Book Review: In 'When Breath Becomes Air' Paul Kalanithi offers lessons in life and vocation

Blue Sage Sunday Book Review

When Breath Becomes Air
By Paul Kalanithi

It’s not a book most people would reach for when pondering vocational questions. I’m sure it’s not in the career section at the local bookstore. But if you are looking for a book that will help you delve into the deeper questions of work and life, you won’t find anything better.

Paul Kalanithi, on the verge of entering his professional life as a neurosurgeon and beginning a family with his wife Lucy, is diagnosed with inoperable lung cancer. After training for almost a decade, he faces his own terminal illness and a profound identity crisis. Instead of a becoming a practicing doctor, he finds himself instead in the role of a patient. The book begins with this realization.

“I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.“

Written in achingly beautiful prose, Kalanithi begins his story in the desert town of Kingman, Arizona where his mother, worried that the poor school system would “hobble” her children’s education acquires a college prep reading list for Paul and his siblings and sets Paul’s love of literature aflame. A doctor’s son, Kalanithi “knew with certainty” that he would never be a doctor. He “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.” He is accepted to Stanford and completes degrees in English literature and human biology and then a master’s degree in English literature. He ponders the questions of life with T.S Eliot, Sir Thomas Browne, Samuel Beckett and Augustine, to name just a few, and their words and writings are scattered throughout the book. 

And so, as we watch a young man prepare to die, we also hear the story of his career choices. Kalanithi chooses his education and career based on his personal values and philosophy. He writes

“I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain. Meaning, while a slippery concept, seemed inextricable from human relationships and moral values.” 

Kalanithi realized that his interest in neuroscience and the physiological-spiritual didn’t quite fit in an English department. He couldn’t let go of the question: “Where did biology, morality, literature and philosophy intersect?”  He writes

“Walking home from a football game one afternoon, the autumn breeze blowing, I let my mind wander. Augustine’s voice in the garden commanded, “Take up and read,” but the voice I heard commanded the opposite.”Set aside the books and practice medicine.” Suddenly it all seemed obvious. Although - perhaps because - my father, my uncle and my elder brother were all doctors, medicine had never occurred to me as a serious possibility.”   

In medicine, Paul continues to ponder the metaphysical questions he had struggled with in his studies of literature and philosophy. In his fourth year, he is puzzled when many of his classmates decided to specialize in “less demanding areas, (radiology or dermatology for example) which promised “more humane hours, higher salaries and lower pressures.” He writes “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.”

After observing a pediatric neurosurgeon talk a set of parents through the devastating news that their child has brain cancer, Kalanithi chooses neurosurgery as his speciality.

“While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity a manipulation of the substance of our selves…  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 one of the most poignant moments of the book, Kalinithi’s mentor is diagnosed with cancer. Kalinithi describes V as unlike most of the other scientists he knew.  “One could count on V to always choose the honest (and, often, self-effacing) way forward…V maintained that our only obligation was to be authentic to the scientific story and tell it uncompromisingly.  I’d never met someone so successful who was also so committed to goodness.” V asks Kalinithi to put on his doctor hat and tells him his dismal news.  V pauses and then worries aloud. "Paul," he said, “do you think my life has meaning? Did I make the right choices?” Kalanithi is stunned. Even this man with such moral and professional integrity had these questions in the face of his own mortality.

Those are the questions we all struggle with in our relationships, in our career choices, in our lives. In a book saturated with questions of philosophy and meaning, Kalanithi tells his own story of living out his life and his death with integrity, grit and deep thought. He worries about the time he has left.

“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.” 

In reality, he had only 22 months left. But in that time, he wrote a book that will continue to influence lives and haunt its readers with questions of life, vocation and meaning. In the foreword to the book, Abraham Verghese writes

“Be ready. Be seated. See what courage sounds like. See how brave it is to reveal yourself in this way. But above all, see what it is to still live, to profoundly influence the lives of others after you are gone… Listen to Paul. In the silences between his words, listen to what you have to say back.”

That’s some of the best advice - for a career or simply for life -  that can be offered.