Overview
When Breath Becomes Air is Paul Kalanithi’s memoir. It was published in 2016. Kalanithi narrates the account of his struggle with cancer while working as a neurosurgeon. The book is organized chronologically, chronicling his life from boyhood to death, and is interspersed with profound philosophical thought and literary language. His musings blend the knowledge of a professional with the experience of a patient, resulting in a book that conveys significant significance about life and death.
Kalanithi grew raised in Arizona, surrounded by nature and periods of solitude. He had always enjoyed reading and, upon entering college, studied biology and literature. During these years, he recognizes the importance of living, of immersing himself in his surroundings, rather than only studying. His master’s program in English literature proves unsatisfactory, so he decides to attend medical school.
Some of his most vivid memories of medical school involve the examination of cadavers. It is at this point that Paul first encounters the duality of practicing medicine. As he continues to learn and grow via his studies, he recognizes how he has become numb to situations that might otherwise be traumatic. The body is both wondrous and quotidian. He selects neurosurgery as his specialty.
Prologue (Part 1), Section 2 Analysis
When Breath Becomes Air begins with the reader being plunged into the book’s primary conflict, where the pinnacle of Paul’s profession meets the early stages of his disease. The Prologue also introduces us to the book’s other important narrative element: Paul and Lucy’s marriage.
Kalanithi then introduces himself by highlighting many childhood hobbies, including literature, a love of learning, and a desire to explore the world around him (at this stage, primarily the landscapes of Arizona). It is apparent that the combination of his mother’s encouragement and the solitude of their lives in Arizona creates a fertile atmosphere in which Paul thrives in school and develops a strong ability to focus.
The book Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S., by Jeremy Leven, which Paul receives from his fiancée, signals the start of a long engagement with literature, one in which individual books and moments indicate critical changes in Paul’s perspective. As a college student, he reads T.S. Eliot’s The Wasteland, and the insights he acquires from reading Satan are augmented by his comprehension of figurative language from The Wasteland.
When Paul visits Eldorado National Forest, he has already developed a critical skill set for contemplating the major existential problems that humans face: what role do we play as individuals in our cosmos, and what gives life meaning?
When Paul visits the home for children with head injuries, he witnesses a significant event. He notices a young woman crying in front of a television, watching a soap opera with the sound turned off. She appears to reflect both the study of meaning (viewing television) and the experience of meaning (her seeming grief). This image reverberates throughout the book, as Paul alternates between studying and experiencing life.
This conflict is only heightened after Paul finishes his master’s thesis, understanding that literature has somehow created a barrier between himself and the world around him.
Part 1: Sections 3-5 Analysis
These chapters cover Paul’s years of medical school. During these chapters, Kalanithi begins exposing the distinguishing characteristics of a doctor, specifically through the eyes of the nonprofessional public. He characterizes cadaver dissection as “the transformation of the somber, respectful student into the callous, arrogant doctor” (44). Kalanithi provides these concepts in order to confound them. Paul’s classmates and professors are not typical of the doctor stereotype. Kalanithi likes to share experiences that demonstrate not only arrogance but also humility, empathy, fear, and comedy.
As he moves from the classroom to the hospital, Paul learns to rely on a completely new set of concepts to advance in his job. Thus, the terminology in these chapters gets more technical. The language established here is important later in the novel, when Paul must recount his own story as a patient. However, because Paul is still fresh to the operating room, numerous scenes of medical operations, such as the premature twins’ C-section, are written with a tonal investment that conveys his astonishment and, at times, revulsion as a future surgeon.
Kalanithi also begins to confront the messiness that exists outside the pages of his textbooks. Despite his mastery of his academics, nothing can fully prepare him for the unanticipated intricacies of real-life practice. The “experience” he dreamed for when opting to enter medical school is finally becoming a reality. During his residency, Paul’s habits of thinking develop, as the lightness of tone he used to have while frolicking in nature fades. There are no cadavers left on the surgical tables. He begins to feel the constant burden of caring for bodies other than his own. It is clear at this point that Paul’s understanding of the world is expanding through cycles of “reading books” and “taking action” (63). These two disciplines reinforce one another.
Part 1, Sections 6–9. Analysis
The issue of death is most fully examined during these chapters of Paul’s residency, when he is responsible for making decisions about his patients’ medical plans. The vehicle accident and subsequent death of his close buddy is a watershed point in his life, during which he effectively becomes a family member in the waiting room, a loved one disturbed by an unpleasant and unexpected phone call from the hospital.
Until now, Paul has been so preoccupied with the fast-paced nature of his new tasks that he has had difficulty thinking about the patient’s life after surgery. Paul recognizes that his own demeanor influences how a patient views his or her disease, and that the patient is not alone in bearing the responsibility of coping. He states, “You must always leave some room for hope” (95).
When Paul starts working in the lab as a neuroscientist, V serves as a sort of double for future Paul’s cancer-ridden self, and their interactions are heavily emphasized. Kalanithi synthesizes his own opinion of V’s qualifications as a respected neurosurgeon-neuroscientist while also allowing his interactions with V to unfold as dialogue. Although Paul has worked under many respected professionals in his area, he cherishes V’s unwavering dedication to his work and the fact that V is unaffected by the prospect of popularity. These exchanges have some dramatic irony, given the reader is aware from the Prologue that Paul will eventually become ill. Paul is then unintentionally given tools that he may need in the future.
