When Breath Becomes Air

by Paul Kalanithi

felt less like someone preparing to climb a career ladder than a buzzing electron about to achieve escape velocity, flinging out into a strange and sparkling universe.

I knew medicine only by its absence—specifically, the absence of a father growing up, one who went to work before

dawn and returned in the dark to a plate of reheated dinner.

T. S. Eliot’s The Waste Land resonated profoundly, relating meaninglessness and isolation, and the desperate quest for human connection.

In other words, I could either study meaning or I could experience

A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form.

Cadaver dissection epitomizes, for many, the transformation of the somber, respectful student into the callous, arrogant doctor.

Anatomy lab, in the end, becomes less a violation of the sacred and more something that interferes with happy hour, and that realization discomfits. In our rare reflective moments, we were all silently apologizing to our cadavers, not because we sensed the transgression but because we did not.

Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.

At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you

Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living? I was compelled

I feared I was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease—and utterly missing the larger human significance.

Technical excellence was not enough.

What kind of life exists without language?

so. Torn between being a doctor and being a patient, delving into medical science and turning back to literature for answers, I struggled, while facing my own death, to rebuild my old life—or perhaps find a new one.

And so it was literature that brought me back to life during this time. The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action.

seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.

She has your cell membrane,” I remarked to Lucy.)

the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning—to consider a world that is self-evidently not the world we live in. That’s not to say that if you believe in meaning, you must also believe in God. It is to say, though, that if you believe that science provides no basis for God, then you are almost obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any. In other words, existential claims have no weight; all knowledge is scientific knowledge.

And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it. The main message of Jesus, I believed, is that mercy trumps justice every time.

I was neither angry nor scared. It simply was.

And even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder. Some days, I simply persist. If time dilates when one moves at high speeds,

Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection. So what tense am I living in now? Have I proceeded beyond the present tense and into the past perfect? The future tense seems vacant and, on others’ lips, jarring.

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.

We hosted cozy dinner parties, held each other at night, and delighted in our daughter’s bright eyes and calm nature. And, of course, Paul wrote, reclining in his armchair, wrapped in a warm fleece blanket. In his final months, he was singularly focused on finishing this book.

Paul accepted his limited life expectancy, neurologic decline was a new devastation, the prospect of losing meaning and agency agonizing.

I thought of our cozy bed empty at home, remembered falling in love in New Haven twelve years earlier, surprised right away by how well our bodies and limbs fit together, and thought of how ever since, we’d both slept best when entwined.

say, ‘So that’s what it looks like from here…sooner or later I’ll be back here in my own shoes.’ That’s what I’m aiming for, I think. Not

Conversely, we knew that one trick to managing a terminal illness is to be deeply in love—to be vulnerable, kind, generous, grateful.

“I will share your joy and sorrow / Till we’ve seen this journey through.”

At home in bed a few weeks before he died, I asked him, “Can you breathe okay with my head on your chest like this?” His answer was “It’s the only way I know how to breathe.”

Although these last few years have been wrenching and difficult—sometimes almost impossible—they have also been the most beautiful and profound of my life, requiring the daily act of holding life and death, joy and pain in balance and exploring new depths of gratitude and love.

frail but never weak.

For much of his life, Paul wondered about death—and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness.