The cover of Paul Kalanithi’s book says it all. The front shows a view from behind of a doctor in surgeon’s mask, cap and scrubs; the reverse shows a view from the same angle of a patient in a gaping printed gown. In When Breath Becomes Air, Kalanithi tells the story of his journey from surgeon to patient, which began one nightmarish day with the news that he had terminal lung cancer and ended twenty-two months later on 9 March 2015, when he died at the age of thirty-seven.

It would be hard to conceive of a more tragic story. All early deaths are wrenchingly sad; deaths from lung cancer are brutal and frequently fast. Yet Kalanithi’s premature death seems all the more shocking, wasteful and wretched. He was a gifted neurosurgeon, an inspirational teacher and a dedicated researcher who had just completed eleven gruelling years of medical training and was looking forward to a stellar career combining surgery and scientific research. Yet on the day he saw the CT scan of his own lungs he swapped his surgeon’s scrubs for a patient’s gown. As a surgeon it was easy to decipher the grainy picture and make the terminal diagnosis; the future was clear. As a patient the news was impossible to digest, the diagnosis unbearable and the future foggy, confusing and unimaginable. As he charts his life in his dual role – the paths sometimes running parallel to each other, sometimes combining and one finally obliterating the other – Kalanithi provides a uniquely valuable perspective. 

Born in New York and raised in Arizona, Kalanithi initially had no interest in becoming a doctor. Determined to be a writer, he gained a BA and an MA in English literature at Stanford University. But coming from a medical family, he could not escape the lure of science. While studying English he concurrently majored in human biology and then opted for medical school, winning a coveted place at Yale, with a year at Cambridge studying the history and philosophy of science in between. Throughout this polymathic education he felt driven by an urge to understand what makes life meaningful: was meaning gained through literature or science? Finally he chose a career in neurosurgery on the basis that it seemed to present ‘the most challenging and the most direct confrontation with meaning, identity and death’. He was compelled by that elusive interface between the brain and the mind.

Newly married to a fellow medical graduate, Kalanithi embarked on seven years’ frontline training in neurosurgery at Stanford, including a year in neuroscience research. Working a hundred hours a week, he patched up emergencies, performed ten-hour operations and relayed good and bad news to patients and their families as he rose through the ranks. At last he emerged, garlanded with honours, eager to embark on his career as a fully fledged neurosurgeon. His life lay mapped out before him: he would spend twenty years as a neurosurgeon-scientist, followed by twenty years as a writer. But then came the sudden reversal, the twist in the tale.

The symptoms began with weight loss, chest pains and excruciating backache. Finally Kalanithi found himself waiting in a room in his own hospital, a room where he had previously treated numberless patients, wearing that patient’s gown. A nurse told him the doctor would see him soon. And with those words, ‘the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated’.

Kalanithi writes with eloquence, humour and honesty from both sides of the medical fence. His prose is fluid and precise, enlivened by brisk dialogue and offbeat anecdotes, mixing a surgeon’s precision with a human touch. As a neurosurgeon he shares the triumphs and disasters, the feelings of elation and devastation, the beauty and banality of lives lost and saved. The chief lesson he learned as a doctor was that technical excellence was not enough; guiding patients and families towards an understanding of illness and death was what mattered. What he learned as a patient was, perhaps, even more important and enduring.

Faced with an unknown number of years or months, Kalanithi tried to make sense of his situation through science and literature. As a pragmatic doctor, his first reaction was to tie up his finances, stop work and tell his wife to remarry. Yet encouraged by an understanding oncologist, he returned to work for a brief but significant time, started a family – his daughter was born eight months before he died – and devoted his final months to writing. Samuel Beckett, he concluded, seemed to offer the best answer: ‘I can’t go on. I’ll go on.’

Writing was Paul Kalanithi’s first ambition; it became his last task. The result is this book, short and unfinished like Kalanithi’s life, but filled to the brim, also like his life, with joy, humour and meaning.