When Breath Becomes Air

by Paul Kalanithi

At age thirty-six, I had reached the mountaintop; I could see the Promised Land, from Gilead to Jericho to the Mediterranean Sea.

We’d survived the most difficult part of our journey.

Didn’t she see that I had only one year left in residency, that I loved her, that we were so close to the life together we’d always wanted?

“If it were just residency, I could make it,” she said. “We’ve made it this far. But the problem is, what if it’s not just residency? Do you really think things will be better when you’re an academic neurosurgery attending?”

“The doctor will be in soon.” And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

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

Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that’s the point. Putting lifestyle first is how you find a job—not a calling.)

Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving.

Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward.

“I can’t go on. I’ll go on.”

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

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.

The way forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases. The truth that you live one day at a time didn’t help: What was I supposed to do with that day?

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 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.

Yet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth.

Science is based on reproducibility and manufactured objectivity.

Between these core passions and scientific theory, there will always be a gap. No system of thought can contain the fullness of human experience. The realm of metaphysics remains the province of revelation (this, not atheism, is what Occam argued, after all).

The main message of Jesus, I believed, is that mercy trumps justice every time.

About God I could say nothing definitive, of course, but the basic reality of human life stands compellingly against blind determinism.

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.

If time dilates when one moves at high speeds, does it contract when one moves barely at all? It must: the days have shortened considerably.

Now the time of day means nothing, the day of the week scarcely more. Medical training is relentlessly future-oriented, all about delayed gratification; you’re always thinking about what you’ll be doing five years down the line. But now I don’t know what I’ll be doing five years down the line. I may be dead. I may not be. I may be healthy. I may be writing. I don’t know. And so it’s not all that useful to spend time thinking about the future—that is, beyond lunch.

Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past.

The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.

There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

Paul faced each stage of his illness with grace—not with bravado or a misguided faith that he would “overcome” or “beat” cancer but with an authenticity that allowed him to grieve the loss of the future he had planned and forge a new one. He cried on the day he was diagnosed.

He cried on his last day in the operating room. He let himself be open and vulnerable, let himself be comforted. Even while terminally ill, Paul was fully alive;

frail but never weak.

What happened to Paul was tragic, but he was not a tragedy.