Nick Ang

Notes from When Breath Becomes Air by Paul Kalanithi

September 27, 2020

When Breath Becomes Air is a precious book about life as it is experienced through the lens of impending cancer-induced death. It is poignantly written by the neurosurgeon Paul Kalanithi and it reads like a part memoir, part treatise on the meaning of life. Reading it, I felt inspired, sad, melancholic, but perhaps most importantly, alive knowing my death is not far away. Paul died in his 40’s.

When Breath Becomes Air by Paul Kalanithi book cover

I don’t think there is more I took from reading this book beyond the feelings it evoked, but it did evoke many feelings and so it makes this book worth every second.

I’d recommend anyone contemplating the meaning of their life to read this book. It has helped me feel grateful for the breaths I am still able to take, and I believe it can for you too. As Paul’s wife, Lucy, wrote in the Epilogue, “Dying in one’s fourth decade is unusual now, but dying is not.”

Facing mortality with a partner

Broaching the topic of death for the first time with a partner is awkward, sad, and confusing:

She glimpsed my phone screen, which displayed medical database search results: “frequency of cancers in thirty- to forty-year-olds.”

“What?” she said. “I didn’t realize you were actually worried about this.”

I didn’t respond. I didn’t know what to say.

“Do you want to tell me about it?” she asked.

She was upset because she had been worried about it, too. She was upset because I wasn’t talking to her about it. She was upset because I’d promised her one life, and given her another.

“Can you please tell me why you aren’t confiding in me?” she asked.

I turned off my phone. “Let’s get some ice cream,” I said.

And it can tear a couple apart before uniting them:

Lucy picked me up from the airport, but I waited until we were home to tell her. We sat on the couch, and when I told her, she knew. She leaned her head on my shoulder, and the distance between us vanished.

“I need you,” I whispered.”

I will never leave you,” she said.

On unrealised goals

Despite having the acumen of a medical doctor and the suspicion of having cancer, Paul’s instinct was to finish the last year of his gruelling 7-year medical residency instead of seriously investigating his health:

But our careers were peaking now most universities wanted both of us: me in neurosurgery, Lucy in internal medicine. We’d survived the most difficult part of our journey. Hadn’t we discussed this a dozen times? Didn’t she realize this was the worst possible time for her to blow things up? Didn’t she see that I had only one year left in residency, that I loved her, that we were so close to the life together we’d always wanted?

When I read this I felt like he was being a fool. But when I started to ask why he had chosen to wilfully ignore the signs, I saw the error in my judgement. I think deep down we all hope that signs of bad news are nothing more than noise, so until a dramatic event forcefully creates a turning point, I think I would keep busy for a while and wish for it to be a false alarm, too.

Perhaps one of the hardest things we have to grapple with when we know our expiration date has suddenly been rewritten is to come to terms with the things we want to accomplish but can no longer:

“The doctor will be in soon.”

And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

On the primacy of language in meaning-making

I applied for a master’s in English literature at Stanford and was accepted into the program. I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion. A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form. It was the relational aspect of humans—i.e., “human relationality” that undergirded meaning.

What kind of life exists without language? Paul tells us that the answer is “not much” through his encounter with a patient who had suffered some head injury and who could no longer speak anything but numbers:

“Fourteen one two eight,” he pleaded with me, holding my hand. “Fourteen one two eight.”

“I’m sorry.”

“Fourteen one two eight,” he said mournfully, staring into my eyes.

And then I left to catch up to the team. He died a few months later, buried with whatever message he had for the world.

On the importance of direct experience

[…] at Cambridge. I spent the next year in classrooms in the English countryside, where I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them. Words began to feel as weightless as the breath that carried them. Stepping back, I realized that I was merely confirming what I already knew: I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action. I finished my degree and headed back to the States. I was going to Yale for medical school.

On work being a calling

Being with patients in these moments certainly had its emotional cost, but it also had its rewards. I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul was obvious in its sacredness.

Putting lifestyle first is how you find a job — not a calling.

When I read that sentence, I felt as though Paul reached and grabbed me by my arms and shook me hard. Here was a person, now dead, who felt like he was called to the duty of saving lives by performing neurosurgery. And here I am, definitely putting lifestyle first as I live in Berlin away from home, trying to experience life and letting my work just be work.

I am careful not to draw a comparison because everyone is different (I, like most people I know, never knew my calling), but this sentence nevertheless got me thinking. For now, I still believe strongly that one can live a meaningful and happy life without one’s work being “obvious in its sacredness.”

Neurosurgery is eerily powerful

This passage was an eye-opener to me although sounded just like black magic:

Another day, I placed an electrode nine centimeters deep in a patient’s brain to treat a Parkinson’s tremor. The target was the subthalamic nucleus, a tiny almond-shaped structure deep in the brain. Different parts of it subserve different functions: movement, cognition, emotion. In the operating room, we turned on the current to assess the tremor. With all our eyes on the patient’s left hand, we agreed the tremor looked better.

Then the patient’s voice, confused, rose above our affirmative murmurs: “I feel… overwhelmingly sad.”

“Current off!” I said.

“Oh, now the feeling is going away,” the patient said.

“Let’s recheck the current and impedance, okay? Okay. Current on… “

No, everything… it just feels… so sad. Just dark and, and… sad.”

“Electrode out!”

We pulled the electrode out and reinserted it, this time two millimeters to the right. The tremor went away. The patient felt, thankfully, fine.


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