Ryan’s notes

When Breath Becomes Air by Paul Kalanithi

★★★★

As I took stock of my collection of books, I came across When Breath Becomes Air. I had no recollection of buying it, so with curiosity I picked it up and read the jacket: “At the age of 36, on the verge of completing a decade’s worth of training as a neurosurgeon, Paul Kalanithi was diagnosed with stage IV lung cancer… What do you do when the future, no longer a ladder toward your goals in life, flattens out into a perpetual present?”

I’d been thinking about my own priorities after a decade of near single-minded focus on work, and while I’m not dying (though I suppose we all are), I wanted to learn what this accomplished man, concerned with what gives life meaning, decided after his diagnosis. Paul doesn’t discover the Meaning of Life of course, but he does offer up useful frameworks for thinking and some ideas that pushed against my own.

A young Paul saw literature as the best way to understand what gives life meaning so he embarked on a degree to study it more deeply and one day become a writer. But he also felt a tension between study and lived experience: “If the unexamined life was not worth living, was the un-lived life worth examining?” The proper balance of doing and thinking is something I consider quite a bit. We shouldn’t endlessly “live in the moment” since we’d never get to make full sense of those moments, nor should we incessantly examine our days for meaning: it takes dedication and commitment over time to bring about rich chapters of experience that we can’t always see developing in the present.

Like Hemingway, Paul hopes to gather rich experiences, then retreat “to cogitate and write about them.” He pours himself into what he believes to be a 40+ year career: the first half practicing neurosurgery and the second half as a writer. But when Paul learns that he doesn’t have 40 years, he must reconsider his identity and his plan. What should he do if he only has one year to live? Ten? Should he continue to practice surgery? Or write? He decides to return to the operating room and presents this decision as a well considered one, but it struck me as one of inertia and denial, an effective way to distract himself from his diagnosis with the comfort of his old routines. Paul states repeatedly throughout his memoir that relationships are what give life meaning, but in returning the the O.R. he lets many of his own languish, and he effectively gives up his dream of writing. Ultimately he only writes this memoir when he falls into health so poor that he can no longer practice medicine. I wonder if Paul realized that he failed to integrate many of the things he believed made a meaningful life into his own. The trap of viewing work as a prerequisite to our other aspirations (“I will build a career, then I will write / then I will travel / then I will revel in friendship”) is one that I’ve fallen into as well. But when we defer happiness and fulfillment to a later date, we gamble that we’ll live long enough and be in good enough health to enjoy the fruits of our sacrificial labor. The idea of a linearly progressing life is flawed: it’s important to me to engage in meaningful work, close relationships, and play in parallel.

Paul, in his dying days, provides a surprisingly coherent argument for religion despite being an atheist for most of his life: “[I] came to believe in… an ultimately scientific worldview… The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only God… but also love, hate, meaning—to consider a world that is self-evidently not the world we live in.” What I hear in this passage is someone searching for a useful model to live by. There’s a saying that no model is accurate, but some are useful: weather models, economic models, climate models, financial models, and models of political thought are never totally correct, but they can be useful. When it comes to choosing the best model to live by, classical religions like Christianity more directly speak to lived human experiences—hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue, justice, mercy, goodness—than scientific models do. Perhaps it’s not the correctness but the usefulness that should inform which we embrace (I say this as an atheist).

When contemplating whether they should have a child together, Paul’s wife asks: “Don’t you think that saying goodbye to your child will make your death more painful?” Paul’s response: “Wouldn’t it be great if it did?” Impending death doesn’t stop Paul from creating new joys and connection, even if it adds to his weight of loss. Living life to minimize pain is not fully living; we aught to build a life we’d envy leaving behind, to pursue beauty we might not witness ourselves. Or, in Paul’s words: “It occurred to me that Darwin and Neitzche agreed on one thing: the defining characteristic of the organism is striving.”

I read When Breath Becomes Air in two sittings and finished with tears in my eyes alone in my living room. So, I did what any teary-eyed kid wants to do: I called my mom. We talked not only about this book, but about our own constructions of meaning and where they come from. Paul hoped that we’d read his words and contemplate our own mortality: “[The reader] can get into these shoes, walk a bit, and say, ‘So that’s what it looks like from here’.” And, for a moment, that’s exactly what we did.


Highlights & notes

Saw literature as the best way to understand what gives life meaning, then stumbled upon the truth that the brain is what constructs this meaning. Sees relationships as the source of meaning. Contemplates the tension between learning / inspecting and experiencing. Saw Sierra Camp in Tahoe as high experience: friends, conversation, nature.

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 isn’t worth living, is the unlived life worth examining?

Contemplating having a child while Paul is sick with terminal cancer:

“Don’t you think that saying goodbye to your child will make your death more painful?” / “Wouldn’t it be great if it did?” Lucy and I both felt that life wasn’t about avoiding suffering.

It occurred to me that Darwin and Neitzche agreed on one thing: the defining characteristic of the organism is striving.

During some of his toughest days:

“I can’t go on. I’ll go on” — Samuel Beckett

When deciding what to do after his diagnosis, he sees his desire to do neurosurgery as “a moral duty” to “bear mortal responsibility” ... but is this duty really what drove him back? Seems like more of a comforting justification than an overriding principle to me.

Fun fact: Freud started as a neuroscientist but when he realized it’d take 100 years to actually understand the brain, he switched course.

Idea: the physician’s job is not to rebuild a life or construct a new one, it’s to stand the patient and family back up so they can find their own meaning in the experience.

On religion:

I... came to believe in the possibility of a material conception of reality, an ultimately scientific worldview... The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only God... but also love, hate, meaning—to consider a world that is self-evidently not the world we live in. In other words, existential claims have no weight: all knowledge is scientific knowledge.

^ Returned to Christianity because it more directly speaks to the lived human experience—hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue... justice, mercy... that goodness is something we can never quite live up to.

In the end, it cannot be doubted that each of us can see only a part of the picture... Human knowledge... grows from the relationships we create between each other and the world, and still it is never complete.

If time dialates while moving at high speeds, does it contract when one moves barely at all? It must: the days have shortened considerably.

Closing thoughts: brutal. Teared up at the end. Had a loving team around him as he passed—a partner, too. And they weren’t in a good place before his illness—testament to slowing down and breathing in what’s around you right now—and striving to create more moments of connection, understanding, trust, togetherness.