When Breath Becomes Air

by Paul Kalanithi

I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful?

miscommunication between people can so profoundly impact their lives.

Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection.

If the unexamined life was not worth living, was the unlived life worth examining?

The camp delivered on its promise, concentrating all the idylls of youth: beauty manifest in lakes, mountains, people; richness in experience, conversation, friendships.

There is a moment, a cusp, when the sum of gathered experience is worn down by the details of living. We are never so wise as when we live in this moment.

Only later would I realize that our trip had added a new dimension to my understanding of the fact that brains give rise to our ability to form relationships and make life meaningful. Sometimes, they break.

But it would allow me a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay.

How could I ever learn to make, and live with, such judgment calls? 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.

And as I sat there, I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context.

the question is not simply whether to live or die but what kind of life is worth living.

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?

The days when someone was simply “killed in a car accident” were long gone. Now those words opened a Pandora’s box, out of which emerged all the images: the roll of the gurney, the blood on the trauma bay floor, the tube shoved down her throat, the pounding on her chest.

When there’s no place for the scalpel, words are the surgeon’s only tool.

I had met her in a space where she was a person, instead of a problem to be solved.

Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient’s life worth living, and planning to save those things if possible—or to allow the peace of death if not.

Even if you are perfect, the world isn’t.

Severe illness wasn’t life-altering, it was life-shattering. It felt less like an epiphany—a piercing burst of light, illuminating What Really Matters—and more like someone had just firebombed the path forward.

The fact of death is unsettling. Yet there is no other way to live.

Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.

My brain was fine, but I did not feel like myself.

was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again.

even if I’m dying, until I actually die, I am still living.

Reconnecting with patients brought back the meaning of this work.

The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. It felt like someone had taken away my credit card and I was having to learn how to budget. You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently. Two months after that, you may want to learn to play the saxophone or devote yourself to the church. Death may be a one-time event, but living with terminal illness is a process.

Maybe, in the absence of any certainty, we should just assume that we’re going to live a long time. Maybe that’s the only way forward.

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.

“We all have a notion of what it means to be good, and we can’t live up to it all the time.”

Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete.

Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day.

And so it’s not all that useful to spend time thinking about the future—that is, beyond lunch.