When Breath Becomes Air

by Paul Kalanithi

  Endless books and authors followed, as we worked our way methodically down the list: The Count of Monte Cristo, Edgar Allan Poe, Robinson Crusoe, Ivanhoe, Gogol, The Last of the Mohicans, Dickens, Twain, Austen, Billy Budd…By the time I was twelve, I was picking them out myself, and my brother Suman was sending me the books he had read in college: The Prince, Don Quixote, Candide, Le Morte D’Arthur, Beowulf, Thoreau, Sartre, Camus. Some left more of a mark than others. Brave New World founded my nascent moral philosophy and became the subject of my college admissions essay, in which I argued that happiness was not the point of life. Hamlet bore me a thousand times through the usual adolescent crises. “To His Coy Mistress” and other romantic poems led me and my friends on various joyful misadventures throughout high school—we often sneaked out at night to, for example, sing “American Pie” beneath the window of the captain of the cheerleading team. (Her father was a local minister and so, we reasoned, less likely to shoot.) After I was caught returning at dawn from one such late-night escapade, my worried mother thoroughly interrogated me regarding every drug teenagers take, never suspecting that the most intoxicating thing I’d experienced, by far, was the volume of romantic poetry she’d handed me the previous week. Books became my closest confidants, finely ground lenses providing new views of the world.

  In her quest to see that her children were educated, my mom drove us more than a hundred miles north, to the nearest big city, Las Vegas, so we could take our PSATs, SATs, and ACTs. She joined the school board, rallied teachers, and demanded that AP classes be added to the curriculum. She was a phenom: she took it upon herself to transform the Kingman school system, and she did. Suddenly there was a feeling in our high school that the two mountain ranges that bounded the town no longer defined the horizon: it was what lay beyond them.

  Senior year, my close friend Leo, our salutatorian and the poorest kid I knew, was advised by the school guidance counselor, “You’re smart—you should join the army.”

  He told me about it afterward. “Fuck that,” he said. “If you’re going to Harvard, or Yale, or Stanford, then I am, too.”

  I don’t know if I was happier when I got into Stanford or when Leo got into Yale.

  Summer passed, and since Stanford began classes a month later than every other school, all of my friends scattered, leaving me behind. Most afternoons, I’d trek into the desert alone and nap and think until my girlfriend, Abigail, got off her shift at Kingman’s lone coffee shop. The desert offered a shortcut, through the mountains and down into town, and hiking was more fun than driving. Abigail was in her early twenties, a student at Scripps College who, wanting to avoid loans, was taking a semester off to stockpile tuition money. I was taken with her worldliness, the sense that she knew secrets one only learned at college—she had studied psychology!—and we’d often meet as she got off work. She was a harbinger of the sub rosa, the new world awaiting me in just a few weeks. One afternoon, I woke from my nap, looked up, and saw vultures circling, mistaking me for carrion. I checked my watch; it was almost three. I was going to be late. I dusted off my jeans and jogged the rest of the way through the desert, until sand gave way to pavement, the first buildings appeared, and I rounded the corner to find Abigail, broom in hand, sweeping the coffee shop deck.

  “I already cleaned the espresso machine,” she said, “so no iced latte for you today.”

  The floors swept, we went inside. Abigail walked to the cash register and picked up a paperback she’d stashed there. “Here,” she said, tossing it at me. “You should read this. You’re always reading such high-culture crap—why don’t you try something lowbrow for once?”

  It was a five-hundred-page novel called Satan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S., by Jeremy Leven. I took it home and read it in a day. It wasn’t high culture. It should have been funny, but it wasn’t. However, it did make the throwaway assumption that the mind was simply the operation of the brain, an idea that struck me with force; it startled my naïve understanding of the world. Of course, it must be true—what were our brains doing, otherwise? Though we had free will, we were also biological organisms—the brain was an organ, subject to all the laws of physics, too! Literature provided a rich account of human meaning; the brain, then, was the machinery that somehow enabled it. It seemed like magic. That night, in my room, I opened up my red Stanford course catalog, which I had read through dozens of times, and grabbed a highlighter. In addition to all the literature classes I had marked, I began looking in biology and neuroscience as well.

  —

  A few years later, I hadn’t thought much more about a career but had nearly completed degrees in English literature and human biology. I was driven less by achievement than by trying to understand, in earnest: 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. T. S. Eliot’s The Waste Land resonated profoundly, relating meaninglessness and isolation, and the desperate quest for human connection. I found Eliot’s metaphors leaking into my own language. Other authors resonated as well. Nabokov, for his awareness of how our suffering can make us callous to the obvious suffering of another. Conrad, for his hypertuned sense of how miscommunication between people can so profoundly impact their lives. Literature not only illuminated another’s experience, it provided, I believed, the richest material for moral reflection. My brief forays into the formal ethics of analytic philosophy felt dry as a bone, missing the messiness and weight of real human life.

