When Breath Becomes Air Summary

The memoir When Breath Becomes Air recounts neurosurgeon Paul Kalanithi’s fight against Stage IV lung cancer.

  • Kalanithi is raised in Kingman, Arizona; attends Stanford to study literature; and ultimately enrolls at Yale Medical School.
  • Kalanithi meets his wife, Lucy, while in medical school, and they move to California to begin their residencies soon after. While chief resident of neurosurgery at Stanford, Kalanithi is diagnosed with Stage IV lung cancer.
  • Following his diagnosis, Kalanithi and Lucy decide to have a child, whom they name Cady.
  • Kalanithi dies in March 2015.

Summary

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Last Updated on February 7, 2020, by eNotes Editorial. Word Count: 1044

Introduction

When Breath Becomes Air is neurosurgeon Paul Kalanithi’s heartbreaking memoir of life and death. Written in the last year of the author’s life, while he was dying of Stage IV lung cancer, the memoir recounts Kalanithi’s story: beginning with the onset of his symptoms, the book then takes readers...

(The entire section contains 2798 words.)

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Introduction

When Breath Becomes Air is neurosurgeon Paul Kalanithi’s heartbreaking memoir of life and death. Written in the last year of the author’s life, while he was dying of Stage IV lung cancer, the memoir recounts Kalanithi’s story: beginning with the onset of his symptoms, the book then takes readers back in time to trace his development from a bookish teenager and inquisitive student to a talented and well-trained resident with a bright future in neurosurgery ahead of him. Kalanithi’s cancer diagnosis derailed his career but gave him time to write his memoir, which ruminates on life, death, and what it means to be human when a debilitating illness alters one’s identity.

Plot Summary

Paul begins having symptoms while a resident in neurosurgery. His back begins to spasm, and in a period of six months, he loses enough weight to cinch his belt two notches tighter. He suspects that he has cancer even before he sees a doctor. His X-rays look fine to the physician covering for his usual doctor, and he relaxes a bit, chalking up his fatigue and pain to the long hours and stress of being a medical student; soon, though, he begins experiencing chest pain. He and his wife, Lucy, are supposed to fly to New York to visit friends. Lucy decides to stay back in California while she considers their marriage; she feels alone and unsupported, particularly given how busy Paul is. Before Paul leaves, he has a series of tests done, including a chest X-ray, but when he arrives at his friend’s house, he is so exhausted and in pain that he decides to go home early. His primary care doctor calls the moment he gets off the plane in San Francisco: his X-rays are blurry.

Here, the memoir jumps to Paul’s childhood. When he is just ten, his family moves from Bronxville, New York, to Kingman, Arizona. His father establishes his own cardiology practice in Kingman, and Paul and his two brothers come to love the desert; the public schools in Kingman, however, are the worst in the nation, and his mother worries that her children won’t receive a proper education. She joins the PTA, lobbies for the school to offer AP classes, and gives her three sons books recommended on college reading lists. This sparks Paul’s lifelong love of literature, which leads him to study literature and literary theory at Stanford. At some point, however, he begins to question whether literature has all the answers he seeks about the meaning of life and human identity. His interest in psychology and neuroscience increases, and he begins taking classes to fulfill the prerequisites for medical school.

Paul spends a year studying medical history at Cambridge before he enrolls in medical school at Yale. He meets Lucy, who is also a medical student, there. Paul’s first two years are spent studying anatomy and pathology, building the base of knowledge he will need to become an effective surgeon. His medical training includes dissections of human cadavers, which give him the opportunity to practice his skills and help anesthetize him to the more gruesome aspects of surgery. He begins his practical training in the third year of medical school, starting off in obstetrics and gynecology, where he works in the delivery room. This provides him his first real experience of death. One of the patients on the ward begins having contractions at twenty-three weeks—what doctors consider the edge of viability for a fetus. She gives birth to twins via C-section, but both of the babies are severely underdeveloped and die within twenty-four hours.

Paul’s residency is grueling but rewarding. His work week is frequently one hundred hours long, and many of his fellow residents leave to pursue “lifestyle specialties,” such as dermatology, that offer more humane hours. Kalanithi is determined to become a neurosurgeon, however, and is one of the most dedicated residents in the hospital. In the operating room, he learns how to balance perfection and speed, and he performs many spectacularly successful surgeries. Not all brain cancer is operable, however, and one of the most important lessons he learns is when not to operate. All this work takes its toll, though. It puts a strain on his personal life, threatening his new marriage with Lucy, and often leaves him too exhausted to explain what ails him. His dedication results in his being named chief resident. It also comes at a great cost.

Paul is diagnosed with Stage IV lung cancer. His cancer has spread, and the metastases are present in several organ systems. When he sees his CT scan, Paul knows without a doubt that he is going to die. It is just a question of when. His doctor tests him for a specific mutation that would allow him to skip chemotherapy and instead take a pill called Tarceva. The results are remarkable, and Paul’s disease recedes enough for him to return to his surgical work and complete his residency. His superiors and professors confide in him that he is the top resident and will have his pick of job offers upon his graduation—if he survives that long, of course. Faced with his mortality, Paul and his wife begin thinking about his legacy. Together, they decide to have a child.

