When Breath Becomes Air

by Paul Kalanithi

Kingman, Arizona,

Location

She was a phenom: she took it upon herself to transform the Kingman school system, and she did.

Role of hs mom

Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it. It seemed like magic.

Literature to biology to medicine

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.

Literature to Biology - 4

To the east, the full light of day beamed toward you; to the west, night reigned with no hint of surrender. No philosopher can explain the sublime better than this, standing between day and night.

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.

Literature to Biology - 5

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.

Decision on Neuroscience - 6

I applied for a master’s in English literature at Stanford and was accepted into the program. I

Masters program 7

But I couldn’t quite let go of the question: Where did biology, morality, literature, and philosophy intersect? Walking home from a football game one afternoon, the autumn breeze blowing, I let my mind wander. Augustine’s voice in the garden commanded, “Take up and read,” but the voice I heard commanded the opposite: “Set aside the books and practice medicine.” Suddenly, it all seemed obvious.

Decision on medicine - 8

It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action. I finished my degree and headed back to the States. I was going to Yale for medical school.

Medicine decision - 9

Medical school sharpened my understanding of the relationship between meaning, life, and death. I saw the human relationality I had written about as an undergraduate realized in the doctor-patient relationship.

Learnings from being a doc - 10

Few books I had read so directly and wholly addressed that fundamental fact of existence: all organisms, whether goldfish or grandchild, die. I

Understanding mortality - 11

The first birth I witnessed was also the first death.

Doctor experiences - 12

Surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I had to believe, I would gain not only knowledge but wisdom, too. After all, when I had walked into the hospital just one day before, birth and death had been merely abstract concepts. Now I had seen them both up close.

Doctor experiences 13

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

Decision on residency - 14

While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact.

Decision on neurosurgery - 15

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?

Meaning of life - 16

An eight-year-old named Matthew, for example, came in one day complaining of headaches only to learn that he had a tumor abutting his hypothalamus. The

Experiences in residency - 17

Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.

One day, Matthew, the little boy with the brain tumor who had charmed the ward a few years back, was readmitted. His

Experiences in residency 1mm- 18

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

But the most sacrosanct regions of the cortex are those that control language. Usually located on the left side, they are called Wernicke’s and Broca’s areas; one is for understanding language and the other for producing it. Damage to Broca’s area results in an inability to speak or write, though the patient can easily understand language. Damage to Wernicke’s area results in an inability to understand language; though the patient can still speak, the language she produces is a stream of unconnected words, phrases, and images, a grammar without semantics. If both areas are damaged, the patient becomes an isolate, something central to her humanity stolen forever. After someone suffers a head trauma or a stroke, the destruction of these areas often restrains the surgeon’s impulse to save a life: What kind of life exists without language?

Experiences in Residency - Importance of language - 19

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

End of first half - Grappling with death - 20

I began to realize that coming in such close contact with my own mortality had changed both nothing and everything. 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 I would die, but I didn’t know when. But now I knew it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.

As a patient - 21

The word hope first appeared in English about a thousand years ago, denoting some combination of confidence and desire. But what I desired—life—was not what I was confident about—death. When I talked about hope, then, did I really mean “Leave some room for unfounded desire?” No.

Meaning of hope - 22

began to view the world through two perspectives; I was starting to see death as both doctor and patient.

Emerging perspectives - as a doc and a patient - 23

I had passed from the subject to the direct object of every sentence of my life.

Note 6

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

Note 7

Death may be a one-time event, but living with terminal illness is a process.

Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence—and, eventually, death. Perhaps later than I think, but certainly sooner than I desire.

Note 10

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.

Note 9

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.

Note 11