  Throughout college, my monastic, scholarly study of human meaning would conflict with my urge to forge and strengthen the human relationships that formed that meaning. If the unexamined life was not worth living, was the unlived life worth examining? Heading into my sophomore summer, I applied for two jobs: as an intern at the highly scientific Yerkes Primate Research Center, in Atlanta, and as a prep chef at Sierra Camp, a family vacation spot for Stanford alumni on the pristine shores of Fallen Leaf Lake, abutting the stark beauty of Desolation Wilderness in Eldorado National Forest. The camp’s literature promised, simply, the best summer of your life. I was surprised and flattered to be accepted. Yet I had just learned that macaques had a rudimentary form of culture, and I was eager to go to Yerkes and see what could be the natural origin of meaning itself. In other words, I could either study meaning or I could experience it.

  After delaying for as long as possible, I finally chose the camp. Afterward, I dropped by my biology adviser’s office to inform him of my decision. When I walked in, he was sitting at his desk, head in a journal, as usual. He was a quiet, amiable man with heavy-lidded eyes, but as I told him my plans, he became a different person entirely: his eyes shot open, and his face flushed red, flecks of spit spraying.

  “What?” he said. “When you grow up, are you going to be a scientist or a…chef?”

  Eventually the term ended and I was on the windy mountain road to camp, still slightly worried that I’d made a wrong turn in life. My doubt, however, was short-lived. The camp delivered on its promise, concentrating all the idylls of youth: beauty manifest in lakes, mountains, people; richness in experience, conversation, friendships. Nights during a full moon, the light flooded the wilderness, so it was possible to hike without a headlamp. We would hit the trail at two A.M., summiting the nearest peak, Mount Tallac, just before sunrise, the clear, starry night reflected in the flat, still lakes spread below us. Snuggled together in sleeping bags at the peak, nearly ten thousand feet up, we weathered frigid blasts of wind with coffee someone had been thoughtful enough to bring. And then we would sit and watch as the first hint of sunlight, a light tinge of day blue, would leak out of the eastern horizon, slowly erasing the stars. The day sky would spread wide and high, until the first ray of the sun made an appearance. The morning commuters began to animate the distant South Lake Tahoe roads. But craning your head b
ack, you could see the day’s blue darken halfway across the sky, and to the west, the night remained yet unconquered—pitch-black, stars in full glimmer, the full moon still pinned in the sky. 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. It was as if this were the moment God said, “Let there be light!” You could not help but feel your specklike existence against the immensity of the mountain, the earth, the universe, and yet still feel your own two feet on the talus, reaffirming your presence amid the grandeur.

  This was summer at Sierra Camp, perhaps no different from any other camp, but every day felt full of life, and of the relationships that give life meaning. Other nights found a group of us on the dining room deck, sipping whiskey with the assistant director of the camp, Mo, a Stanford alum taking a break from his English PhD, and discussing literature and the weighty matters of postadolescent life. The next year he returned to his PhD, and later he sent me his first published short story, summing up our time together:

  Suddenly, now, I know what I want. I want the counselors to build a pyre…and let my ashes drop and mingle with the sand. Lose my bones amongst the driftwood, my teeth amongst the sand….I don’t believe in the wisdom of children, nor in the wisdom of the old. There is a moment, a cusp, when the sum of gathered experience is worn down by the details of living. We are never so wise as when we live in this moment.

  —

  Back on campus, I didn’t miss the monkeys. Life felt rich and full, and over the next two years I kept at it, seeking a deeper understanding of a life of the mind. 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. We raided the school cafeteria dressed as Mongols; created a full fake fraternity, complete with fake rush-week events, in our co-op house; posed in front of the gates at Buckingham Palace in a gorilla suit; broke into Memorial Church at midnight to lie on our backs and listen to our voices echo in the apse; and so on. (Then I learned that Virginia Woolf once boarded a battleship dressed as Abyssinian royalty, and, duly chastened, stopped boasting about our trivial pranks.)