On his graduation day, Paul, who is suffering from dehydration and diarrhea, is rushed to the hospital. It appears that he might die, but his fever breaks, and he eventually regains consciousness. Lucy has her first contractions two days after Paul’s release from the hospital. She stays home while his mother takes him to his follow-up appointment. His cancer has stabilized, and his doctor says he has “five good years left.” Soon after, he and Lucy welcome their daughter, Cady, and Paul begins writing his memoir, which remains unfinished despite its publication.

In Lucy’s epilogue, written after Paul’s death, she relates how her husband’s health deteriorated in his last year. His disease worsened, and he suffered neurological decline. He eventually signed a Do Not Resuscitate order, asked that his breathing mask be removed, and died peacefully in his hospital bed. He was buried in the Santa Cruz Mountains, where Lucy still visits him.

Summary

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Last Updated on January 11, 2022, by eNotes Editorial. Word Count: 1754

Author: Paul Kalanithi (1977–2015)

Publisher: Random House (New York). 256 pp.

Type of work: Memoir

Time: 2013–15

Locale: California

When Breath Becomes Air is a memoir that examines the meaning of life from the perspective of author Paul Kalanithi, a dying neurosurgeon.

Principal personages

Paul Kalanithi, the author, a neurosurgeon who was diagnosed with stage IV lung cancer at the age of thirty-sixCourtsy of Penguin Random House

Lucy Kalanithi, his wife, also a doctor

Elizabeth Acadia Kalanithi, his infant daughter

Emma, his oncologist

When the subject of human mortality is explored in literature, more often than not it is from the perspective of someone who is learning to cope with the loss of a loved one. For example, in her award-winning memoir The Year of Magical Thinking (2005), American author Joan Didion writes about how mourning the death of her husband affected her emotionally and physically. Similarly, C. S. Lewis’s A Grief Observed (1961), written after the death of his wife, American poet Joy Davidman, functions primarily as a collection of personal and spiritual reflections on his experience with bereavement. What makes When Breath Becomes Air (2016) more unique is the fact that the author, Dr. Paul Kalanithi, writes about death while he is dying.

After being diagnosed with terminal lung cancer at the age of thirty-six, Kalanithi was asked by his oncologist, Emma, what he would like to do with the rest of his life. He replied that he was unsure; only a few months earlier he was on a self-designed forty-year career track, of which he planned to spend the first half as a neurosurgeon and the second half writing books. However, with an estimated two years left to live, he decided that his dream of becoming a writer would have to be expedited. His first piece was an essay titled “How Long Have I Got Left?,” about the first eight months of his life as a terminal patient, which was published on January 24, 2014, in the New York Times. Readers responded quickly and emphatically to his writing, ultimately moved by his beautiful prose, honesty, and optimism. Kalanithi decided soon afterward to turn “How Long Have I Got Left?” into a memoir.

Kalanithi chose the title When Breath Becomes Air for his memoir because it both captured the existential journey he was on and paid tribute to his love of literature. It is paraphrased from the first lines of Fulke Greville’s seventeenth-century sonnet “Caelica 83,” which read, “You that seek what life is in death / Now find it air that once was breath.” The underlying message of “Caelica 83” aligns neatly with Kalanithi’s purpose in writing When Breath Becomes Air: just as Greville concluded the poem by writing, “Reader! then make time, while you be / But steps to your eternity,” Kalanithi’s decision to write a memoir was his attempt to make the most out of the limited time he had left while immortalizing his life.

In the first half of his memoir, Kalanithi describes his life before cancer. Relatively spare in the details of his childhood, the anecdotes that he does provide about growing up in New York and Arizona are intended to illuminate how he came to love literature and why he always felt conflicted about medicine as a profession. He reveals that as a young child, he blamed medicine for keeping his father, a cardiologist, away from their family. As he got older, however, he felt he could no longer deny his own personal calling to become a doctor. After earning two bachelor’s degrees and a master’s degree in literature from Stanford University as well as a master’s degree in the history and philosophy of science and medicine from the University of Cambridge, Kalanithi went on to graduate in the top of his class from the Yale School of Medicine. He was finishing his residency in neurosurgery at Stanford when he learned that he had terminal lung cancer.

By contextualizing who he was before his diagnosis, Kalanithi amplifies the tragedy of it. For most of his life, he was training for a career that he would never have. He reveals that this is one of the most difficult truths he ever had to face: in the years prior to his diagnosis, his education and training prevented him from learning how to truly live; then, suddenly, he had no choice but to learn how to die. While the process of dying would be difficult for most people to articulate, Kalanithi brings unprecedented, eloquent insight to the experience. In part this is due to his background in philosophy and literature, which drives him to look for meaning in his mortality. However, what really makes Kalanithi an interesting and effective writer on the subject of death is his medical perspective. As a doctor, he knows exactly what is happening inside of his body and what his odds of survival are. Subsequently, When Breath Becomes Air is both a physical and a metaphysical examination of the nature of death.

