I’m deeply moved by Dr. Paul Kalanithi’s When Breath Becomes Air, a posthumously-published memoir describing the author’s quest for meaning in the face of his impending death.
Paul, an ambitious neurosurgeon, lost his hard-earned career trajectory to a diagnosis of stage IV lung cancer. After years of counseling terminally ill patients through their final days, preparing them to die, he suddenly found himself in their shoes. He now had to prepare himself to die.
In his eloquent prose, Paul explores his experience on both sides of the patient-physician relationship, grappling with questions of meaning, purpose, and direction. By the end, he had addressed not only what it means to die, but what it means to live. On his pursuit of medicine, he writes:
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. Before operating on a patient’s brain, I realized, I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.
Death is a reality for all of us. We know this, but in our youth and in our health it often feels like a foreign, distant entity, looming just far enough over the horizon to be of little concern. As Paul writes, there’s a subtle but important difference between knowing you will die and knowing you will die soon:
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.
After the diagnosis, Paul faced the notorious dilemma of what to do with his remaining time, shackled by a series of unpromised tomorrows:
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?
The book ends rather abruptly; as Paul’s wife Lucy notes in the epilogue, he died before he could finish the manuscript. But I wonder if there could have been any better place to close than this final paragraph, addressed to his then-eight-month-old daughter:
When you come to one of the many moments in life when 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.
Paul Kalanithi’s life was cut tragically short, but his legacy will endure through this book, one final occasion to do precisely what he spent his career doing: helping people to cope with illness and mortality, find meaning in troubled times, and live and die with grace and integrity.