When Breath Becomes Air: a summary

“What makes life meaningful? ...Meaning, while a slippery concept, seemed inextricable from human relationships and moral values.”
— Paul Kalanithi

Main Points

• The meaning of life is found in relationships and through direct experience, not philosophical concepts.
• Physicians should understand their patients' suffering and have a duty to uphold quality of life, not merely extend it at all costs.
• Even when faced with mortality, you have the ability to define your identity and decide what to do with your remaining time to make your life worth living.

Full Summary

Paul Kalanithi was a stellar neurosurgeon who relentlessly searched for what defines a meaningful life. Treating serious head injuries and cancer, he grappled with death daily and strove to help his terminal patients come to terms with their inevitable deaths. After being diagnosed with terminal cancer at age 36, he was suddenly faced with his own mortality and experienced the same process from the patient's perspective.

Growing up, Kalanithi devoured literature and studied English at Stanford. He was driven to find an answer to the question: What gives human life meaning? He continued his English studies possessed by this question, until he realized that he could only find the meaning of life through direct experience. He knew he had an opportunity to observe the boundary between life and death first hand--he set his sights on becoming a doctor.

In medical school, dissecting cadavers in anatomy class was a visceral blurring of the boundaries between life/death and human/object. He saw the incongruity between the joking, cavalier med students and the deathly cadavers for which their professors held profound respect and kinship. Were these cadavers still people or mere bodies to cut up? Kalanithi observed that doctors see people at their most vulnerable, and seeing a human being as a machine of different systems was the price to pay for easing human suffering.

He chose neurosurgery as his specialty, again looking for direct experience of life and death, and what meaning lay between the two. He was drawn to the supreme standard of excellence held in neurosurgery, one of the most challenging arenas of medicine. Operating on the human brain which creates conscious experience, he felt a strong moral obligation to preserve his patients' identity and quality of life. He carefully evaluated the risks of surgery and wrestled with difficult questions: what kind of life was worth saving? Would it be more meaningful to have a longer life, comatose and unable to speak, or to live out the rest of your days to the fullest? Making judgment calls on whose life they could save through surgery, whose they couldn't, and whose they shouldn't, were some of the hardest decisions he had to make.

Kalanithi distinguished himself as a doctor who saw his patients as humans who were suffering, not mere problems to be solved. He met them sincerely and helped them process their monumental diagnoses, explained the risks, and helped them decide whether to proceed with surgery. In doing so, he felt a palpable connection to the relationship between life, death, and meaning. He dealt with 12-16 hour days, endless paperwork, and physical fatigue, and he baldly stated that you wouldn't choose neurosurgery for a job, as it was one of the worst possible jobs--it was a calling, and it had chosen him. He felt connected to his patients and the meaning of life, especially in the face of death. He had a sense of moral satisfaction in his work and conduct.

He could not realize exactly what imminent mortality was like, however, until he had to face it himself. He received the devastating diagnosis of Stage IV lung cancer.

After going through difficult treatments, he lost the will to carry on with the fervor he had in his career. His whole future he had planned, his career goals, his life with his wife, were suddenly cut short and dissolved into nothingness. In his descent into depression, he found hope in literature again, particularly in the words of Samuel Beckett: "I can't go on. I'll go on." He came to appreciate his oncologist for continually asking him when he would return to surgery when he had given up hope--she held his dreams and ambitions for him when he couldn't himself. Eventually he was able to return to the O.R. and work towards the demanding role of chief resident. He found the will to give himself fully to his work and all the pressures that came with it. He decided to live his own life as much as he could, to continue following his calling.

Kalanithi and his wife were faced with making important decisions with an ever looming final deadline, the greatest choice being whether to have a child. He did not know how much longer he had to live, and his choices would differ if he had 10 years, 3 years, or 6 months. Eventually they decided to have a child. Like with his work, he decided to continue living, instead of dying.

As his cancer progressed, he became unable to work and again began pondering the meaning of life and whether it was worth going on or giving up. He continued to strive to find the truth of the meaning of life, even if there wasn't a correct answer to be found.

“Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never completed.”

As he felt the cancer taking away his remaining time and energy, Kalanithi wondered at his new relationship to the experience of time. He existed in an infinite present with no future, when striving for his future was what he had done all his life.

Yet in the desert of his last days, he found joy and comfort in his newborn daughter, one whose life was only future, full of possibilities. When he had lost all hope of his own future, he found peace and satisfaction in the new life of his daughter.

And so Paul Kalanithi's legacy of excellence, human connection, and searching for meaning lives on in this book and his daughter.