When Breath Becomes Air

by

Paul Kalanithi

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When Breath Becomes Air: Prologue Summary & Analysis

Summary
Analysis
The memoir opens on Paul flipping through his CT scan images, seeing that his lungs are matted with numerous tumors. He explains that he’s very familiar with these scans, as he himself is a neurosurgical resident in his last year of training at Stanford. His wife Lucy sits by his side, and asks if he thinks it could be something else. Paul tells her he knows that it is cancer.
The opening of Paul’s memoir introduces not only its primary theme but also its primary purpose. Paul realizes that he is going to have to confront his death much more immediately than he had previously thought. Though the reader doesn’t realize it directly from the outset, Paul wrote the book in order to allow others to confront their own mortality as well.
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Paul describes the circumstances that led to this moment: he had been losing weight and experiencing ferocious back pain. His primary care doctor had suggested that he take X-rays to try and determine the cause. Paul had worried that he might have cancer but reassured himself that cancer is improbable at thirty-six years old.
Paul’s confrontation of mortality comes as a surprise to him, particularly so early in his life. His discussion of probability will recur later in the memoir when he realizes the limits of textbook knowledge, understanding that there must be room left for some optimism.
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The X-rays had not indicated any issues, and Paul had chalked it up to hard work and an aging body. Paul explains that this hard work had earned him the respect of his seniors and won him prestigious national awards, followed by job offers from major universities. He describes that he had “reached the mountaintop,” and looked forward to a more manageable life with Lucy and their future children.
Paul reveals some of his values early on in his narration: spending time with family. However, it is clear that he places achievement of these values in the future—they are a goal towards which he is working. When Paul’s time is cut short, he must work towards his goal more immediately.
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A few weeks later, Paul’s weight drops again and he has severe chest pain. He decides to get another X-ray, this time of his chest. Lucy sees that Paul is researching the frequency of cancer in people his age, and she is upset that he isn’t confiding in her.
Paul’s worry spurs more research, but as he describes later, statistical research rarely provides comfort. What does support him and provide that comfort is his family, but as he is confronted by fear, Paul turns away from his wife.
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Lucy decides not to join Paul on a vacation they had planned to take to New York City to see some of his friends, saying that she had decided instead to move out for the week. She expresses concern that they want different things from their relationship. Paul is absent much of the time, and she worries that his schedule won’t change once he becomes an attending neurosurgeon.
Even prior to Paul’s diagnosis, there is a conflict between the time he possesses and the values on which he chooses to spend it. He aims to become a successful neurosurgeon, but at the expense of spending time with his family. This will become Paul’s major dilemma as he realizes that he has much less time left in his life than he had previously thought.
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Paul offers to skip the trip and see a couple’s therapist, but Lucy is adamant about needing time alone. Paul decides to go on the trip, figuring that if he has severe cancer, as he suspects, this may be the last time to see his friends. Lucy tells him she loves him as she drops him off at the airport.
Paul begins to make those decisions. Even as Lucy pulls away from him, Paul recognizes that it might be valuable to be able to spend time with his friends before he discovers whether he has cancer.
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Paul’s back stiffens in pain during the flight to New York. He hopes his symptoms will clear after a few days away from his hectic life, but he quickly realizes that this is not the case. He confesses to his friend Mike that he may have cancer. Paul’s doctor calls, telling him that the X-rays look blurry, and that she’s not quite sure what that means. Paul knows that it likely means he has cancer.
Paul’s years of experience with various forms of brain cancer provide him with his own diagnosis, even if his doctor isn’t quite certain. Throughout the book, as here, Paul attempts to handle much of his own medical care, and is relieved when his oncologist eventually releases him from that burden.
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Lucy picks Paul up from the airport. He tells her that he has cancer. She affirms that she will never leave him, setting aside her previous concerns.
Just as with Paul, the cancer diagnosis also clarifies the value that Lucy places on family.
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Paul is admitted to the hospital. As he sits in a room in which he has seen many of his own patients, he reflects on his time as a doctor—that in this room, he had congratulated patients on being cured of a disease, and had pronounced patients dead. In his mind, he sees the future toward which he had been striving for the majority of his life evaporate.
Paul’s reflection here marks a break in the narrative and Paul’s life. Prior to this moment, Paul had been exclusively living for the future: setting up a career, a family, and waiting on goals that he planned to accomplish later in life. Here, his future “evaporates” and he must focus on the only thing he has definitively: the present.
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