When Breath Becomes Air

by Paul Kalanithi

At age thirty-six, I had reached the mountaintop;

But I’m worried we want different things from our relationship. I feel like we’re connected halfway.

I need to do something different.

I made it to Grand Central to catch a train to my friends’ place upstate, my body was rippling with pain.

I received the plastic arm bracelet all patients wear, put on the familiar light blue hospital gown,

buzzing electron about to achieve escape velocity,

knew medicine only by its absence

It was a five-hundred-page novel called Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S., by Jeremy Leven.

driven less by achievement than by trying to understand,

literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.

At Stanford, I had the good fortune to study with Richard Rorty, perhaps the greatest living philosopher of his day, and under his tutelage I began to see all disciplines as creating a vocabulary, a

“the Physiological-Spiritual Man”?

Because the med school application cycle takes eighteen months, I had a free year once my classes were over.

So I applied for, and was accepted into, the HPS program at Cambridge.

Medical school sharpened my understanding of the relationship between meaning, life, and death.

Somehow, I had to believe, I would gain not only knowledge but wisdom, too. After

identity: every operation on the brain is, by necessity, a manipulation of the substance of

At those critical junctures, the question is not simply whether to live or die but

What makes life meaningful enough to go on

had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking.

observed a lot of suffering; worse, I became inured to it. Drowning,

Thirty minutes in the freezer resuscitated the sandwich. Pretty tasty, I thought, picking chocolate chips out of my teeth as the family said its last goodbyes. I wondered if, in my brief time as a physician, I had made more moral slides than strides. A few days

A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy, and you can’t be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or: “I get your strategy: by the time you finish sewing the top half of the wound, the bottom will have healed on its own! Half the

Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity.

Our patients’ lives and identities may be in our hands, yet death always wins.

said. I told her to remarry, that I couldn’t bear the thought of her being alone.

My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come so

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,

Before my cancer was diagnosed, I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday

It occurred to me that my relationship with statistics changed as soon as I became one.

the weight of mortality does not grow lighter, does it at least get more familiar?

Should Lucy and I have a child?

“Don’t you think saying goodbye to your child will make your death more painful?”

Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving. Describing life otherwise was like painting a tiger without stripes. After so many years of living with death, I’d come to understand that the easiest death wasn’t necessarily the best. We talked it over. Our families gave their blessing. We decided to have a child. We would carry on living, instead of dying.

Even in having children in this new life, death played its part.

I hadn’t expected the prospect of facing my own mortality to be so disorienting, so dislocating. I

everywhere I turned, the shadow of death obscured the meaning of any action.

made a decision: I would push myself to return to the OR. Why? Because I could. Because that’s who I was. Because I would have to learn to live in a different way, seeing death as an imposing itinerant visitor but knowing that even if I’m dying, until I actually die, I am still living.

I altered my physical therapy program, focusing now on building strength specifically for operating: long hours of standing, micromanipulation of small

Eventually, though, the itch to hold a surgical drill again had become too compelling. Moral duty has weight, things that have weight have gravity, and so the duty to bear mortal responsibility pulled me back into the operating room. Lucy was fully supportive.

five stages of grief—the “Denial → Anger → Bargaining → Depression → Acceptance”

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. Between these...

morbidity and mortality conference, a regular meeting in which the neurosurgeons gathered to review mistakes that had been made and cases that had gone wrong. Afterward, I spent an extra couple of

“This is not the end,” she said, a line she must have used a thousand times—after all, did I not use similar speeches to my own patients?—to those seeking impossible answers. “Or even the beginning of the end. This is just the end of the beginning.”

leaned back in my hospital bed and closed my eyes. As the darkness of delirium descended again, I finally relaxed.

brightening newness surrounds her. As

sits in my lap smiling, enthralled by my tuneless singing, an incandescence lights the room.

Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next r...