When Breath Becomes Air

by Paul Kalanithi

there was an honesty, a truth in the writing that took my breath away.

When we did see him, late at night or on weekends, he was an amalgam of sweet affections and austere diktats, hugs and kisses mixed with stony pronouncements: “It’s very easy to be number one: find the guy who is number one, and score one point higher than he does.” He had reached some compromise in his mind that fatherhood could be distilled; short, concentrated (but sincere) bursts of high intensity could equal…whatever it was that other fathers did. All I knew was, if that was the price of medicine, it was simply too high.

“Country facts” became my term for the rural cousin of the urban legend.

She made me read 1984 when I was ten years old; I was scandalized by the sex, but it also instilled in me a deep love of, and care for, language.

I don’t know if I was happier when I got into Stanford or when Leo got into Yale.

She was a harbinger of the sub rosa, the new world awaiting me in just a few weeks.

naïve understanding of the world. Of course, it must be true—what were our brains doing, otherwise? Though we had free will, we were also biological organisms—the brain was an organ, subject to all the laws of physics, too! Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it. It seemed like magic.

I was driven less by achievement than by trying to understand, in earnest: What makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.

our suffering can make us callous to the obvious suffering of another.

Throughout college, my monastic, scholarly study of human meaning would conflict with my urge to forge and strengthen the human relationships that formed that meaning. If the unexamined life was not worth living, was the unlived life worth examining?

Makes you think how important human relationships are

I could either study meaning or I could experience it.

I studied literature and philosophy to understand what makes life meaningful, studied neuroscience and worked in an fMRI lab to understand how the brain could give rise to an organism capable of finding meaning in the world, and enriched my relationships with a circle of dear friends through various escapades.

“Yeah,” he said. “Good. Good for you. But sometimes, you know, I think it’s better if they die.” I grabbed my bag and left. She had been smiling, hadn’t she? 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.

“the Physiological-Spiritual Man.”

One of my thesis advisers remarked that finding a community for myself in the literary world would be difficult, because most English PhDs reacted to science, as he put it, “like apes to fire, with sheer terror.” I wasn’t sure where my life was headed. My

Cadaver dissection is a medical rite of passage and a trespass on the sacrosanct, engendering a legion of feelings: from revulsion, exhilaration, nausea, frustration, and awe to, as time passes, the mere tedium of academic exercise.

Cadavers reverse the polarity. The mannequins you pretend are real; the cadavers you pretend are fake. But that first day, you just can’t. When I faced my cadaver, slightly blue and bloated, his total deadness and total humanness were undeniable. The knowledge that in four months I would be bisecting this man’s head with a hacksaw seemed unconscionable.

We were instructed to no longer call them “cadavers”; “donors” was the preferred term.

Nuland was a renowned surgeon-philosopher whose seminal book about mortality, How We Die,

I was standing next to the attending as he sliced open the woman’s belly, making a single long curvilinear incision beneath her belly button, just below the apex of her protuberant womb. I tried to follow every movement, digging in my brain for textbook anatomical sketches. The skin slid apart at the scalpel’s touch. He sliced confidently through the tough white rectus fascia covering the muscle, then split the fascia and the underlying muscle with his hands, revealing the first glimpse of the melon-like uterus. He sliced that open as well, and a small face appeared, then disappeared amid the blood. In plunged the doctor’s hands, pulling out one, then two purple babies, barely moving, eyes fused shut, like tiny birds fallen too soon from a nest. With their bones visible through translucent skin, they looked more like the preparatory sketches of children than children themselves. Too small to cradle, not much bigger than the surgeon’s hands, they were rapidly passed to the waiting neonatal intensivists, who rushed them to the neonatal ICU.

The human brain has rendered the organism’s most basic task, reproduction, a treacherous affair. That same brain made things like labor and delivery units, cardiotocometers, epidurals, and emergency C-sections both possible and necessary.

“But how do you know when the tracing looks bad enough? Which is worse, being born too early or waiting too long to deliver?” “Judgment call.” What a call to make. In my life, had I ever made a decision harder than choosing between a French dip and a Reuben? How could I ever learn to make, and live with, such judgment calls?

Putting lifestyle first is how you find a job—not

Something to think about

not a calling.)

At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability—or your mother’s—to talk for a few extra months of mute life? The expansion of your visual

blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? 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?

From that point on, I resolved to treat all my paperwork as patients, and not vice versa.

I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough. As a resident, my highest ideal was not saving lives—everyone dies eventually—but guiding a patient or family to an understanding of death or illness.

In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador.

Any major illness transforms a patient’s—really, an entire family’s—life. But brain diseases have the additional strangeness of the esoteric.

The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul—was obvious in its sacredness.

While most scientists connived to publish in the most prestigious journals and get their names out there, V maintained that our only obligation was to be authentic to the scientific story and to tell it uncompromisingly.

In residency, there’s a saying: The days are long, but the years are short.

passing. If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed.

“He, uh—he apparently had a difficult complication, and his patient died. Last night he climbed onto the roof of a building and jumped off. I don’t really know anything else.”

Had the confirmation of my fears—in the CT scan, in the lab results, both showing not merely cancer but a body overwhelmed, nearing death—released me from the duty to serve, from my duty to patients, to neurosurgery, to the pursuit of goodness? Yes, I thought, and therein was the paradox: like a runner crossing the finish line only to collapse, without that duty to care for the ill pushing me forward, I became an invalid.

(Alexander Pope: “A little learning is a dangerous thing; / Drink deep, or taste not the Pierian spring.”)

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.

Shouldn’t terminal illness, then, be the perfect gift to that young man who had wanted to understand death? What better way to understand it than to live it?

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.

Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.

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.

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.