When Breath Becomes Air by Paul Kalanithi

Book Summary

Paul Kalanithi was a gifted young doctor with a bright future in medicine and neuroscience. But his whole life changed when he was diagnosed with terminal lung cancer in his mid thirties. When Breath Becomes Air is the memoir he wrote during the final years of his life.

It’s a shame that Kalanithi had his life cut so short. Yet at the same time, his experience gave the world this book, which offers eloquent reflections on mortality and meaning.

Notes and Quotes

When Breath Becomes Air Summary (Credit: Wikipedia)
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Before starting college, Paul was certain he didn’t want to become a doctor. If anything, he wanted to pursue a literary path as a writer. But he didn’t know that life would push him towards medicine while studying at Stanford.

  •  “I knew medicine only by its absence – specifically, the absence of a father growing up, one who went to work before dawn and returned in the dark to a plate of reheated dinner.”
    • From Paul’s perspective, the demands of a career in medicine were too high.
  • As an avid reader, he read a book that argued that “the mind was simply the operation of the brain.” This inspired him to look into biology and neuroscience courses at Stanford.

Why Paul decided to go into medicine:

  • “I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful?”
    • “Meaning…seemed inextricable from human relationships and moral values.”
    • “If the unexamined life was not worth living, was the unlived life worth examining?”
  • “It would mean setting aside literature. But it would also allow me a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay.”
  • “It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action.
  • “Medical school sharpened my understanding of the relationship between meaning, life, and death.”
  • “I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context.”

Paul’s reflections on finding meaning in life.

  • “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?”
  • “In taking up another’s cross, one must sometimes get crushed by the weight.”
  • “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.”

Paul’s philosophy on tackling death as a doctor:

  • “Learning to judge whose lives could be saved, whose couldn’t be, whose shouldn’t be requires an unattainable prognostic ability.”
  • “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…I came to see this as a more egregious failure than the patient dying.”
  • “As a resident, my highest ideal was not saving lives – everyone dies eventually – but guiding a patient or family to an understanding of death or illness.”
  • “Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end.”

Paul on cancer

  • “Cancer of the brain comes in two varieties: primary cancers, which are born in the brain, and metastases, which emigrate from somewhere else in the body, most commonly from the lungs.”
    • “Surgery does not cure the disease, but it does prolong life; for most people, cancer in the brain suggests death within a year, maybe two.”
  • “Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day.”

The Kaplan-Meier Curve: the number of patients who survive a deadly illness or disease over time. It’s a metric that doctors use to gauge and understand the “ferocity of a disease.”

  • Paul wouldn’t give his patients a specific number. Instead he would tell them that they could live many months to a couple of years.
    • “I came to believe that it is irresponsible to be more precise than you can be accurate.”

Paul on handling the loss of identity:

  • “Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused.”
  • “My life had been building potential, potential that would now go unrealized.”
  • He only felt like himself when he was in his doctor’s office. Outside of it, he had trouble figuring out who he was.
    • “Because I wasn’t working, I didn’t feel like myself, a neurosurgeon, a scientist – a young man, relatively speaking, with a bright future spread before him.”
  • He also didn’t feel like much of a husband to his wife.

Despite his familiarity with death, the experience of being a patient versus a doctor was totally different:

  • “Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.”
  • “Before my cancer was diagnosed, I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.”

After his diagnosis, Paul saw the world through two different perspectives:

  • As a doctor, he knew not to declare that he could win the fight or ask “why me?”
    • Stage IV lung cancer had a story that was changing. Death would still ultimately win out in the end, but there was a possibility of living longer thanks to emerging therapies.
  • As a patient, he needed to learn what his life worth living.  The understanding of the data and statistics around his cancer wouldn’t really help. He faced questions where there were no right or wrong answers. Questions such as:
    • Should he and his wife Lucy have a child?
    • Should he continue to fight for his career?

“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…”

  • “Death may be a one-time event, but living with terminal illness is a process.”

Paul on the concept of time:

  • “The way forward would seem obvious if only I knew how many months or years I had left. Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases. The truth that you live one day at a time didn’t help: What was I supposed to do with that day?
  • “Medical training is relentlessly future-oriented, all about delayed gratification; you’re always thinking about what you’ll be doing five years down the line. But now I don’t know what I’ll be doing five years down the line. I may be dead. I may not be. I may be healthy. I may be writing. I don’t know. And so it’s not all that useful to spend time thinking about the future – that is, beyond lunch.”

Paul on the roles of science and religion roles in discovering meaning:

  • Making science “the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning – to consider a world that is self-evidently not the world we live in.”
    • “That’s not to say that if you believe in meaning, you must also believe in God. It is to say, though, that if you believe that science provides no basis for God, then you are almost obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any.”
  • “Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.”
  • “No system of thought can contain the fullness of human experience.”
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