When Breath Becomes Air

WhenBreathBecomesAir

PaulKalanithi

RandomHousePublishingGroup(2016)

Forewordcopyright©2016byAbrahamVerghese

Allrightsreserved.

PublishedintheUnitedStatesbyRandomHouse,animprintanddivisionofPenguinRandomHouseLLC,New

York.

RANDOMHOUSEandtheHOUSEcolophonareregisteredtrademarksofPenguinRandomHouseLLC.

LibraryofCongressCataloging-in-PublicationData

Names:Kalanithi,Paul,author.

Title:Whenbreathbecomesair/PaulKalanithi;forewordbyAbrahamVerghese.

Description:NewYork:RandomHouse,2016.

Identifiers:LCCN2015023815|ISBN9780812988406(hardback)|ISBN9780812988413(ebook)

Subjects:LCSH:Kalanithi,Paul—Health.|Lungs—Cancer—Patients—UnitedStates—Biography.|

Neurosurgeons—Biography.|Husbandandwife.|BISAC:BIOGRAPHY&AUTOBIOGRAPHY/Personal

Memoirs.|MEDICAL/General.|SOCIALSCIENCE/Death&Dying.

Classification:LCCRC280.L8K352016|DDC616.99/424—dc23LCrecordavailableat

http://lccn.loc.gov/2015023815

eBookISBN 9780812988413

randomhousebooks.com

BookdesignbyLizCosgrove,adaptedforeBook

Coverdesign:RachelAke

v4.1

Contents
Cover
TitlePage
Copyright
Editor'sNote
Epigraph
ForewordbyAbrahamVerghese
Prologue
PartI:InPerfectHealthIBegin
PartII:CeaseNottillDeath
EpiloguebyLucyKalanithi
Dedication
Acknowledgments
AbouttheAuthor

EVENTS DESCRIBED ARE BASED on Dr. Kalanithi’s memory of real-world situations.

However, the names of all patients discussed in this book—if given at all—have

beenchanged.Inaddition,ineachofthemedicalcasesdescribed,identifyingdetails

—such as patients’ ages, genders, ethnicities, professions, familial relationships,

placesofresidence,medicalhistories,and/ordiagnoses—havebeenchanged.With

one exception, the names of Dr. Kalanithi’s colleagues, friends, and treating

physicians have also been changed. Any resemblance to persons living or dead

resultingfromchangestonamesoridentifyingdetailsisentirelycoincidentaland

unintentional.

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toyoureternity.

—BaronBrookeFulkeGreville,“Caelica83”

FOREWORD

AbrahamVerghese

IT OCCURS TO ME, as I write this, that the foreword to this book might be better

thought of as an afterword. Because when itcomes toPaul Kalanithi, all sense of

timeisturnedonitshead. To begin with—or, maybe, to endwith—I gotto know

Paulonlyafterhisdeath.(Bearwithme.)Icametoknowhimmostintimatelywhen

he’dceasedtobe.

ImethimonememorableafternoonatStanfordinearlyFebruary2014.He’d

justpublishedanop-edtitled“HowLongHaveIGotLeft?”inTheNewYorkTimes,

anessaythatwouldelicitanoverwhelmingresponse,anoutpouringfromreaders.

Intheensuingdays,itspreadexponentially.(I’maninfectiousdiseasesspecialist,so

pleaseforgivemefornotusingthewordviralasametaphor.)Intheaftermathof

that,he’daskedtocomeseeme,tochat,togetadviceaboutliteraryagents,editors,

thepublishingprocess—hehadadesiretowriteabook,thisbook,theoneyouare

now holding in your hands. I recall the sun filtering through the magnolia tree

outsidemyofficeandlightingthisscene:Paulseatedbeforeme,hisbeautifulhands

exceedinglystill,hisprophet’sbeardfull,thosedarkeyestakingthemeasureofme.

Inmymemory,thepicturehasaVermeer-likequality,acameraobscurasharpness.I

rememberthinking,Youmustrememberthis,becausewhatwasfallingonmyretina

wasprecious.Andbecause,inthecontextofPaul’sdiagnosis,Ibecameawareofnot

justhismortalitybutmyown.

We talked about a lot of things that afternoon. He was a neurosurgical chief

resident. We had probably crossed paths at some point, but we hadn’t shared a

patientthatwecouldrecall.HetoldmehehadbeenanEnglishandbiologymajoras

anundergraduateatStanford,andthenstayedonforamaster ’sinEnglishliterature.

Wetalkedabouthislifelongloveofwritingandreading.Iwasstruckbyhoweasily

hecouldhavebeenanEnglishprofessor—and,indeed,hehadseemedtobeheaded

downthatpathatonepointinhislife.Butthen,justlikehisnamesakeontheroadto

Damascus, hefeltthecalling.Hebecamea physicianinstead,but one whoalways

dreamedofcomingbacktoliteratureinsomeform.Abook,perhaps.Oneday.He

thoughthehadtime,andwhynot?Andyetnowtimewastheverythinghehadso

littleof.