The end of Part 1 shows the first clear junction between death, medicine, and literature, as Paul discusses how even the smallest error in neurosurgery can impair one’s ability to make and understand language. In this way, the reader is set up for the section’s last pages, in which Paul hears of his friend Jeff’s death and dwells on the depths of misery Jeff must have experienced. Paul argues “you can’t ever reach perfection” but that you can “strive” for it as a method to handle the circumstances and demands of neurosurgery.
Part 2, Sections 1–3 Analysis
These chapters immediately follow the events of Prologue and depict the beginning of Paul’s reorientation to his future. As he wonders what he would do one day at a time, statistics emerge as a motif throughout the book. This initially occurs when he discovers Emma is one of the top practitioners in her area. He “wondered at the string of events” that brought him to this point (124), and he starts examining his Kaplan-Meier curve to figure out the likelihood of his death. Paul states that “only 0.0012 percent of thirty-six-year-olds get lung cancer” (133). This is the early step of information processing. Because Paul is so overwhelmed by the news of his disease, he tries to shape it and make sense of it. This is all a prelude to the existential inquiry that follows. He wraps up: “It occurred to me that my relationship with statistics changed as soon as I become one” (134).
Emma, Paul’s doctor, plays a significant role in these chapters. Although people in her field regard her as caring, the majority of her actions on these pages are measured against what Paul would do if he were in her situation. He appreciates that she has “plan A, B, and C at all times,” but he becomes angry that she refuses to discuss survival rates with him (129). It is difficult to understand her motivations immediately away because Paul is (as we later discover) unwilling to give up his career as a doctor.
While Paul’s disease has stabilized, he is moved to attend his Stanford reunion, but he is disturbed that he is surrounded by people chasing a dream that may no longer be within his reach. This tension most likely drives him to immerse himself in reading. Kalanithi has not described such a voracious reading habit since his undergraduate days, and a sense of regeneration and rebirth emerges, however this time he is “searching for a vocabulary with which to make sense of death” (148). This reliance on word undermines Paul’s previous dichotomy of literature and experience. How does one live without the other? Kalanithi’s observations here appear to indicate that this is when he recognized that they are, in his opinion, two sides of the same coin.
Part 2, Sections 4-6 Analysis
In these passages, Paul begins to regain his prior identity. He works hard enough to look for work again, which leads to his Wisconsin visit, where he is offered his ideal job. At this point, he realizes that “the lab wasn’t the place I wanted to plunk the remainder of my chips” (165).
His rejection of his dream career is more than just a reset in his life; it is a reworking of his perfect future. Kalanithi highlights the benefits of the employment, including “millions of dollars to start a neuroscience lab, head of my own clinical service, flexibility if I needed it for my health[…]” (163). It is then followed by a list of the reasons why those positive qualities no longer fit into his life: “Lucy would be isolated, stripped of her friends and family, alone, caring for a dying husband and a new child” (164). This combination of pros and cons helps to frame Paul’s existence as a cancer patient. It’s not only that these things are out of reach; he no longer desires the same future he once desired.
The succeeding church scenario serves as the narrative framework for Paul’s thoughts on the link between science and meaning. The narrative begins to take on an autumnal feel, reflecting both the length of Paul’s illness and a foreboding of future events. For example, Kalanithi writes: “No system of thought can contain the fullness of human experience,” and “In the end, it cannot be doubted that each of us can only see a part of the picture” (170, 172). As Kalanithi proceeds to connect the topics established early in the book–death, medicine, and literature–the portrait of a fulfilled thinker develops.
Part 2: Sections 7-9 Analysis
After learning that his cancer has progressed, Paul works his final day in the OR before starting treatment. Kalanithi’s narrative depicts his motions of washing, operating, and visiting patients sparingly, with the events of the day interrupted only by brief remarks of Paul’s back aches and pains. The hollow tone conveys Paul’s realization that he will most likely never return to OR.
These pages also detail the conversations in which he eventually prioritizes his “perspective” as a patient alongside his “perspective” as a doctor (190). The two have been at odds since his diagnosis, and as his health deteriorates, his continual engagement in his treatment drains him. So, allowing oneself to be cared for does not imply that he is giving up; rather, he is experiencing his existence in a new way, one in which he may “finally relax” (191).
These chapters contain several beginnings and endings, many of which are final. Cady’s arrival, on the other hand, cannot be contained narratively, like Paul’s graduation or the last day of work. The possibility she offers transcends Paul’s pain and success because she brings unquantifiable bliss. She is “blank page” (196). This refers back to Paul’s unwillingness to reconcile scientifically impossible notions with some human experiences. She presents Paul with “core passions” whose existence is explained by “scientific knowledge” (170). She is, in other words, something impossible, a bridge that connects two domains of human experience that would otherwise “always be a gap” (170).
Epilogue Summary
Lucy sees Paul’s writing as an act of love, as he depicted the people in his life with colorful and lively brushstrokes. Lucy Kalanithi, in turn, enables Paul to be the object of affection in the book’s last portion. She chronicles his ability to quote Eliot from memory, as well as the instances when he would fall asleep and say, “This might be how it ends” (206). So the character and writer we’ve grown to love is given a new type of limelight that, even as he dies, illuminates how he moved around his world.
“Paul’s decision not to avert his eyes from death” is strongly supported by the particular, image-focused aspects of Paul’s final hours and breath, as well as the attitude his loved ones take when confronted with his death (215).