Arguably one of the most affecting elements of When Breath Becomes Air is Kalanithi’s unwavering honesty. Throughout the memoir, he is consistently willing to share his most personal experiences, emotions, and fears, even when they make him look flawed. For example, in the prologue, he reveals that he instinctively knew that he had cancer for months before he received the test results. In addition to losing a significant amount of weight, he was in tremendous pain all of the time. However, he did not tell his wife, Lucy, also a doctor, about his suspicions. When she discovered that he was looking for the statistical likelihood of cancer in people in their thirties on a medical search engine on his smartphone, Lucy questioned whether or not they should separate. Ultimately, she was devastated that he could not share his thoughts and fears with her. Kalanithi reveals later the bittersweet irony that his cancer helped save their marriage in the end by forcing them to address their issues and make the most of the time they had left together.

Much of When Breath Becomes Air is about anticipating and mourning the loss of one’s own life and saying good-bye to loved ones. Beneath Kalanithi’s honest portrayal of fear and grief, however, is a message of hope. Halfway through the book, he learns that the tumors in his lungs have shrunk and that he is getting stronger, which means there is a chance that he could live for longer than he originally anticipated. With this news, he struggles to decide whether or not he wants to return to practicing medicine. He reflects on the fact that Friedrich Nietzsche and Charles Darwin agreed on only one thing: that the defining characteristic of an organism is “striving.” He decides that he cannot stop trying to live and briefly returns to medicine. It is this same logic that fuels his decision to have a baby with Lucy before he dies. When she asks him if he is certain that he can handle the fact that having a baby might make dying even more emotionally painful, he replies that he hopes it does. The wisdom that he aims to impart with these anecdotes is that people must never stop trying to infuse their lives with ambition and meaning.

In the epilogue, Lucy Kalanithi reveals that her husband died on March 9, 2015. The epilogue is written in a style that emulates Dr. Kalanithi’s previous pages; it is an account of his final days, including his last breath, that blends raw, human emotion with scientific fact. Ultimately, this is what makes When Breath Becomes Air a truly engaging book: the Kalanithis are deft writers with a powerful story. Since its publication, the book has received overwhelmingly positive reviews, with many critics praising the memoir for its courage. What makes When Breath Becomes Air feel remarkable at times is the fact that Kalanithi is willing to look deeply upon an event that most people are too scared to think about when they are healthy, and he never falters in his quest to understand the nature and meaning of death. Book critic Nora Krug praised this effort in her review for the Washington Post, writing that Kalanithi’s “words are bracing for their honesty.” It is the honest insight that Kalanithi provides regarding his experience that makes the memoir feel simultaneously personal and universal.

The universality and humanness of Kalanithi’s message is likely to resonate long after readers have finished his book. Alice O’Keeffe commented on this impact in her review for the Guardian, noting, “The power of this book lies in its eloquent insistence that we are all confronting our mortality every day, whether we know it or not.” In addition to the universality of his message, Kalanithi has also been praised for his ability to craft beautiful prose about a scientific, medical phenomenon. Where a lesser writer might have produced a drier, less accessible narrative, Kalanithi’s love for the written word enabled him to express complex ideas in a lyrical way. In her New York Times review, Janet Maslin wrote that much of the memoir’s poignancy stems from the way Kalanithi “conveys what happened to him—passionately working and striving, deferring gratification, waiting to live, learning to die—so well. None of it is maudlin. Nothing is exaggerated.” Indeed, Kalanithi’s intelligence and eloquence are a large part of what make his memoir arguably one of the best books ever published on the subject of death. One of the few negative attributes of When Breath Becomes Air is that, at times, Kalanithi’s medical perspective, and the ideas and jargon that accompany it, makes parts of the narrative feel as though they are only for fellow doctors. Besides these rare moments, however, When Breath Becomes Air is an immensely compelling and worthwhile read.

Review Sources

  • Krug, Nora. “When Breath Becomes Air: Young Doctor’s Last Words of Wisdom, Hope.” Review of When Breath Becomes Air, by Paul Kalanithi. The Washington Post, 8 Jan. 2016, www.washingtonpost.com/entertainment/books/when-breath-becomes-air-in-a-young-doctors-final-words-wisdom-and-hope/2016/01/08/aa5a8402-b60e-11e5-9388-466021d971de_story.html. Accessed 16 Nov. 2016.
  • Maslin, Janet. “In When Breath Becomes Air, Dr. Paul Kalanithi Confronts an Early Death.” Review of When Breath Becomes Air, by Paul Kalanithi. The New York Times, 6 Jan. 2016, www.nytimes.com/2016/01/07/books/review-in-when-breath-becomes-air-dr-paul-kalanithi-confronts-an-early-death.html. Accessed 16 Nov. 2016.
  • O’Keeffe, Alice. “How to Live, by a Doctor Who Died Aged 37.” Review of When Breath Becomes Air, by Paul Kalanithi. The Guardian, 3 Feb. 2016, www.theguardian.com/books/2016/feb/03/when-breath-becomes-air-paul-kalanithi-review. Accessed 16 Nov. 2016.
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