Paul Kalanithi was a chief resident in neurosurgery at Stanford, with advanced degrees from Stanford, Cambridge and Yale, Building a brilliant career. He also had metastatic lung cancer, and but for that, the world might never have known he was a writer.
After his diagnosis at age 36, Kalanithi wrote essays for this magazine and for The New York Times in which he eloquently contemplated time, relationships, medicine and mortality. “Before I go,” published in our spring 2015 issue, garnered millions of readers around the world. Many thanked him, publicly and privately, for his candor and the depth of his insight.
Those essays became the basis for Kalanithi’s posthumous book, When Breath Becomes Air, published in January by Random House with a foreword by author and Stanford professor of medicine Abraham Verghese, MD. In it, Kalanithi talks about how his oncologist repeatedly refused to estimate his remaining life span in years or months, instead exhorting him to focus on what mattered most to him. In the last months of his life, says his wife, Lucy Kalanithi, MD, a Stanford clinical instructor in medicine, he conserved his limited energy for one purpose: to finish the book from which this excerpt is taken.
The bulk of my week was spent not in cognitive therapy but in physical therapy. I had sent nearly every one of my patients to physical therapy. And now I found myself shocked at how difficult it was. As a doctor, you have a sense of what it’s 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. When you get an IV placed, for example, you can actually taste the salt when they start infusing it. They tell me that this happens to everybody, but even after 11 years in medicine, I had never known.
In physical therapy, I was not even lifting weights yet, just lifting my legs. This was exhausting and humiliating. My brain was fine, but I did not feel like myself. My body was frail and weak — the person who could run half marathons was a distant memory — and that, too, shapes your identity. Racking back pain can mold an identity; fatigue and nausea can, as well. Karen, my PT, asked me what my goals were. I picked two: riding my bike and going for a run. In the face of weakness, determination set in. Day after day I kept at it, and every tiny increase in strength broadened the possible worlds, the possible versions of me. I started adding reps, weights and minutes to my workouts, pushing myself to the point of vomiting. After two months, I could sit for 30 minutes without tiring. I could start going to dinner with friends again.
One afternoon, Lucy and I drove down to Cañada Road, our favorite biking spot. (Usually we would bike there, pride forces me to add, but the hills were still too formidable for my lightweight frame.) I managed 6 wobbly miles. It was a far cry from the breezy, 30-mile rides of the previous summer, but at least I could balance on two wheels.
Was this a victory or a defeat?
I began to look forward to my meetings with Emma [the oncologist]. In her office, I felt like myself, like a self. Outside her office, I no longer knew who I was. Because I wasn’t working, I didn’t feel like myself, a neurosurgeon, a scientist — a young man, relatively speaking, with a bright future spread before him. Debilitated, at home, I feared I wasn’t much of a husband for Lucy. I had passed from the subject to the direct object of every sentence of my life. In 14th-century philosophy, the word patient simply meant “the object of an action,” and I felt like one. As a doctor, I was an agent, a cause; as a patient, I was merely something to which things happened. But in Emma’s office, Lucy and I could joke, trade doctor lingo, talk freely about our hopes and dreams, try to assemble a plan to move forward. Two months in, Emma remained vague about any prognostication, and every statistic I cited she rebuffed with a reminder to focus on my values. Though I felt dissatisfied, at least I felt like somebody, a person, rather than a thing exemplifying the second law of thermodynamics (all order tends toward entropy, decay, etc.).
Flush in the face of mortality, many decisions became compressed, urgent and unreceding. Foremost among them for us: Should Lucy and I have a child? Even if our marriage had been strained toward the end of my residency, we had always remained very much in love. Our relationship was still deep in meaning, a shared and evolving vocabulary about what mattered. If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning. It had been something we’d always wanted, and we were both impelled by the instinct to do it still, to add another chair to our family’s table.
Both of us yearning to be parents, we each thought of the other. Lucy hoped I had years left, but understanding my prognosis, she felt that the choice — whether to spend my remaining time as a father — should be mine.
“What are you most afraid or sad about?” she asked me one night as we were lying in bed.
“Leaving you,” I told her.
I knew a child would bring joy to the whole family, and I couldn’t bear to picture Lucy husbandless and childless after I died, but I was adamant that the decision ultimately be hers: she would likely have to raise the child on her own, and to care for both of us as my illness progressed.
“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.
Years ago, 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. We talked it over. Our families gave their blessing. We decided to have a child. We would carry on living, instead of dying.