When Breath Becomes Air

by Paul Kalanithi

“It’s very easy to be number one: find the guy who is number one, and score one point higher than he does.”

the mind was simply the operation of the brain,

To one woman, who was recovering from a cardiac procedure: “Are you hungry? What can I get you to eat?” “Anything,” she said. “I’m starving.” “Well, how about lobster and steak?” He picked up the phone and called the nursing station. “My patient needs lobster and steak—right away!” Turning back to her, he said, with a smile: “It’s on the way, but it may look more like a turkey sandwich.” The easy human connections he formed, the trust he instilled in his patients, were an inspiration to me.

“Okay,” I said. “We have a lot to talk about. If you don’t mind, can you tell me what you understand is happening? It’s always helpful for me to hear, to make sure I don’t leave anything unanswered.”

In the OR, the dark gray rotting tumor seemed an invader in the fleshy peach convolutions of the brain, and I felt real anger (Got you, you fucker, I muttered). Removing the tumor was satisfying—even though I knew that microscopic cancer cells had already spread throughout that healthy-looking brain.

He paused. “Paul,” he said, “do you think my life has meaning? Did I make the right choices?” It was stunning: even someone I considered a moral exemplar had these questions in the face of mortality.

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 work—very smart!”

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.

“It’s Jeff. He killed himself.” “What?” Jeff was finishing his surgical fellowship in the Midwest, and we were both so punishingly busy…we’d lost touch. I tried to recall our last conversation and couldn’t.

“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.” I searched for a question to bring understanding. None was forthcoming. I could only imagine the overwhelming guilt, like a tidal wave, that had lifted him up and off that building.

Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.

Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection.

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.

Cady arrived in short order—our friend Victoria had retrieved her from home—and began her own unwitting, cheerful vigil, happily nestled in the crook of Paul’s right arm, tugging at her tiny socks, batting at his hospital blankets, smiling and cooing, unbothered by the BiPAP machine as it continued to blow, keeping Paul alive.

“He doesn’t want a Hail Mary,” I said. “If he doesn’t have a chance of meaningful time, he wants to take the mask off and hold Cady.”

When Paul told me, immediately after his diagnosis, to remarry after he died, it exemplified the way he would, throughout his illness, work hard to secure my future.

Indeed, the version of Paul I miss most, more even than the robust, dazzling version with whom I first fell in love, is the beautiful, focused man he was in his last year, the Paul who wrote this book—frail but never weak.