Jeffrey Galbraith
“What kind of life exists without language?” Paul Kalanithi raises this question near the midpoint of When Breath Becomes Air (2016), a memoir that weaves together medicine, literature, and the mortality that must be faced after a diagnosis of Stage IV lung cancer. As the memoir reveals, literature proved central to his efforts to live meaningfully in the face of illness. Fiction, poetry, and philosophy had long shaped his identity, and they now offered him not only “a vocabulary with which to make sense of death” but also a means of understanding his own story (148).
Literature is central to Kalanithi’s account of his intellectual, moral, and professional formation—which may come as a surprise to readers. His father and uncle were doctors, his mother was a trained physiologist, his older brother would become a neurologist, and yet it was literature, not science, that first captured Kalanithi’s imagination. When Kalanithi was 10 years old, his mother introduced a rigorous reading program, beginning with George Orwell’s 1984, to prepare him for university. The experience of reading Orwell proved transformative, he explains, describing how it “instilled in me a deep love of, and care for, language” (26). One by one he worked through “The Count of Monte Cristo, Edgar Allen Poe, Robinson Crusoe, Ivanhoe, Gogol, The Last of the Mohicans, Dickens, Twain, Austen, Billy Budd” (26). These and other works, Kalanithi writes, “became my closest confidants, finely ground lenses providing new views of the world” (27). This early experience of immersive reading shaped his inner life, leading him to see the literary imagination as essential to human meaning.
In early adulthood, the love of literature came to inhabit a growing tension with the reductionist claims of neuroscience. Soon after high school graduation, a girlfriend urged him to read something other than that “high-culture crap” he was fond of (29). The novel she recommended suggested that consciousness might be nothing more than brain activity. Kalanithi recalls that the idea “startled my naïve understanding of the world” (30). Could the mind really be reduced to the mere firing of neurons? What, then, of the power of fiction and poetry to transport the reader? Kalanithi reveled in the mystery: “Literature provided a rich account of human meaning,” he observed, and “the brain, then, was the machinery that somehow enabled it. It seemed like magic.” He viewed the interplay between brain and imagination as crucial for understanding the questions of existence. At Stanford, he pursued a double major in English literature and human biology. He wanted to know “in earnest: What makes human life meaningful?” (31).
Throughout the memoir, Kalanithi portrays language as a force that grounds human meaning and transcends material explanation. He reflects on the “relationality” of words, a term he uses to suggest that meaning itself, whether verbal or existential, arises from the bonds forged by language (51). “A word meant something only between people,” he observes, “and life’s meaning, its virtue, had something to do with the depth of the relationships we form” (39). While pursuing graduate studies in English, Kalanithi explains that he thought of language as “an almost supernatural force, existing between people, bringing out brains, shielded in centimeter-thick skulls, into communion” (39). At the same time, he learned from his scientific training that language depends on specific neural circuits in regions known as Broca’s and Wernicke’s areas. Though Kalanithi remained unconvinced by the materialist account of consciousness, neither was he ready to dismiss it. He continued to seek more intimate access to the nexus of mind and brain: “There must be a way, I thought, that the language of life as experienced—of passion, of hunger, of love—bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats” (39). The breakthrough came while writing his master’s thesis on the poet Walt Whitman. As he looked deeply into Whitman’s work, he realized that the practice of medicine could provide the “direct experience of life-and-death questions” that literature had awakened in him (41). Medicine offered the possibility of combining intellectual inquiry with decisive action. To him, the physician seemed a valiant figure, someone who demonstrated “the heroic spirit of responsibility amid blood and failure.”
