When Breath Becomes Air

by Paul Kalanithi

Everything teeters between pathos and bathos: here you are, violating society’s most fundamental taboos, and yet formaldehyde is a powerful appetite stimulant, so you also crave a burrito.

Cadavers reverse the polarity. The mannequins you pretend are real; the cadavers you pretend are fake.

Putting lifestyle first is how you find a job—not a calling.)

What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find on her own. 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.

care for both of us as my illness progressed. “Will having a newborn distract from the time we have together?” she asked. “Don’t you think saying goodbye to your child will make your death more painful?” “Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering. 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 isn’t about avoiding suffering’, so much emotional maturity in just one line.

“Denial → Anger → Bargaining → Depression → Acceptance” cliché—but I had done it all backward. On diagnosis, I’d been prepared for death. I’d even felt good about it. I’d accepted it. I’d been ready. Then I slumped into a depression, as it became clear that I might not be dying so soon after all, which is, of course, good news, but also confusing and strangely enervating. The rapidity of the cancer science, and the nature of the statistics, meant I might live another twelve months, or another 120. Grand illnesses are supposed to be life-clarifying. Instead, I knew I was going to die—but I’d known that before. My state of knowledge was the same, but my ability to make lunch plans had been shot to hell. 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? At some point, then, I began to do a little bargaining—or not exactly bargaining.

In the end, it cannot be doubted that each of us can see only a part of the picture. The doctor sees one, the patient another, the engineer a third, the economist a fourth, the pearl diver a fifth, the alcoholic a sixth, the cable guy a seventh, the sheep farmer an eighth, the Indian beggar a ninth, the pastor a tenth. 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. And Truth comes somewhere above all of them, where, as at the end of that Sunday’s reading, the sower and reaper can rejoice together. For here the saying is verified that “One sows and another reaps.” I sent you to reap what you have not worked for; others have done the work, and you are sharing the fruits of their work.

This book carries the urgency of racing against time, of having important things to say. Paul confronted death—examined it, wrestled with it, accepted it—as a physician and a patient. He wanted to help people understand death and face their mortality. Dying in one’s fourth decade is unusual now, but dying is not.

“Always the seer is a sayer,” Emerson wrote. “Somehow his dream is told; somehow he publishes it with solemn joy.” Writing this book was a chance for this courageous seer to be a sayer, to teach us to face death with integrity.