When Breath Becomes Air
Paul Kalanithi
Foreword by Abraham Verghese
“We carry with us the wonders, we seek without us: There is all Africa, and her prodigies in us; we are that bold and adventurous piece of nature, which he that studies, wisely learns in a compendium, what others labour at in a divided piece and endless volume.”
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Part I: In Perfect Health I Begin
He had reached some compromise in his mind that fatherhood could be distilled; short, concentrated (but sincere) bursts of high intensity could equal…whatever it was that other fathers did. All I knew was, if that was the price of medicine, it was simply too high.
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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.)
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The families who gather around their beloved—their beloved whose sheared heads contained battered brains—do not usually recognize the full significance, either. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery—or, sometimes more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador. I had to help those families understand that the person they knew—the full, vital independent human—now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle.
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For glioblastoma, the curve drops sharply until only about 5 percent of patients are alive at two years. Second, it is important to be accurate, but you must always leave some room for hope. Rather than saying, “Median survival is eleven months” or “You have a ninety-five percent chance of being dead in two years,” I’d say, “Most patients live many months to a couple of years.” This was, to me, a more honest description. The problem is that you can’t tell an individual patient where she sits on the curve: Will she die in six months or sixty? I came to believe that it is irresponsible to be more precise than you can be accurate.
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apocryphal
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I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life—and not merely life but another’s identity; it is perhaps not too much to say another’s soul—was obvious in its sacredness.
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self-effacing)
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I’d never met someone so successful who was also so committed to goodness. V was an actual paragon.
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prognosis,
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In residency, there’s a saying: The days are long, but the years are short. In neurosurgical residency, the day usually began at six A.M. and lasted until the operating was done, which depended, in part, on how quick you were in the OR.
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In the OR, everyone’s eyes are always on the clock. For the patient’s sake: How long has he been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, kidneys can fail. For everyone else’s sake: What time are we getting out of here tonight?
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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. Two hours could feel like a minute. Once the final stitch was placed and the wound was dressed, normal time suddenly restarted.
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prosody,
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When tumors or malformations abut these language areas, the surgeon takes numerous precautions, ordering a host of different scans, a detailed neuropsychological examination. Critically, however, the surgery is performed with the patient awake and talking. Once the brain is exposed, but before the tumor excision, the surgeon uses a hand-held ball-tip electrode to deliver electrical current to stun a small area of the cortex while the patient performs various verbal tasks: naming objects, reciting the alphabet, and so on. When the electrode sends current into a critical piece of cortex, it disrupts the patient’s speech: “A B C D E guh guh guh rrrr…F G H I…” The brain and the tumor are thus mapped to determine what can be resected safely, and the patient is kept awake throughout, occupied with a combination of formal verbal tasks and small talk.
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“Why’d you stop? You some kinda asshole? I told you I want the fucking thing gone!” “It’s done,” I said. “It’s out.” How was he still talking? Given the size and location of the tumor, it seemed impossible. Profanity supposedly ran on a slightly different circuit from the rest of language. Perhaps the tumor had caused his brain to rewire somehow…
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I wished I could have told Jeff what I had come to understand about life, and our chosen way of life, if only to hear his wise, clever counsel. Death comes for all of us. For us, for our patients: it is our fate as living, breathing, metabolizing organisms. Most lives are lived with passivity toward death—it’s something that happens to you and those around you. But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. 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.
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Part II: Cease Not till Death
prognostication.
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prognosis?
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How are you?” “Oh, I’m okay.” She paused—patients don’t typically ask how their doctors are doing, but Emma was also a colleague.
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“Don’t you get it?” she said, taking my hand in hers. “If we’re the best at this, that means it doesn’t get better than this.”
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like to be sick, but until you’ve gone through it yourself, you don’t really know. It’s like falling in love or having a kid. You don’t appreciate the mounds of paperwork that come along with it, or the little things.
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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.
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expedience
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I can’t go on, I thought, and immediately, its antiphon responded, completing Samuel Beckett’s seven words, words I had learned long ago as an undergraduate: I’ll go on. I got out of bed and took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.”
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It struck me that I had traversed the five stages of grief—the “Denial → Anger → Bargaining → Depression → Acceptance” cliché—but I had done it all backward.
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Freud started his career as a successful neuroscientist. When he realized neuroscience would need at least a century to catch up with his true ambition of understanding the mind, he set aside his microscope. I think I felt something similar.
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Yet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth. We build scientific theories to organize and manipulate the world, to reduce phenomena into manageable units. 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. 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). And atheism can be justified only on these grounds. The prototypical atheist, then, is Graham Greene’s commandant from The Power and the Glory, whose atheism comes from a revelation of the absence of God. The only real atheism must be grounded in a world-making vision. The favorite quote of many an atheist, from the Nobel Prize–winning French biologist Jacques Monod, belies this revelatory aspect: “The ancient covenant is in pieces; man at last knows that he is alone in the unfeeling immensity of the universe, out of which he emerged only by chance.”
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