Kalanithi’s decision to attend medical school evokes the familiar opposition that pits practice against theory, seeming to represent a rejection of his love for language and literature. Kalanithi himself framed it in these terms at the time. “Words began to feel as weightless as the breath that carried them,” he explains, concluding that “[m]oral speculation was puny compared to moral action” (43). Yet it is more accurate to say that medicine, rather than renouncing his love for language, offered a way to unite his divergent interests. As a physician, he would be able to continue asking the existential questions he valued so highly. This becomes clear as he listens to a pediatric neurosurgeon advise the parents of a child in need of brain surgery. The family was confronted with questions of existence that resembled the ones he had deliberated in literature and philosophy classes. “I realized,” Kalanithi writes, “that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context. In the actual situations where one encounters these questions, it becomes a necessarily philosophical and biological exercise” (emphasis mine, 70). For patients facing brain surgery, these questions are far from abstract: “At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability—or your mother’s—to talk for a few extra months of mute life?” (70).
Kalanithi’s reference to “the heroic spirit of responsibility,” along with the longing for direct experience, suggests his understanding that medical training was formative in nature. To become a physician required cultivating technical expertise, but it also required developing his mind, moral outlook, and emotional life. The decision to specialize in neurosurgery, which came later in the process, deepened the formation he would need to undergo, demanding that he become someone who could safeguard the very substance of a patient’s identity. A slip of the scalpel by even one millimeter could destroy the capacity to make and understand language. It is no wonder, during training, that Kalanithi reflects, “Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought” (88). The remark emphasizes how medicine was much more than a career. It was a calling.
The love of words that began with reading Orwell continues to shape Kalanithi’s story of medical school and residency. As a neurosurgical resident, he remained attentive to imagery and etymology, noting that “The root of disaster means a star coming apart, and no image expresses better the look in a patient’s eyes when hearing a neurosurgeon’s diagnosis” (90). This sensitivity to language culminated one day in a moral epiphany, when he realized, chagrined, that he was thinking of his patients as sets of symptoms rather than as persons. Chastened, he vowed to uphold a more rigorous ethic of care. In his interactions with patients, he would ensure that his words reflected “the singular importance of human relationships” (86). In this way, language serves as a point of convergence in the memoir. Kalanithi’s long education fostered both an appreciation for the transcendence of poetry and the technical ability to resect the tumor that could silence speech. As a scholar-physician, he came to understand that language uplifts but that it also eludes, subject to the losses of age, illness, and injury. He became someone to whom others turned when the search for life’s meaning encountered, as it does, the limits of the fragile physical brain.
When Breath Becomes Air debuted to immediate success, spending more than a year on the New York Times bestseller list. Reviews of the book were universally positive, with critics registering a note of fellow feeling in their assessments. The book drew them in. “We ache for this man, we hurt for this marriage,” wrote Beth Kephart in The Chicago Tribune, adding, “We think of all the patients who benefited from Kalanithi's sheer humanity…and all those who will never have the honor of having him stand by their bedside.” Kalanithi may have been a polymath in the tradition of the Renaissance physician Sir Thomas Browne, as Abraham Verghese suggests in the book’s Foreword, but the learning on display in the memoir proves no obstacle to its impact. That readers do not find it difficult to feel along with the author is due partly to the restraint that Kalanithi shows in the writing. As Janet Maslin remarks, “None of it is maudlin. Nothing is exaggerated.” The events are moving enough, without need of emotional embellishment. For good reason it was selected as a finalist for the Pulitzer Prize.
Still, Kalanithi’s high view of literature appears throughout the memoir in allusions and carefully chosen epigraphs. His references to literary and intellectual tradition illuminate the purpose and power of the work. Kalanithi possessed an extensive knowledge of authors and literary works, ranging from Augustine’s Confessions and Sir Thomas Browne’s Religio Medici to T.S. Eliot’s The Waste Land, Tolstoy’s War and Peace, and Graham Greene’s The Power and the Glory, as well as the philosophers Marin Heidegger, Richard Rorty, and Thomas Nagel.
