, understood through a series of biological processes.

“Some days, this is how it felt when I was in the hospital: trapped in an endless jungle summer, wet with sweat, the rain of tears of the families of the dying pouring down.”

This is a particularly bleak description of the hospital, one given regarding Paul’s first year of residency. Although the prose is fluid, the diction does not give in to flights of fancy or melodramatics, suggesting a somewhat removed sorrow.

“In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador.”

There are times when Paul’s most sound advice to a family is to let the loved one die, rather than keep them alive on life support. By saying he must act as death’s “ambassador,” he means that a relationship to death exists that is not one of hopeless darkness. It can also mean saving a loved one from a significant amount of unnecessary suffering, in addition to saving a loved one’s family from trying to reclaim a person from death.

“Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.”

Kalanithi discusses the undivided obligation a surgeon has to his or her patients, as he reflects on a teary-eyed drive home after a day of loss at the hospital. There is a veer toward the axiomatic here, in order to incorporate the weightiness of Bible verse he later reveals as foundational to his thinking.

“After someone suffers a head trauma or a stroke, the destruction of these areas often restrains the surgeon’s impulse to save a life: What kind of life exists without language?”

Asking “What kind of life exists without language” is an exploration of another question Paul asked: “What makes life meaningful enough to go on living?” (71). At this point in his residency, Paul has been practicing long enough to have an extremely tight grip on neurosurgery’s complications, and the stakes involved in surgery. He is finally making judgment calls about what he thinks is best for a patient.

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

Jeff’s suicide devastates Paul as he imagines what advice he could have given to help his friend. This sentence closes the first part of the book, and is, in a way, an homage to Jeff, a reminder of their duty and purpose as surgeons. But the tone here is uplifting, rather than mournful: it acknowledges the inevitability of human error within the larger framework of human goodness.

“The fact of death is unsettling. Yet there is no other way to live.”

Although the news of Paul’s cancer brings sorrow, Emma seems willing to help him return to the OR, though she does not truly reveal whether or not she thinks this will happen. Because his future is still in sight, and still somewhat intact, there is stoic optimism during the early stages of Paul’s diagnosis, before he suffers the more severe symptoms of treatment and illness.

“The angst of facing mortality has no remedy in probability.”

Paul reminds himself how he treats his own patients. He refuses to feed them an overload of statistics, because he knows that a scared patient wants help navigating the big questions of life, not the faceless numbers of others who share his or her condition. Now, as Paul avoids succumbing to prepackaged data to explain his likelihood of survival, he decides to turn his method to practice.

“‘Don’t you get it?’ she said, taking my hand in hers. ‘If we’re the best at this, that means it doesn’t get any better than this.’”

Lucy talks to Paul after their first session with their relationship therapist. The inclusion of Lucy’s skepticism humanizes their relationship, making it three-dimensional. She is able to love and care for him while being realistic about the state of their marriage. This scene also gives a momentary relief from the fluorescent hue of the hospital. It shows that Paul’s life continues, even alongside the cancer.

“I had passed from the subject to the direct object of every sentence of my life.”

Paul fears he is becoming stagnant as Lucy’s husband, as she continuously attends to him. Because he is ill, he becomes the receiver of action, rather than the perpetrator of it. He seems to ask: In what terms do we describe our lives? Do we have power over language, or does language dictate the meaning of our lives?

“I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again.”

This is nearly a direct response to Paul’s becoming the “direct object” of sentences. Reading literature will expand his capacity and, therefore, give him agency over his experiences. This is a continuation of the phases Paul goes through, in which he sometimes prioritizes literature and sometimes prioritizes medical practice. The rush of residency has left him little time to enjoy reading over the past years, but now that he grapples with his own identity, a renewed relationship to books has become urgent.

“The curse of cancer created a strange and strained existence, challenging me to be neither blind to, nor bound by, death’s approach. Even when the cancer was in retreat, it cast long shadows.”

Paul is in the midst of receiving his dream job offer, but he’s having second thoughts. Because his cancer prophesies death’s existence, he can no longer make a decision without considering his illness. Denying illness seems just as foolish as readily accepting it. In the following pages, Paul concludes that the best way for him to make decisions is rationally and on a case-by-case basis. In this particular instance, he abandons his dream job and heads back to California.

“Human knowledge is never contained in one person.”

Paul reflects on what it means to pursue the “capital T-Truth” after witnessing a sermon with his parents and Lucy, and this is his conclusion. He suggests that each person is a conglomeration of those who have come before, and that we are shaped and informed by the people around us. This is an argument for the unknown, something that has brought Paul great discomfort over the course of his illness. As he is coming to reshape his life, he makes space for gray area, for things that he can explore but not explain.

“Emma was now the captain of the ship, lending a sense of calm to the chaos of this hospitalization.”

Paul finally decides to end the professional relationship with his own illness and let Emma be the doctor. It happens after a particularly tempestuous week, during which the doctors of various departments could not coordinate, and his family was at odds with what to do. This handing-over of his power is, in a way, an indication that Paul is even more powerful, is even more in-control over the course of his days. He no longer wishes to give priority to details that may be more appropriately managed by someone else. Now he can focus.

“Looking out over the expanse ahead I saw not an empty wasteland but something simpler: a blank page on which I would go on.”

The birth of Cady occurs with no complications, no oddities. She is a healthy baby, and Paul holds her in his arms. He uses the term “empty wasteland,” which is purposefully muddled. It invokes the confusion of his own life, the murky waters through which he’s waded to arrive at the birth of his daughter. Amidst the extreme gravity of his days, she is pure and uncomplicated. She is an absolute expression of love and joy, and she anchors Paul to his own livelihood.

“The manuscript for his book was only partially finished, and Paul now knew that he was unlikely to complete it—unlikely to have the stamina, the clarity, the time.”

Lucy Kalanithi writes the Epilogue for the book. This quotation provides a crucial piece of information, as it quite literally completes the story. Being given the circumstances of the author’s creation is a rare glimpse, one that only elevates the triumph that is When Breath Becomes Air.