Irememberhiswry,gentlesmile,ahintofmischiefthere,eventhoughhisface

wasgauntandhaggard.He’dbeenthroughthewringerwiththiscancerbutanew

biologicaltherapyhadproducedagoodresponse,allowinghimtolookaheadabit.

Hesaid duringmedical schoolhe’dassumedthathewouldbecomeapsychiatrist,

onlytofallinlovewithneurosurgery.Itwasmuchmorethanafallinginlovewith

theintricaciesofthebrain,muchmorethanthesatisfactionoftraininghishandsto

accomplishamazingfeats—itwasaloveandempathyforthosewhosuffered,for

whattheyenduredandwhathemightbringtobear.Idon’tthinkhetoldmethisas

muchasIhadheard aboutthisquality ofhisfromstudentsofminewhowerehis

acolytes: his fierce belief in the moral dimension of his job. And then we talked

abouthisdying.

Afterthatmeeting,wekeptintouchbyemail,butneversaweachotheragain.It

wasnotjustthatIdisappearedintomyownworldofdeadlinesandresponsibilities

butalsomystrongsensethattheburdenwasonmetoberespectfulofhistime.It

was up to Paul if he wanted to see me. I feltthat the lastthing he needed was the

obligationtoserviceanewfriendship.Ithoughtabouthimalot,though,andabout

hiswife.Iwantedtoaskhimifhewaswriting.Washefindingthetime?Foryears,

asabusyphysician,I’dstruggledtofindthetimetowrite.Iwantedtotellhimthata

famous writer, commiserating about this eternal problem, once said to me, “If I

wereaneurosurgeonandIannouncedthatIhadtoleavemygueststogoinforan

emergencycraniotomy,noonewouldsayaword.ButifIsaidIneededtoleavethe

guestsinthelivingroomtogoupstairstowrite…”IwonderedifPaulwouldhave

foundthisfunny.Afterall,hecouldactuallysayhewasgoingtodoacraniotomy!It

wasplausible!Andthenhecouldgowriteinstead.

While Paul was writing this book, he published a short,remarkable essay in

StanfordMedicine,inanissuethatwasdevotedtotheideaoftime.Ihadanessayin

thesameissue,mypiecejuxtaposedtohis,thoughIlearnedofhiscontributiononly

whenthemagazinewasinmyhands.Inreadinghiswords,Ihadasecond,deeper

glimpseofsomethingofwhichtherehadbeenahintintheNewYorkTimesessay:

Paul’swritingwassimplystunning.Hecouldhavebeenwritingaboutanything,and

itwouldhavebeenjustaspowerful.Buthewasn’twritingaboutanything—hewas

writingabouttimeandwhatitmeanttohimnow,inthecontextofhisillness.Which

madeitallsoincrediblypoignant.

Buthere’sthethingImustcomebackto:theprosewasunforgettable.Outof

hispenhewasspinninggold.

IrereadPaul'spieceagainandagain,tryingtounderstandwhathehadbrought

about.First,itwasmusical.IthadechoesofGalwayKinnell,almostaprosepoem.

(“Ifonedayithappens/youfindyourselfwithsomeoneyoulove/inacaféatone

end/of thePontMirabeau,atthezincbar / wherewine stands in upwardopening

glasses…” to quote a Kinnell line, from a poem I once heard him recite in a

bookstoreinIowaCity,neverlookingdownatthepaper.)Butitalsohadatasteof

something else, something from an antique land, from a time before zinc bars. It

finally came to me a few days later when I picked up his essay yet again: Paul’s

writingwasreminiscentofThomasBrowne’s.BrownehadwrittenReligioMedici

intheproseof1642,withallitsarchaicspellingsandspeech.Asayoungphysician,

Iwasobsessedwiththatbook,keptatitlikeafarmertryingtodrainabogthathis

fatherbeforehimhadfailedtodrain.Itwasafutiletask,andyetIwasdesperateto

learnitssecrets,tossingitasideinfrustration,thenpickingitupagain,unsurethatit

hadanythingformebut,insoundingthewords,sensingthatitdid.IfeltthatIlacked

somecritical receptor forthe letters to sing,toimpart their meaning.Itremained

opaque,nomatterhowhardItried.

Why,youask?WhydidIpersevere?WhocaresaboutReligioMedici?

