When Breath Becomes Air

by Paul Kalanithi

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. Meaning, while a slippery concept, seemed inextricable from human relationships and moral values.

Nabokov, for his awareness of how our suffering can make us callous to the obvious suffering of another.

I've thought a lot about this, but Kalantithi expresses it so well..

One of my thesis advisers remarked that finding a community for myself in the literary world would be difficult, because most English PhDs reacted to science, as he put it, “like apes to fire, with sheer terror.” I wasn’t sure where my life was headed. My thesis—“Whitman and the Medicalization of Personality”—was well-received, but it was unorthodox, including as much history of psychiatry and neuroscience as literary

television—and I briefly considered joining them and starting anew. But I couldn’t quite let go of the question: Where did biology, morality, literature, and philosophy intersect?

I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them.

Yet the best-informed people—doctors—almost never donated their bodies. How informed were the donors, then? As one anatomy professor put it to me, “You wouldn’t tell a patient the gory details of a surgery if that would make them not consent.”

All of medicine, not just cadaver dissection, trespasses into sacred spheres. Doctors invade the body in every way imaginable. They see people at their most vulnerable, their most scared, their most private. They escort them into the world, and then back out. Seeing the body as matter and mechanism is the flip side to easing the most profound human suffering. By the same token, the most profound human suffering becomes a mere pedagogical tool.

And as I sat there, I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context. In the actual situations where one encounters these questions, it becomes a necessarily philosophical and biological exercise. Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.

like the ancient Greek concept arete, I thought, virtue required moral, emotional, mental, and physical excellence.

The chairman, passing through the ward: “Always eat with your left hand. You’ve got to learn to be ambidextrous.”

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 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.

That morning, I 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.

And now, finally, maybe I had arrived at denial. Maybe total denial. 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 physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

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.

Science is based on reproducibility and manufactured objectivity. As strong as that makes its ability to generate claims about matter and energy, it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable. 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.

There is a tension in the Bible between justice and mercy, between the Old Testament and the New Testament. And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it. The main message of Jesus, I believed, is that mercy trumps justice every time.

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,

stage. But now I lived in a different world, a more ancient one, where human action paled against superhuman forces, a world that was more Greek tragedy than Shakespeare.

No amount of effort can help Oedipus and his parents escape their fates; their only access to the forces controlling their lives is through the oracles and seers, those given divine vision.

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

Paul’s decision not to avert his eyes from death epitomizes a fortitude we don’t celebrate enough in our death-avoidant culture. His strength was defined by ambition and effort, but also by softness, the opposite of bitterness. He spent much of his life wrestling with the question of how to live a meaningful life, and his book explores that essential territory.

Although these last few years have been wrenching and difficult—sometimes almost impossible—they have also been the most beautiful and profound of my life, requiring the daily act of holding life and death, joy and pain in balance and exploring new depths of gratitude and love.

Even while terminally ill, Paul was fully alive; despite physical collapse, he remained vigorous, open, full of hope not for an unlikely cure but for days that were full of purpose and meaning.

Caring for our daughter, nurturing relationships with family, publishing this book, pursuing meaningful work, visiting Paul’s grave, grieving and honoring him, persisting … my love goes on—lives on—in a way I’d never expected.