The decision to write his graduate thesis on Walt Whitman registers his deep affinity with the nineteenth-century poet and highlights his insistence on living life fully despite death’s encroachment. Kalanithi drew the titles of Part 1 (“In Perfect Health I Begin”) and Part 2 (“Cease Not Till Death”) from Whitman’s long poem Song of Myself. These borrowings reveal both identity and difference. Early in the poem, Whitman declares himself boldly: “I, now thirty-seven years old in perfect health begin, / Hoping to cease not till death” (ll. 8-9, emphases mine). This declaration marks the starting point for an expansive affirmation of life that brings about a striking transformation. In the poem’s conclusion, the poet dissolves into the natural world: “I depart as air, I shake my white locks at the runaway sun, / I effuse my flesh in eddies, and drift it in lacy jags” (ll. 1337-1338).
Kalanithi began his memoir when he was about the same age as Whitman, though he could not claim to be in “perfect health.” When he received his diagnosis, death gathered pace, forcing him to live with a more “contracted sense of the future” (146). In this context, his use of the phrase “Cease Not Till Death” becomes an ironic mantra, an imperative to push forward in times of difficulty. This kind of imperative appears from a different literary voice at another point in the memoir. One morning, during an excruciating round of treatment, Kalanithi recalled the closing words of Samuel Beckett’s novel The Unnamable (1953): “I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over: ‘I can’t go on. I’ll go on.’” (149). By turns vulnerable and defiant, Beckett’s words capture a paradox that stirs Kalanithi to push forward, giving him language to voice a seemingly inexpressible experience.
In service of that end, the memoir’s most significant literary reference is its elegant title. Kalanithi fashioned the phrase “when breath becomes air” from a poem by the Renaissance poet Fulke Greville. Although the poem appears in a sequence of love lyrics, it departs from the theme of courtship, turning to address the reader directly about death:
You that seek what life is in death,
Now find it air that once was breath.
New names unknown, old names gone:
Till time end bodies, but souls none.
Reader! then make time, while you be,
But steps to your eternity.
Greville begins the poem by acknowledging our long-standing curiosity about death—that “undiscovered country,” in the words of Shakespeare’s Hamlet, “from whose bourn / No traveler returns.” How are we transformed in death? Does something endure, or are we utterly extinguished? The poem first imagines a materialist perspective, whereby death is merely the event of matter changing form. Our breath, which for Greville represents the vital life within us, returns into the air that sustained it. Our atoms disperse into the environment. As Kalanithi clinically describes it, “the basic requirement of life is metabolism, and death its cessation” (70). In Greville’s lines, time serves as the agent of this dissolution (“Till time end bodies”), erasing our bodies and even our “names” from earthly memory.
Yet the fourth line pivots to the vantage offered by eternity. For Greville, finitude is not the only, or even the most appropriate, lens through which to view death. Although time may “end bodies,” it cannot destroy the immaterial soul. Renaissance poets were captivated by the image of time as a consuming enemy. The phrase Tempus edax rerum (“Time, that devours all things”) appeared in Ovid’s first-century Latin poem The Metamorphoses, where it served as inspiration for such works as Shakespeare’s Sonnet 19 and Andrew Marvell’s “To His Coy Mistress.” In Marvell’s carpe diem poem, love offers the only stay against the time’s “slow-chapped power.” Greville, by contrast, urges the reader to treat time not as an enemy but as a means of preparing the soul for its eternal destiny. True to the memento mori tradition, he refuses to obscure the reality that awaits us. Living with a clear view of our end, the poem suggests, allows us to make time an instrument, perhaps a ladder or stair, for living well.
The phrase “when breath becomes air,” lyrically expressive on its own, shows a deft, creative touch. It hangs in the air, a dependent clause in need of completion. What follows when breath becomes air? The missing main clause leaves us waiting in expectation. Which seems to be the point. This tension increases in Part 2, which begins with the fraught period following Kalanithi’s diagnosis, as we are ushered into the experience of sitting and grappling with the knowledge of mortality. By narrating his efforts to orient himself to the shortened span of his days, Kalanithi invites readers to ask their own questions. What would we do in his situation? How would we choose to live?
