When Breath Becomes Air by Paul Kalanithi review – how to live, by a doctor who died aged 37

This book, already a bestseller in the United States, opens with a trainee surgeon examining a set of images from a CT scan. His highly trained eye takes in how the tumours are dispersed across the lungs, how the spine is deformed, how one lobe of the liver has been obliterated. The diagnosis is straightforward: “Cancer, widely disseminated.” Only one thing makes this case different from the dozens he deals with each week: these are scans of his own body.

The doctor in question was Paul Kalanithi, who discovered he had inoperable lung cancer at the age of 36. The cliche about someone having everything to live for could have been formulated for him: he was on the verge of qualifying as a neurosurgeon after a decade of training, and was planning to start a family with his wife, Lucy. Instead, he found himself confronting not only a terminal illness, but also a profound identity crisis: having aspired to be “the pastoral figure … I found myself the sheep, lost and confused”. This account of his transition from doctor to patient was written in the year or so prior to his death early last year, by which time he was 37 and his daughter, Cady, was nine months old.

Before I die, some words for my baby daughter
Paul Kalanithi
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Prior to his illness, Kalanithi’s life had been one of relentless striving and exceptional achievement. A doctor’s son in the Arizona desert town of Kingman, he was given a place at Stanford University and went on to complete a postgraduate degree in English literature. But his scientific interests did not fit comfortably into an English department (his thesis was on “the medicalisation of personality” in the work of the poet Walt Whitman), and, besides, he was tired of sitting around reflecting on the meaning of life – he wanted action, real responsibility, “answers that are not in books”. So he enrolled in medical school.

For Kalanithi, medicine was never just a job, it was another approach to the metaphysical questions he had taken aim at during his English degree. In his fourth year he was puzzled when many of his contemporaries decided to specialise in areas, such as radiology or dermatology, which promised humane hours, high salaries and only moderate pressure. Of such “egotistical” concerns, he tartly observes: “Putting lifestyle first is how you find a job – not a calling.” (I wondered at this point whether, had he worked in England, he would have joined the striking junior doctors, but despite his interest in ethics he doesn’t venture anywhere near the grubbier business of health policy).

He chose neurosurgery, the most difficult specialism of all, drawn by its “unforgiving call to perfection”. The demands of the training are almost unimaginable: he worked more than 100 hours a week, doing operations in which the difference between life, death and worse could be a matter of millimetres. Late one night, as he cuts into a tumour deep inside a patient’s brain, his supervisor asks him what would happen if he increased the incision by two millimetres. Double vision, guesses Kalanithi. “Locked-in syndrome”, comes the reply.