[Ecis2023]
When Breath Becomes Air is the story of Paul, a Stanford neurosurgeon. At 36, he was diagnosed with terminal lung carcinoma and published an opinion piece in The New York Times titled How Long Do You Have Left? That article went viral. Paul wrote When Breath Becomes Air, about his death. It was published last week, ten years after he had died.
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This book will break your heart in half and it is also hilarious. You will find more inspirational When Breath Becomes Air Quotes if you are interested.
When Breath Becomes Air Quotes
You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.
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.
Will having a newborn distract from the time we have together?” she asked. “Don’t you think saying goodbye to your child will make your death more painful?”
“Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.
I can’t go on. I’ll go on.
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.
Years ago, it had occurred to me that Darwin and Nietzsche agreed on one thing: the defining characteristic of the organism is striving.
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.
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.
The main message of Jesus, I believed, is that mercy trumps justice every time.
The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. It felt like someone had taken away my credit card and I was having to learn how to budget.
You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently. Two months after that, you may want to learn to play the saxophone or devote yourself to the church. Death may be a one-time event, but living with a terminal illness is a process.
“Graham Greene once said that life was lived in the first twenty years and the remainder was just reflection.”
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“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.”
Life wasn’t about avoiding suffering.
What makes life meaningful enough to go on living?
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 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.
even if I’m dying until I actually die, I am still living.
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.
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?
Literature not only illuminated another’s experience, but it also 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.
I expected to feel only empty and heartbroken after Paul died. It never occurred to me that you could love someone the same way after he was gone, that I would continue to feel such love and gratitude alongside the terrible sorrow, the grief so heavy that at times I shiver and moan under the weight of it.
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Those burdens are what make medicine holy and wholly impossible: in taking up another’s cross, one must sometimes get crushed by the weight.
Bereavement is not the truncation of married love, C. S. Lewis wrote, but one of its regular phases—like the honeymoon.
If the unexamined life was not worth living, was the unlived life worth examining?
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.
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 the moment.
“Any part of me that identified with being handsome was slowly being erased—though, in fairness, I was happy to be uglier and alive.”
At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability or your mother’s to talk for a few extra months of mute life? The expansion of your visual blind spot in exchange for the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurological suffering would you let your child endure before saying that death is preferable?
Because the brain mediates our experience of the world, any neurosurgical problem forces a patient, and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?
I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own experiences, I would have to translate them back into language.
Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward.
In the silences between his words, listen to what you have to say back. Therein lies his message.
You that seek what life is in death, Now find it air that once was breath. New names unknown, old names are gone: Till time end bodies, but souls none. Reader! then make time, while
There must be away, I thought, that 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.
Frail but never weak.
Everything teeters between pathos and bathos: here you are, violating society’s most fundamental taboos and yet formaldehyde is a powerful appetite stimulant, so you also crave a burrito.
She was upset because I’d promised her one life, and given her another.
values of Christianity—sacrifice, redemption, forgiveness—because
The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning—to consider a world that is self-evidently not the world we live in. 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.
Struggle toward the capital-T Truth, but recognize that the task is impossible—or that if a correct answer is possible, verification certainly is impossible.
In the end, it cannot be doubted that each of us can see only part of the picture. The doctor sees one, the patient another, the engineer a third, the economist a fourth, the pearl diver a fifth, the alcoholic a sixth, the cable guy a seventh, the sheep farmer an eighth, the Indian beggar a ninth, the pastor a tenth. 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 the truth comes somewhere above all of them, where, as at the end of that Sunday’s reading: the sower and reaper can rejoice together. For here the saying is verified that One sow and another reaps. I sent you to reap what you have not worked for; others have done the work, and you are sharing the fruits of that work.
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.
All have a notion of what it means to be good, and we can’t live up to it all the time.
If the weight of mortality does not grow lighter, does it at least get more familiar?
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.
What patients seek is not scientific knowledge that doctors hide but existential authenticity each person must find on her own. Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.
We shall rise insensibly, and reach the tops of the everlasting hills, where the winds are cool and the sight is glorious.
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The word hope first appeared in English about a thousand years ago, denoting some combination of confidence and desire. But what I desired life was not what I was confident about death. When I talked about hope, then, did I really mean Leave some room for unfounded desire?
No. Medical statistics not only describe numbers such as mean survival, they measure our confidence in our numbers, with tools like confidence levels, confidence intervals, and confidence bounds. So did I mean Leave some room for a statistically improbable but still plausible outcome a survival just above the measured 95 percent confidence interval?
Is that what hope was? Could we divide the curve into existential sections, from defeated to pessimistic to realistic to hopeful to delusional? Weren’t the numbers just the numbers? Had we all just given in to the hope that every patient was above average? It occurred to me that my relationship with statistics changed as soon as I became one.
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.
That message is simple: 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.
Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.
I will share your joy and sorrow / Till we’ve seen this journey through.
He knew he would never be alone, never suffer unnecessarily. At home in bed a few weeks before he died, I asked him, Can you breathe okay with my head on your chest like this? His answer was It’s the only way I know how to breathe. That Paul and I formed part of the deep meaning of each other’s lives is one of the greatest blessings that has ever come to me.
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 back, 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.
Well, I guess I learned one thing: if I’m ever feeling down about my work, I can always talk to a neurosurgeon to cheer myself up.
I sat, staring at a photo of Lucy and me from medical school, dancing and laughing; it was so sad, those two, planning a life together, unaware, never suspecting their own fragility.
Words began to feel as weightless as the breath that carried. Stepping back, I realized that I was merely confirming what I already knew: I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action.
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.
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.
As a resident, my highest ideal was not saving lives — everyone dies eventually — but guiding a patient or family to an understanding of death or illness.
Books became my closest confidants, finely ground lenses providing new views of the world.
life’s meaning, its virtue, had something to do with the depth of the relationships we form.
The most obvious might be an impulse to frantic activity: to live life to its fullest, to travel, to dine, to achieve a host of neglected ambitions. Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. And even if I had the energy, I prefer a more tortoise-like approach. I plod, I ponder. Some days, I simply persist.
‘What are you most afraid or sad about?’ she asked me one evening while we were lying in bed. ‘Leaving you,’ I told her.
Moral duty has weight, things that have weight have gravity, and so the duty to bear mortal responsibility pulled me back into the operating room.
It’s very easy to be number one: find the guy who is number one, and score one point higher than he does.
I had a nagging sense that there was still far too much unresolved for me, that I wasn’t done studying.
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