Awareness of mortality comes in various ways—through a diagnosis, a sudden brush with death, the slow approach of advancing age, or even the suffering of others. Sometimes this awakening comes inexplicably, unbidden. Confronting our mortality provokes a wide range of responses: fear, anger, denial, even bitterness. Some turn away, convinced that avoidance is easier. Others search for peace, frantically perhaps, or with quiet determination. As priorities sharpen, we let go of what seems unnecessary and our thoughts turn to legacy: Have we accomplished enough? How will we be remembered?
While Kalanithi experienced many of these responses during his treatment, he also sought to provide guidance for others experiencing their own encounters with mortality. The epigraph he placed at the beginning of Part 2, from Montaigne’s Essays, communicates this aim: “If I were a writer of books,” Montaigne writes, “I would compile a register of the various deaths of men: he who should teach men to die would at the same time teach them to live” (119). Kalanithi’s use of Montaigne’s self-reflexive words, from the essay “That to Study Philosophy Is to Learn How to Die” (1580), affirms his aim to teach others as he undergoes his own suffering. In the essay, Montaigne drew on Stoic tradition, familiarizing himself with classical accounts of death as a means of overcoming his fears and cultivating a state of peace. Kalanithi’s own learning process takes a different path, however. Rather than pursue stoic self-mastery, Kalanithi sought to understand how cancer had created a “strange and strained existence,” a state of being he described as “challenging me to be neither blind to, nor bound by, death’s approach” (165).
Among the rewards of reading When Breath Becomes Air are the insights into this newly strange existence that Kalanithi gains by returning to the literature that shaped his early life. Although he once rejected literature aside in pursuit of direct experience, he came to understand the value of stories, poems, and memoirs during his last months and days. These insights are best left for readers to discover for themselves, but as a final note it is worth briefly describing Kalanithi’s shift of mindset.
After his diagnosis, Kalanithi initially responded as a doctor, approaching the illness objectively by learning everything he could about the nature of his cancer. The rapport he established with his oncologist, for instance, derived from the fact that she acknowledged his medical expertise. He writes of her detailed plan of treatment: “I immediately felt a kinship. This was exactly how I approached neurosurgery: have a plan A, B, and C at all times” (129). The limits of this approach soon became apparent, however, and Kalanithi realized he needed a different kind of knowledge. Feeling rudderless amid “the reams of scientific studies, intracellular molecular pathways, and endless curves of survival statistics,” he reports that he “began reading literature again: Solzhenitsyn’s Cancer Ward, B. S. Johnson’s The Unfortunates, Tolstoy’s Ivan Ilyich,” and other works about mortality (148). Although the words of imaginative literature had once seemed weak and insubstantial, they suddenly took on new weight. No longer did he associate literature with mere speculation or the avoidance of hard decisions. He now understood that literature served as a guide, a means of orienting him to this new stage of life. Kalanithi ascribes to it a power that seems almost medical: “And so it was literature that brought me back to life during this time” (149).
Kalanithi’s return to literature becomes central to the remainder of the memoir, enabling him not only to fulfill his goal of helping others but also to model a way of engaging life more deeply. His story offers us motivation to enrich our own lives. Poems, stories, and memoirs remain valuable because they do not shield us from difficult realities. Rather, they give us the means to work through tragedy and live fully in the knowledge of our end.
Works Cited
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What is Core Book?
An ars moriendi for our time, Paul Kalanithi’s When Breath Becomes Air is the absorbing and profound memoir of a 36-year-old wunderkind neurosurgeon and neuroscientist who receives a grave diagnosis and writes his way through to the end of life on earth. His book is the rich distillation of an experience and an education that integrates faith and learning in literature, science, and philosophy to inquire into the most fundamental of life’s enduring questions: what does my life and death mean? A gift to all who read it, this book will especially serve communities that surround a Christian liberal arts college like Wheaton as we seek, with the Psalmist, to “number our days, that we may gain a heart of wisdom.”
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