Book Notes: When Breath Becomes Air by Paul Kalanithi

Reading Time: 6 minutes

When Breath Becomes Air, by Paul Kalanithi

Publisher : Random House (2016)


Rating: ⭐⭐⭐⭐

The Book in 3 Sentences

  • Dr. Paul Kalanithi was interested in the intersection of literature, philosophy, science, and medicine. He wanted to understand what makes life meaningful. Kalanithi decided that pursuing neuroscience would provide a pathway to understand how the brain could give rise to an organism capable of finding meaning in the world.
  • All human beings are aware of the fact that each of us will eventually die. If death is inevitable, how does a diagnosis of terminal illness change our ambitions, goals, and overall sense of purpose?
  • How do you go on in the face of terminal illness? What do you do to find meaning in the life you have left? How does one face death with integrity?

Five Key Takeaways

  1. A doctor’s job is to be a bridge between a patient’s past, identity, and values, and the patient’s reimagined future.
  2. We live in the present, but always have a sense of the future. What do you do when one’s future is suddenly taken away?
  3. A doctor must strive to learn and understand a patient’s values and identity, so as to be able to determine what is worth saving for the patient to live a meaningful life on his or her own terms (ie. according to the patient’s values).
  4. Not every illness can be treated. What makes life meaningful enough to go on living? And how do you (both the doctor and the patient) know when it’s time to let go?
  5. Ultimately, death always wins. But, one must try to live a meaningful life in spite of that ever present shadow.

Top 3 Quotes

  • Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving. (pg. 77)
  • The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. (pg. 102)
  • When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing. (pg. 125)


Paul Kalanathi was a neurosurgeon and neuroscientist who died at the age of 37 in March 2015 from stage four lung cancer. He left behind a wife, Lucy, and Cady, his baby daughter, born in 2014. “When Breath Becomes Air” is Kalanathi’s posthumous legacy, an attempt to answer the question of what makes human life meaningful, and what it means to persist in the face of death or serious illness.

Kalanithi attended Stanford University, where he graduated with a Bachelor of Arts and a Master of Arts in English Literature and a Bachelor of Science in Human Biology in 2000. After Stanford, he attended the University of Cambridge, where he studied at Darwin College and graduated with a Master of Arts in the History and Philosophy of Science and Medicine. Kalanithi then attended the Yale School of Medicine, the institution where he also met fellow medical student, Lucy, who he would eventually marry.

As you might discern from his educational background, Kalanithi was a doctor who was also fascinated by words. Growing up, he thought he would have become a writer, if forced to declare a future profession. He was interested in the questions of identity and meaning, stating, “I studied literature and philosophy to understand what makes life meaningful, studied neuroscience and worked in an fMRI lab to understand how the brain could give rise to an organism capable of finding meaning in the world.” (pg. 30). Eventually, Kalanithi was drawn to neurosurgery particularly because “neurosurgery seemed to present the most challenging and direct confrontation with meaning, identity, and death”. (pg. 51)

The book is divided into two sections; the first half of which describes Kalanithi’s childhood and background, as well as the interests that lead him into medicine, his relationships, and eventually, the gruelling training and experiences of a young doctor working in an intensely challenging medical environment. The second half of the book deals with his diagnosis of late stage lung cancer in May 2013, and his struggle to reconcile his transformation from doctor into patient, as well as the fact of living with a terminal illness.

Kalanithi writes about the future he had imagined for himself,  “My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so close”. (pg. 79) Given that this is a memoir written by a dying man, “When Breath Becomes Air” is semi-finished. Its epilogue, written by Kalanithi’s wife, Lucy (a very compelling writer in her own right), describes its unfinished nature as “derailed by Paul’s rapid decline, but …an essential component of its truth, of the reality Paul faced”. (pg. 133) It is a metaphor for a life disrupted before it could reach its full potential.


The following are some of Kalanithi’s words, grouped into some of the themes I found running throughout his writing:

A Doctor’s Duty

  • …the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence. pg. 105.


  • Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living? pg. 51


  • Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. pg. 67

From Doctor to Patient: A Transformation

  • As a doctor, you have a sense of what it’s like to be sick, but until you’ve gone through it yourself, you don’t really know. It’s like falling in love or having a kid. pg. 90


  • That morning, I made a decision: I would push myself to return to the OR. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living. pg. 96


  • Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed. pg. 124


  • Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving. pg. 77


This book moved me to tears; Kalanithi’s writing is beautiful, clear, and haunting. Its unfinished nature is itself a testament to the author’s determination to race against time: a message from the dying, from someone on the precipice to the other side.

One wonders about the life cut short, the life so full of potential, as a physician, a new father, and a husband. What could he have accomplished? What lives could he have saved? What groundbreaking medical innovations would he have discovered? How would his family survive? What would happen to his wife, his young daughter, his parents, his siblings? These questions are what Kalanithi must come to terms with for himself, and try to answer. In the end, he is full of hope. Life goes on. With us, or without us, life abides. “Looking out over the expanse ahead I saw not an empty wasteland but something simpler: a blank page on which I would go on (pg. 123)”

In the epilogue, written after Kalanithi’s death, his wife Lucy says, “This book carries the urgency of racing against time, of having important things to say. Paul confronted death—examined it, wrestled with it, accepted it—as a physician and a patient. He wanted to help people understand death and face their mortality. Dying in one’s fourth decade is unusual now, but dying is not. (pg. 134)

She goes on to write, “It never occurred to me that you could love someone the same way after he was gone, that I would continue to feel such love and gratitude alongside the terrible sorrow, the grief so heavy that at times I shiver and moan under the weight of it. Paul is gone, and I miss him acutely nearly every moment, but I somehow feel I’m still taking part in the life we created together”. (pg. 139)

For her husband, Lucy provides the final answer, “for much of his life, Paul wondered about death—and whether he could face it with integrity. In the end, the answer was yes. ” (pg. 140)