When Breath Becomes Air
Author: Paul Kalanithi

Synopsis

This is a brave autobiography of a doctor’s relentless journey to death. The author bravely chronicles how lung cancer, diagnosed at the very young age of 36, threatened and eventually extinguished his promising future. He was a brilliant neurosurgical trainee who had ‘earned the respect’ of his seniors, ‘won prestigious national awards‘, and was already ‘fielding job offers from several major universities’. With flowing prose, he graphically illustrates his experiences, from unexplained weight loss and ‘ferocious’ back pain, to his CT scan images showing that ‘the lungs were matted with innumerable tumours, the spine deformed, a full lobe of the liver obliterated‘ (pages 3-7). The author’s lofty motivation for writing, summed up by his widow’s epilogue, was ‘to help people understand death and face their mortality‘ (page 215).

The unique feature of the book is the author’s sad transition from high achieving doctor to helpless patient. This theme is excellently reflected by the book’s contrasting front and back covers. The author similarly contrasted his professional life on the one hand, and his illness narrative on the other. The reader is therefore heartened to read of his surgical expertise in complex diseases such as giant aneurysms and arteriovenous malformations, and dismayed to learn of the indignities of admission to hospital dressed in ‘the familiar light blue hospital gown’ with the identifying ‘plastic arm bracelet all patients wear’ (page 10-16 and 106-107). He wrote of his realisation that doctors understand very little about ‘the hells through which we put patients’ when we send them for invasive tests and expose them to harmful treatments (page 102). He says, ‘as a doctor, you have a sense of what it’s like to be sick, but until you’ve gone through it yourself, you don’t really know‘ (page 140).

A key theme, running throughout the book, is how the practice of medicine increasingly falls short of its idealism. The author reflects on his own professional attitudes and behaviours, fearing at one time that he was ‘becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism…and utterly missing the larger human significance‘. He observes that ‘technical excellence was not enough’ if we end up losing sight of ‘the singular importance of human relationships‘ (pages 85-86). Such deep philosophical reflections made him a more humane doctor and influenced his practice such as when he obtains informed consent (page 88), breaks bad news (page 94), or discusses prognosis (page 95). He coined several clinical aphorisms, pearls of wisdom forged from his reflections, such as ‘a tureen of tragedy was best allotted by the spoonful‘, ‘you must always leave room for hope‘, and ‘in taking up another’s cross, one must sometimes get crushed by the weight’ (page 94-95 and 98).

The author’s almost life-long, and perhaps excessive, premorbid preoccupation with death cast an ominous atmosphere on sections of the narrative. As an example, the author had studied literature and the history of medicine mainly as a means to understand the particularities of death‘ (page 53). Medical school exaggerated this obsession with mortality because ‘questions intersecting life, death, and meaning…usually arise in a medical context‘ (page 70). His decision to study neurosurgery was influenced by the ‘intertwining of life and death’ inherent in the field, and he expected his skills will enable him ‘to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking’ (page 81). His fascination for neurosurgery furthermore offered him ‘the most challenging and direct confrontation with meaning, identity, and death (pages 71-72). It is poignant that he was interested in patients who had the shadow of death hovering over them; from neonatal deaths to fatal intestinal obstruction, from bleeding alcoholics to suicides (pages 54, 74, and 77-78).

The author’s insightful account stretched back in time to his earlier life before medicine. In unhurried  prose, he related his childhood, with emphasis on his love of books, objects he compared to ‘finely ground lenses‘ which enriched his views of the world (pages 21-27). His passion for literature indeed competed strongly with his interest in neuroscience, something he termed the ‘most elegant rules of the brain‘ (pages 30-31). His narrative of medical school will resonate with all doctors, for example when he describes cadaver dissection as ‘a medical rite of passage and a trespass on the sacrosanct‘, an activity that marks ‘the transformation of the somber, respectful student into the callous, arrogant doctor‘ (page 44). Asserting that ‘doctors invade the body in every way imaginable’, he reviews many other medical practices which trespass into ‘sacred spheres‘, (page 49).

The author, unsurprisingly, struggled to accept his own impending mortality. He honestly acknowledged that he did not want to die, admitting that the prospect of death was ‘so disorienting, so dislocating‘ (pages 119 and 148). He conceded the ‘life shattering‘ impact of his illness, regretting that ‘my carefully planned and hard-won future no longer existed’ (page 120). Despite this, he managed to project a largely philosophical attitude towards death, appreciating that ‘death comes for all of us… it is our fate‘ (page 114).

Opinion

This account of a steady decline under the shadow of death is gripping. The effect of illness and dying on the author and his wider family is touchingly described and unlikely to leave any reader dry-eyed. It is a deeply moving book which captures the essence of Medicine, and reflects on the singular importance of the doctor-patient relationship. The book brings home the lessons of death, and it comes with added symbolism because the writer was a healer.

Overall opinion

There is a growing realisation that Medicine needs to address the subject of death in more practically effective ways. This book brings it home to doctors that skills and youth are not antidotes to our inevitable mortality. The key lesson of the book for doctors, delivered in excellent prose and with striking honesty, is the need to reflect on our daily interactions with our patients, and to see them as human beings just like us. I unreservedly recommend the book to all doctors.

Book details

Publisher, Place, Year: Penguin, London, 2016
ISBN: 978-1-847-923677
Number of Parts: 2
Number of Pages: 228
Price: £6.29
Star rating: 5