Real Life Leading #7: 'When Breath Becomes Air' by Dr. Paul Kalanithi

Real Life Leading #7:

When Breath Becomes Air

by Dr. Paul Kalanithi


This incredibly powerful book was written while Dr. Kalanithi was fighting an ultimately unsuccessful battle against lung cancer. Prior to his diagnosis, Dr. Kalanithi was a neurosurgeon and writer from Arizona. On his way to becoming a neurosurgeon, he earned degrees in English literature, human biology, a master’s degree in history and philosophy of science and medicine from Cambridge (UK), and eventually graduated from the Yale School of Medicine. (info from the book description of the author)

According to his own testimony, much of the reason for his study of literature and of medicine was an attempt to understand how life got its meaning, and also to better understand our relationship with death. In writing about such difficult and weighty topics, Dr. Kalanithi has shared a number of valuable lessons that are applicable to all leaders, though our leadership roles are often of a less weighty nature.

The book itself is divided into two main parts, the titles of which describe the sections perfectly: In Perfect Health I Begin, and Cease Not till Death. Throughout the book, Dr. Kalanithi describes his experiences, his thoughts, and his understanding of his various roles: college student, medical student, literature studies, husband, surgeon, and finally, cancer patient and father. In each of these roles, he discusses his attempts to grapple with and understand the big questions about life and death, about hope and hopelessness, about meaning and the arbitrary nature of disease. In each of these roles, he shares his thought processes, and from them we see important principles which we can apply in our own lives.

In the whole of the book, his observations are packed with wisdom, with insight, and with all of the weight of one who knows and truly acknowledges that his time is limited. For this reason, the book is not only powerful but also raw and honest but without what he called “the sensationalism of death.” Death’s shadow hovers over the whole book, but it does not cloud or darken his view of life.

In the first part of the book, Dr. Kalanithi briefly describes his background and upbringing before describing in more detail his time in college and then in medical school and as a surgical resident. During each of these stages, it is obvious that he is an exceptionally hard working and driven student, that he is a gifted writer, and that he has a keen eye for observing human nature. He describes his struggles as a doctor who deals with life and death situations every day: the difficulty of meeting these challenges head-on while also not becoming calloused or jaded. In these moments, his honesty sets a great example for what we, as leaders, should strive to do. That is, we should examine a situation with our intellect while also not neglecting the emotional and moral aspects.

Let’s examine a few of the valuable lessons here:

1) In describing his thought process after his first experience of losing a patient, he writes:

“I still had a lot of practical medicine to learn, but would knowledge alone be enough, with life and death hanging in the balance? Surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too…My focus would have to be on my imminent role, intimately involved with the when and how of death—the grave digger with the forceps.” (pg. 66)

Here we see the difficult struggle faced by all leaders set in the sharp relief of life and death: decisions that we are responsible to make but which will have far-reaching consequences for other people not just ourselves. And here we learn a valuable lesson about leadership: Intelligence isn’t enough. Moral clarity is needed as well. If we are to be good leaders in any sense of the word, then there is a moral aspect to leadership that simply cannot be ignored, despite what we see from many ‘leaders’ in our culture today. Leadership is not just about making decisions that are best for the bottom line, or best for ‘our constituency,’ or anything of that nature. Leadership is about making the right or best decisions in all situations, even if that is an unpleasant decision to have to make.

2) While discussing an early experience in learning a difficult surgical technique, he writes: “Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity. The decision to operate at all involves an appraisal of one’s own abilities, as well as a deep sense of who the patient is and what she holds dear.” (pg. 108)

In this passage we see another important truth of leadership: We must understand our own abilities as a leader, but we must also understand the identities and values of those we are leading if we are to make the best decisions for them. All of leadership is about service, and thus we cannot neglect learning about our audience if we are to lead them properly. This is true in the classroom, in sports, and in families: it is imperative that we learn about those we are leading so that we can best know how to lead them in various situations.

3) Right at the end of the first section of the book, Dr. Kalanithi is discussing the awesome (in the true sense of the word) responsibility of neurosurgeons, and the importance of striving for a perfection that is nevertheless unattainable: “Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” (pg. 115)

[Full disclosure: I had to look up what ‘asymptote’ meant, and the easiest way to describe it is a line or curve that approaches ‘0’ (or ‘perfect’) without ever reaching it.] And here we see the next important principle from this book: In this life, we will never attain perfection, yet as leaders we have a responsibility to strive for it at all times. Knowing we cannot be perfect is no excuse for failing to attempt perfection. As leaders, we cannot afford to fall prey to a fatalism or an acceptance that anything less than perfection is ‘good enough.’

3) As his cancer progressed, Dr. Kalanithi and his wife made the decision to have a child, something they had always desired but had put off due to their busy lives (Paul’s wife Lucy is also Dr. Kalanithi) and schedules. Ultimately, their daughter Elizabeth Acadia (affectionately called ‘Cady’) was born about eight months before Paul’s death. Toward the end of the book, Paul wrote that he wondered how his daughter would remember him and what message he most wanted her to know.

Here is what he wrote: “When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.” (pg. 199)

When I first read this passage, the tears began to fall, and they continued off and on throughout the twenty-five page epilogue that his wife wrote. The reason this passage hit me so hard is that I also have daughters, and I often wonder what they will remember about me, moreso than I wonder what other people whom I have led will remember about me.

And in this passage, we see a final lesson from Dr. Kalanithi about leadership: Our job as leaders is to encourage and positively influence our followers, to let them know that they are valued and have something powerful to offer the world, so that they may be encouraged and also positively influence others in the same way.

His message to his daughter was about the powerful and life-changing (even under the shadow of imminent death) joy that her mere presence had brought to his world. If we knew that we had made or could make that type of difference in the life of someone else, how much differently would we approach life? In thinking about leadership, let us remember that we never know whose life we might change today, for better or for worse; and let us always strive to be the type of people who change lives for the better, in large moments and in small.

Practical Takeaway: Today, this day, reach out to someone that you know needs encouragement, and tell them what they mean to you.