A Stanford Neurosurgeon, A Stage IV Diagnosis At Thirty-Six, And The Memoir Finished By His Wife

Paul Kalanithi was, by any conventional measure, on the verge of something rare. In May 2013, in his sixth and final year of neurosurgical residency at Stanford, with the academic faculty offers people who train at his level get one chance to land in front of him, he was diagnosed with stage IV non-small-cell EGFR-positive lung cancer. He was thirty-six. He had spent his life building toward a career that requires roughly a decade of training after medical school and that the diagnosis, in one consultation, made functionally irrelevant. He and his wife Lucy - whom he had met at Yale Medical School and who is herself a physician - had been imagining decades. They were now counting in months. When Breath Becomes Air is the memoir he wrote in the time between the diagnosis and his death on March 9, 2015. He did not live long enough to write his own ending. Lucy did, in an epilogue covering the last weeks of his life, and the manuscript was published in January 2016 with a foreword by Abraham Verghese; it spent sixty-eight weeks on the New York Times bestseller list and was a 2017 Pulitzer Prize finalist for Biography.

A 5.0 reflects: a memoir written by someone uniquely equipped to write it - a neurosurgeon who was also a Stanford English major, a Cambridge philosophy-of-medicine student, and a serious reader of Walt Whitman - confronting his own mortality with a precision that would be unbearable in less honest hands; a structural choice to leave the manuscript at the point where Kalanithi could no longer write rather than have someone ventriloquize him through the ending; and an epilogue by Lucy that does not flinch from the medical, physical, or domestic specifics of his last months.

Part I: How Doctors Learn What Death Is

The book is built in two parts. The first, written from before his diagnosis was the central fact of his life, is the story of how he came to neurosurgery: a childhood in Arizona with a mother who put literature in front of him from the age of ten and a cardiologist father he was less close to; an undergraduate double major at Stanford in English literature and human biology, then a master's in English; a year at Cambridge for a master's in history and philosophy of science and medicine; and then medical school at Yale, on the conviction that the brain - the organ that makes a person who they are - was where the literary question of identity and the biological question of the body were the same question. The medical training section is unsentimental. It is the cadaver lab, the first patient deaths, the residencies, the slow construction of the emotional armor a surgeon needs to do the job and the slow recognition of the cost of that armor. The hardest moments in this section are not Kalanithi's own. They are Jeff's, a fellow resident and friend who took his own life after losing a patient, and they are V's, a mentor of Kalanithi's who survived pancreatic cancer and whose example - a doctor on the patient side of the bed - is sitting in Kalanithi's mind well before he understands what it is preparing him for.

Then comes May 2013. The CT scans. The pivot Kalanithi keeps describing is the one between identities: the doctor who has been delivering this kind of news has now become the patient receiving it, and the technical knowledge he has does not protect him. It makes the scans more legible, the numbers more honest, the trajectory clearer than any patient should have to read on their own films. His oncologist, Emma Hayward, becomes a recurring figure for the rest of the book.

Part II: How A Person Lives What He Already Knows

The second part is Kalanithi writing during treatment. The EGFR-positive subtype of his cancer is treatable in the sense that targeted therapy can buy him time, and time is what he uses. He returns to neurosurgery for a stretch and finishes his residency. He and Lucy decide to have a child even knowing he likely will not see her grow, and on July 4, 2014, their daughter Cady is born. The chapters about Cady are some of the cleanest writing in the book - Kalanithi is unsentimental about what fatherhood means inside a terminal diagnosis, and clear-eyed that the decision was made on the explicit understanding that Lucy would raise her without him. The treatment works for a while. It stops working. The cancer spreads to his brain. He stops doing surgery. He focuses on the book, which by then he understands is the thing he has the time and the standing to leave behind.

The book ends at the place where Kalanithi could no longer write. The closing pages he did finish are a direct address to Cady - written in the knowledge that she will read them as an adult who never knew him - that includes the line about how she has filled a dying man's days with a sated joy, a joy that does not hunger for more.

Lucy's Epilogue

The epilogue is the part of the book almost everyone who has read it talks about, and it is the part the book could not survive without. Lucy picks up where Paul stopped. She writes the medical specifics of his decline that he did not live long enough to write about - the spread of the cancer, the question of the ventilator, his decision to refuse it and choose comfort care, the goodbyes to his family, the last hours in the hospital, his death on March 9, 2015, with Cady eight months old. It is not a tribute. It is a continuation. The voice in it is its own - she is a physician, she is a widow, she is the person who has had to decide what her husband's unfinished book would and would not include - and the structural decision to let her finish the work in her own register rather than ventriloquize him is the thing that makes the book whole.

Why a 5

The strengths are the book itself: prose that earns the literary reputation, a structural integrity that uses the unfinishedness rather than apologizing for it, a refusal of the two easy paths a memoir like this could take (false hope on one side, sentimentalized despair on the other), medical training rendered with the precision of someone who actually did it, and the epilogue. The combination of Kalanithi's first-person account and Lucy's final account is the rare case of a memoir that is more honest because two people had to write it.

There is, in the genre of this book, a reasonable critique - that some readers will want more philosophy and less hospital, or more hospital and less philosophy, that the literary references can land differently for readers who do not share Kalanithi's particular reading list, that the unfinishedness is itself a kind of incompleteness. None of those land on this book the way they would on a less honest one. A 5.0 means: a book that does what it was written to do, in the only way it could be done, by the only two people who could have done it.

Rating: 5.0/5 ⭐

Perfect for: Readers who want memoir at full literary weight, anyone interested in the doctor-patient inversion at the center of medicine, readers who can sit with mortality rendered honestly, parents and partners reading about other people's families with eyes open.

Skip if: You are in active grief and not ready for the medical specifics of a young father's death (when you are ready, this book may help, but not before), or you want a memoir that pulls back from the harder physical and domestic facts of dying.