  Senior year, in one of my last neuroscience classes, on neuroscience and ethics, we visited a home for people who had suffered severe brain injuries. We walked into the main reception area and were greeted by a disconsolate wailing. Our guide, a friendly thirty-something woman, introduced herself to the group, but my eyes hunted for the source of the noise. Behind the reception counter was a large-screen television showing a soap opera, on mute. A blue-eyed brunette with well-coiffed hair, her head shaking slightly with emotion, filled the screen as she pleaded with someone off camera; zoom out, and there was her strong-jawed, undoubtedly gravel-voiced lover; they embraced passionately. The wailing rose in pitch. I stepped closer to peer over the counter, and there, on a blue mat in front of the television, in a plain flower-print dress, was a young woman, maybe twenty, her hands balled into fists pressed into her eyes, violently rocking back and forth, wailing and wailing. As she rocked, I caught glimpses of the back of her head, where her hair had worn away, leaving a large, pale patch of skin.

  I stepped back to join the group, which was leaving to tour the facility. Talking with the guide, I learned that many of the residents had nearly drowned as young children. Looking around, I noticed there were no other visitors besides us. Was that common? I asked.

  At first, the guide explained, a family will visit constantly, daily or even twice a day. Then maybe every other day. Then just weekends. After months or years, the visits taper off, until it’s just, say, birthdays and Christmas. Eventually, most families move away, as far as they can get.

  “I don’t blame them,” she said. “It’s hard caring for these kids.”

  A fury churned in me. Hard? Of course it was hard, but how could parents abandon these kids? In one room, the patients lay on cots, mostly still, arranged in neat rows like soldiers in a barracks. I walked down a row until I made eye contact with one of them. She was in her late teens, with dark, tangled hair. I paused and tried smiling at her, showing her I cared. I picked up one of her hands; it was limp. But she gurgled and, looking right at me, smiled.

  “I think she’s smiling,” I said to the attendant.

  “Could be,” she said. “It can be hard to tell sometimes.”

  But I was sure of it. She was smiling.

  When we got back to campus, I was the last one left in the room with the professor. “So, what’d you think?” he asked.

  I vented openly about how I couldn’t believe that parents had abandoned these poor kids, and how one of them had even smiled at me.

  The professor was a mentor, someone who thought deeply about how science and morality intersected. I expected him to agree with me.

  “Yeah,” he said. “Good. Good for you. But sometimes, you know, I think it’s better if they die.”

  I grabbed my bag and left.

  She had been smiling, hadn’t she?

  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.

  —

  As graduation loomed, I had a nagging sense that there was still far too much unresolved for me, that I wasn’t done studying. I applied for a master’s in English literature at Stanford and was accepted into the program. I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion. A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form. It was the relational aspect of humans—i.e., “human relationality”—that undergirded meaning. Yet somehow, this process existed in brains and bodies, subject to their own physiologic imperatives, prone to breaking and failing. There must be a way, I thought, that the language of life as experienced—of passion, of hunger, of love—bore some relationship, however convoluted, to the language of neurons, digestive tracts, and heartbeats.

  At Stanford, I had the good fortune to study with Richard Rorty, perhaps the greatest living philosopher of his day, and under his tutelage I began to see all disciplines as creating a vocabulary, a set of tools for understanding human life in a particular way. Great literary works provided their own sets of tools, compelling the reader to use that vocabulary. For my thesis, I studied the work of Walt Whitman, a poet who, a century before, was possessed by the same questions that haunted me, who wanted to find a way to understand and describe what he termed “the Physiological-Spiritual Man.”

  As I finished my thesis, I could only conclude that Whitman had had no better luck than the rest of us at building a coherent “physiological-spiritual” vocabulary, but at least the ways in which he’d failed were illuminating. I was also increasingly certain that I had little desire to continue in literary studies, whose main preoccupations had begun to strike me as overly political and averse to science. 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 criticism. It didn’t quite fit in an English department. I didn’t quite fit in an English department.

  Some of my closest friends from college were headed to New York City to pursue a life in the arts—some in comedy, others in journalism and 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? 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. Although—or perhaps because—my father, my uncle, and my elder brother were all doctors, medicine had never occurred to me as a serious possibility. But hadn’t Whitman himself written that only the physician could truly understand “the Physiological-Spiritual Man”?

  The next day, I consulted a premed adviser to figure out the logistics. Getting ready for medical school would take about a year of intense coursework, plus the application time, which added up to another eighteen months. It would mean letting my friends go to New York, to continue deepening those relationships, without me. It would mean setting aside literature. But it would allow me a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay.

  I began working through the necessary premedical courses, loading up on chemistry and physics. Reluctant to take a part-time job—it would slow my studies—but unable to afford Palo Alto rent, I found an open window in an empty dormitory and climbed in. After a few weeks of squatting, I was discovered by the caretaker—who happened to be a friend. She provided a key to the room and some useful warnings, like when the high school girls’ cheerleading camps would be coming through. Thinking it wise to avoid becoming a registered sex offender, I’d pack a tent, some books and granola, and head up to Tahoe until it was safe to return.