I read this book in late 2018 and recently needed to return it, finding my many tabs marking what I felt were important sections of prose.  I decided that I’d write a brief review to capture those ideas.

If you’re not familiar with the book, it’s written by a neurosurgeon and writer who was diagnosed with stage IV lung cancer as he was finishing his residency and a postdoctoral fellowship in neuroscience. The memoir describes his life experience that led to him becoming a neurosurgeon as well as his contemplation on how to face his swiftly oncoming mortality. 

Early on, he questions, “What makes human life meaningful?”  He reckoned that literature gave the best accounting of the life of the mind while neuroscience laid out the rules of the brain.  He notes in particular T.S. Eliot’s The Waste Land which relates meaninglessness and isolation and how Nabokov helps us see how our suffering can make us callous to the obvious suffering of others.  But my favorite reference was to Conrad, perhaps because of some minor ongoing communication problems between Dan and I at the time – noting “his hypertuned sense of how miscommunication between people can so profoundly impact their lives.  I find this idea quite interesting as I contemplate the many times through the years where I carried, perhaps unnecessarily, hurt or anger for something said by someone who had no intention of harming me.  Or the many times I have felt guilt for things I’ve done which were subsequently confirmed as unmemorable by the one toward whom I felt said guilt.  I’m sure there are an equal number of times I’ve caused pain but had no intention or recollection of harming another.

After recounting an amazing experience he had during a summer working as a prep chef at Sierra Camp on the shores of Fallen Leaf Lake.  He notes a friend’s summation of their time there:

Suddenly now, I know what I want.  I want the counselor’s to build a pyre…and let my ashes drop and mingle with the sand. Lose my bones amongst the driftwood, my teeth amongst the sand.   I don’t believe in the wisdom of children, nor in the wisdom of the old.  There is a moment, a cusp, when the sum of gathered experience is worn down by the details of living.  We are never so wise as when we live in the moment.

Pages 34-35, When Breath Becomes Air

His move from literature to biology is clearly shown in this paragraph. 

His praise for Shep Nuland’s How We Die (p. 52) has resulted in my pulling it from the shelf for the To Read pile.

I love his discussion on how brain surgery, as with other major life events, causes us to ask important questions along the lines of what is most important to us.  He eloquently writes:

Would you trade your ability – or your mother’s – to talk for a few extra months of mute life? … The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable?  

Page 71, When Breath Becomes Air

And he shows the vulnerability of us all as he describes having a conversation with someone he respected greatly describing the person as “a moral exemplar” who asked him, “Paul, do you think my life has meaning? Did I make the right choices?”  I guess we all question whether we did what’s right, whether we did our best, as we face what appears to be pending death.  After this same friend had completed a year of treatment and was back to work, he told Kalanithi that “today is the first day that all the suffering seems worth it.”  And this gave him a realization of how little physicians “understand the hells through which we put patients.”

He vulnerably details the effect of his medications on his physical self, and how this affected his relationship with his wife as well as his own self-image.  He discusses the emotional battles and describes the importance of his relationship with his oncologist.  And he again turns to literature as he tries to make sense of it all.

I was searching for a vocabulary with which to make sense of death…

Page 148, When Breath Becomes Air

He denotes going through the process of grief [Denial – Anger – Bargaining – Depression – Acceptance] in reverse order (page 161-162).  This makes perfect sense to me as I’ve studied a bit about grief and realize there is no real true diagram of a grief process.  Unless it’s this:

Photo Credit: Andrea Weir

His wife Lucy writes the epilogue for the book, completed after his death.  I love that it so openly shares the experience, especially of the time of his passing.  She writes in a paragraph at the bottom of page 215: “Paul’s decision not to avert his eyes from death epitomizes a fortitude we don’t celebrate enough in our death-avoidant culture. His strength was defined by ambition and effort, but also by softness, the opposite of bitterness.  He spent much of his life wrestling with the question of how to live a meaningful life, and his book explores that essential territory.”

She talks of how he faced “his illness with grace – not with bravado or a misguided faith that he would “overcome” or “beat” cancer but with an authenticity that allowed him to grieve the loss of the future he had planned and forego a new one.”

I love that she talks about the love she feels, even after his being gone from this plane.  I respect that she recounts the struggles of their confrontation with the disease as well as the beauty of the time they had together.  And I truly believe it was the courage to find and face truth, looking at what brings meaning, that made his life not only meaningful for them, but for all of us who share in reading their story.