Paul Kalanithi became a neurosurgeon because he felt compelled by neurosurgery and “its unforgiving call to perfection… it seemed to present the most challenging and direct confrontation with meaning, identity and death”. He was, in his own words, overwhelmed and intoxicated by neurosurgery – feelings which I certainly shared when I started my own neurosurgical training 35 years ago. He wrote his moving book When Breath Becomes Air as he approached the completion of his training as a neurosurgeon, but after he had developed metastatic lung cancer. He died at the age of 37, before he could ever practise as a fully qualified surgeon. The book, which he wrote as he was dying, is published posthumously.
It is disturbing, at first, to read an autobiographical book in which the author knows he is dying and you know that he will be dead by the end of it. But Kalanithi writes very well, in a plain and matter-of-fact way, without a trace of self-pity, and you are immediately gripped and carried along. The fact that I use the present tense in writing about him shows that the book has taken on a life of its own, as Kalanithi clearly hoped it would. It’s a remarkable book, for many reasons, especially for his description of his transition from all-powerful doctor to anxious patient, and of how he was “so authoritative in a surgeon’s coat but so meek in a patient’s gown”.
Kalanithi came from a medical family and at first had no wish to become a doctor. “I knew medicine only by its absence – specifically, the absence of a father growing up, one who went to work before dawn and returned in the dark to a plate of reheated dinner.”
Instead, he studied English literature and human biology at Stanford University, California, and then a master’s in the history and philosophy of science at Cambridge. He hoped to find what makes life meaningful from writers such as TS Eliot and Nabokov, but was disappointed: “I had spent so much time studying literature at Stanford and the history of medicine at Cambridge in an attempt to better understand the particularities of death, only to come away feeling like they were still unknowable to me.”
He wrote his thesis on the American poet Walt Whitman and his vision of the “Physiological-Spiritual Man” in the modern, secular age, who could only be understood by a physician. As Kalanithi cast about for a career after completing his degree, he realised that medicine was the obvious choice, after all. “Moral speculation,” he writes, “was puny compared to moral action.”
One of the strengths of medical education in America is that it is a postgraduate degree, so that doctors are older and can be more widely educated than those in the UK by the time they qualify. (I would love to see medicine become a postgraduate degree in this country.) That having been said, med school in the US is a gruelling experience, and postgraduate neurosurgical training even more so. When the time came for Kalanithi and his colleagues at med school to decide on their specialities, he was surprised to find that many students opted for “lifestyle” careers and wanted their commencement oath – an updated version of the Hippocratic oath, which was abandoned in this country many years ago – to be rewritten, with the promise to place patients’ interests above their own removed. Kalanithi writes that “putting lifestyle first is how you find a job – not a calling” as he opts for neurosurgery.
This ambivalence between vocation and work has always been at the heart of medicine, and it is more important than ever to recognise it – at least in Britain, where the Conservative government and its hired management consultants seem to see healthcare as just another industry without any moral dimension.
Neurosurgery in the US has the reputation for being the most onerous speciality in which to train. “Neurosurgery residents,” his chief resident tells him, “aren’t just the best surgeons – we’re the best doctors in the hospital.” His chairman tells him that he must only eat with his left hand, so that he becomes ambidextrous. Kalanithi describes neurosurgical residency as a black hole, which even his closest colleagues could not understand.
So he endures the long hours of training and is clearly highly successful and utterly dedicated. But when he looks back on this period – now as a dying patient himself – he regrets that he had become inured to his patients’ suffering : “…being so close to the fiery light only blinded me to their nature”. He considers that the cost of his dedication was high – his failures to save patients brought “nearly unbearable guilt”. One of his colleagues kills themselves over an operative mistake. And yet these burdens a doctor must bear he considers to be both “holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight”.
As with many doctors with cancer – who often deny their symptoms – it was some time before the diagnosis was made. He dismissed his back pain – caused by secondary disease in his spine – as benign. He recounts the months of treatment, and the difficult limbo of prolonged remission, which modern medicine can now give us: we are treated but not cured, and must learn to live with a slow death sentence. He movingly describes the negotiation between hope and the acceptance of death, and the complexity of discussions with one’s oncologist, as different chemotherapy treatments provide only temporary reprieve, and become increasingly toxic. The balance between hope and resignation becomes difficult to strike. He even completes his training and comes close to accepting the job of his dreams, but then must admit it is only a fantasy that he will live long enough to take it up, and turns it down.
Paul Kalanithi became a neurosurgeon because he wanted to learn about “what really matters in life”. His view of medicine remained deeply idealistic and not yet tempered by the sometimes bitter lessons and need for painful moral compromise that come with responsibility.
Towards the end of the book, he and his wife, knowing that he is soon to die, decide to have a child, and he returns to the religious faith in which he was brought up. He was clearly a deeply thoughtful and compassionate man, and his death is a great loss to medicine, but at least he has left this remarkable book behind.
Dr Henry Marsh is a neurosurgeon and the author of Do No Harm, which was shortlisted for the Guardian first book award in 2014.
When Breath Becomes Air is published by Bodley Head (£12.99). Click here to order it from the Guardian Bookshop for just £8.99.
