When Breath Becomes Air

Is contained in

Canonical title

When Breath Becomes Air

Original title

When Breath Becomes Air

Original publication date

2016-01-12

Important places

Kingman, Arizona, USA; New Haven, Connecticut, USA; Palo Alto, California, USA

Epigraph

You that seek what life is in death,
Now find it air that once was breath.
New names unknown, old names gone:
Till time end bodies, but souls none.
  Reader! then make time, while you be,
  But steps t... (show all)o your eternity.

— Baron Brooke Fulke Greville, “Caelica 83”

Dedication

For Cady

First words

I knew with certainty that I would never be a doctor.
 —  Part One

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I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumours, the spine deformed, a full lobe of the liver obliterated.
 —  Prologue

Quotations

I knew with certainty that I would never be a doctor. I stretched out in the sun, relaxing on a desert plateau just above our house. My uncle, a doctor, like so many of my relatives, had asked me earlier that day what I plann... (show all)ed on doing for a career, now that I was heading off to college, and the question barely registered. If you had forced me to answer, I suppose I would have said a writer, but frankly, thoughts of any career at this point seemed absurd. I was leaving this small Arizona town in a few weeks, and I felt less like someone preparing to climb a career ladder than a buzzing electron about to achieve escape velocity, flinging out into a strange and sparkling universe.

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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, the, was the machinery that someho... (show all)w enabled it. It seemed like magic.

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Literature provided, I believed, the richest material for moral reflection.

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Moral speculation was puny compared moral action.

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I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion.

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In anatomy lab, we objectified the dead, literally reducing them to organs, tissues, nerves, muscles. On that first day, you simply could not deny the humanity of the corpse. But by the time you'd skinned the limbs, sliced th... (show all)rough inconvenient muscles, pulled out the lung, cut open the heart, and removed a lobe of the liver, it was hard to recognize this pile of tissue as human. Anatomy lab, in the end, becomes less a violation of the sacred and more something that interferes with happy hour, and that realization discomfits. In our rare reflective moments, we were all silently apologizing to our cadavers, not because we sensed the transgression but because we did not.

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It was not a simple evil, however. All of medicine, not just cadaver dissection, trespasses into sacred spheres. Doctors invade the the body in every way imaginable. They see people at their most vulnerable, their most scared... (show all), their most private. They escoret them into the world, and then back out. Seeing the body as matter and mechanism is th eflip side to easing the most profound human suffering. By the same token, the most profound human suffering becomes a mere pedagogical tool.

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Neurosurgery seemed to present the most challenging and direct confrontation with meaning, identity, and death. Concomitant with the enormous responsibilities they shouldered, neurosurgeons were also masters of many fields: n... (show all)eurosurgery, ICU medicine, neurology, radiology. Not only would I have to train my mind and hands, I realized; I'd have to train my eyes, and perhaps other organs as well. The idea was overwhelming and intoxicating; perhaps I, too, could join the ranks of these polymaths who strode into the densest thicket of emotional, scientific, and spiritual problems and found, or carved, ways out.

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I wondered if, in my brief time as a physician, I had made more moral slides than strides.

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I feared I was on the way to becoming Tolstoy's stereotype of a doctor, preoccupied with empty formalism, focused on rote treatment of disease -- and utterly missing the larger human significance.

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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.

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Any major illness transforms a patient's -- really, an entire family's -- life.

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The root of disaster means a star coming apart, and no image expresses better the look in a patient's eyes when hearing a neurosurgeon's diagnosis.

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A tureen of tragedy was best alloted by the spoonful.

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Second, it is important to be accurate, but you must always leave some room for hope . . . I came to believe that it is irresponsible to be more precise than accurate. Those apocryphal doctors who gave specific numbers ("The ... (show all)doctor told me I had six months to live"): Who were they, I wondered, and who taught them statistics.

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Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.

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Being with these patients in these moments certainly had its emotional cost, but it also had its rewards. I 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 p... (show all)rotect life -- and not merely life but an another's identity; it is perhaps not too much to say another's soul -- was obvious in its sacredness.

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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 de... (show all)dication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burderns are what make medicine holy and wholly impossible: in taking up another's cross, one must sometimes get crushed by the weight.

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Perhaps unique in medicine, the ethos of neurosurgery -- of excellence in all things -- maintains that excellence in neurosurgery alone is not enough. In order to carry the field, neurosurgeons must venture forth and excel in... (show all) other fields as well.

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Certain brain areas are considered near--inviolable, like the primary motor cortex, damage to which results in paralysis of affected body parts. But the most sacrosanct regions of the cortex are those that control language . ... (show all). . What kind of life exists withouth language?

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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,... (show all) I knew that someday I would die, but I didn't know when. But now I knew it acutely. The problem wasn't a scientific one. The fact of death is unsettling. Yet there is no other way to live.

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It occurred to me that my relationship with statistics changed as soon as I became one.

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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 ... (show all)of facing morality has no remedy in probability.

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I had passed from the subject to the direct object of every sentence of my life.

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"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... (show all) life wasn't about avoiding suffering. Years ago, it had occurred to me that Darwin and Nietzshe 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.

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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... (show all) I felt that to understand my own direct 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. And so it was literature that brought me back to life during this time.

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Even working on the dead, with their faces covered, their names a mystery, you fund that their humanity pops up at you—in opening my cadaver’s stomach, I found two indigested morphine pills, meaning that he had died in pa... (show all)in, perhaps alone and fumbling with the cap of a pill bottle.

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Because 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 dyung, until I actually die, I am still living.

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I had learned something, something not found in Hippocrates, Maimonides, or Osler: 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 l... (show all)ives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

Last words

(Click to show. Warning: May contain spoilers.)There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past. That message is simple: When you come to one of the many moments in life where 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.

Blurbers

Gawande, Atul; Patchett, Ann

Original language

English