Well,myheroWilliamOslercared,that’swho.Oslerwasthefatherofmodern

medicine, a man who died in 1919. He had loved the book. He kept it on his

nightstand.He’daskedto beburied witha copy of ReligioMedici. Forthe life of

me,Ididn’tgetwhatOslersawinit.Aftermanytries—andaftersomedecades—the

book finally revealed itself to me. (It helped that a newer edition had modern

spellings.) The trick, I discovered, was to read it aloud, which made the cadence

inescapable:“Wecarrywithusthewonders,weseekwithoutus:ThereisallAfrica,

andherprodigiesinus;wearethatboldandadventurouspieceofnature,whichhe

thatstudies,wiselylearnsinacompendium,whatotherslabouratinadividedpiece

andendlessvolume.”WhenyoucometothelastparagraphofPaul’sbook,readit

aloudandyouwillhearthatsamelongline,thecadenceyouthinkyoucantapyour

feet to…but as with Browne, you will be just off. Paul, it occurred to me, was

Browneredux.(Orgiventhatforwardtimeisourillusion,perhapsit’sthatBrowne

wasKalanithiredux.Yes,it’shead-spinningstuff.)

AndthenPauldied.IattendedhismemorialintheStanfordchurch,agorgeous

spacewhereIoftengowhenitisemptytositandadmirethelight,thesilence,and

where I always find renewal. It was packed for the service. I sat off to one side,

listening to a series of moving and sometimes raucous stories from his closest

friends, his pastor, and his brother. Yes, Paul was gone, butstrangely, I felt I was

coming to know him, beyond that visit in my office, beyond the few essays he’d

written. He was taking form in those tales being told in the Stanford Memorial

Church,itssoaringcathedraldomeafittingspaceinwhichtorememberthisman

whose bodywas now in the earth but who nevertheless was sopalpably alive. He

tookform inthe shape of hislovelywifeandbaby daughter,his grievingparents

andsiblings,inthefacesofthelegionsoffriends,colleagues,andformerpatients

whofilledthatspace;hewasthereatthereceptionlater,outdoorsinasettingwhere

somanycametogether.Isawfaceslookingcalm,smiling,asiftheyhadwitnessed

somethingprofoundlybeautifulinthechurch.Perhapsmyfacewaslikethat,too:we

had found meaning in the ritual of a service, in the ritual of eulogizing, in the

sharedtears.Therewasfurthermeaningresidinginthisreceptionwhereweslaked

our thirst, fed our bodies, and talked with complete strangers to whom we were

intimatelyconnectedthroughPaul.

ButitwasonlywhenIreceivedthepagesthatyounowholdinyourhands,two

monthsafterPauldied,thatIfeltIhadfinallycometoknowhim,toknowhimbetter

thanifIhadbeenblessedtocallhimafriend.Afterreadingthebookyouareabout

toread,IconfessIfeltinadequate:therewasanhonesty,atruthinthewritingthat

tookmybreathaway.

Beready.Beseated.Seewhatcouragesoundslike.Seehowbraveitistoreveal

yourselfinthisway.Butaboveall,seewhatitistostilllive,toprofoundlyinfluence

thelivesofothersafteryouaregone,byyourwords.Inaworldofasynchronous

communication,wherewearesooftenburiedinourscreens,ourgazerootedtothe

rectangularobjectsbuzzinginourhands,ourattentionconsumedbyephemera,stop

and experience this dialogue withmy young departed colleague, now ageless and

extant inmemory. ListentoPaul. Inthesilences betweenhiswords,listentowhat

youhavetosayback.Thereinlieshismessage.Igotit.Ihopeyouexperienceit,too.

Itisagift.LetmenotstandbetweenyouandPaul.

PROLOGUE

Websterwasmuchpossessedbydeath

Andsawtheskullbeneaththeskin;

Andbreastlesscreaturesunderground

Leanedbackwardwithaliplessgrin.

—T.S.Eliot,“WhispersofImmortality”

I FLIPPED THROUGH THE CT scan images, the diagnosis obvious: the lungs were

matted with innumerable tumors, the spine deformed, a full lobe of the liver

obliterated.Cancer,widelydisseminated.Iwasaneurosurgicalresidententeringmy

finalyearoftraining.Overthelastsixyears,I’dexaminedscoresofsuchscans,on

the off chance that some procedure might benefit the patient. But this scan was

different:itwasmyown.

Iwasn’tintheradiologysuite,wearingmyscrubsandwhitecoat.Iwasdressed

inapatient’sgown,tetheredtoanIVpole,usingthecomputerthenursehadleftin

myhospitalroom,withmywife,Lucy,aninternist,atmyside.Iwentthrougheach

sequence again: the lung window, the bone window, the liver window, scrolling

fromtoptobottom,thenlefttoright,thenfronttoback,justasIhadbeentrainedto

do,asifImightfindsomethingthatwouldchangethediagnosis.

Welaytogetheronthehospitalbed.

Lucy,quietly,asifreadingfromascript:“Doyouthinkthere’sanypossibility

thatit’ssomethingelse?”

“No,”Isaid.

We held each other tightly, like young lovers. In the past year we’d both

suspected,butrefusedtobelieve,orevendiscuss,thatacancerwasgrowinginside

me.

Aboutsixmonthsbefore,Ihadstartedlosingweightandhavingferociousback

pain.WhenIdressedinthemorning,mybeltcinchedone,thentwonotchestighter.I

wenttoseemyprimarycaredoctor,anoldclassmatefromStanford.Hersisterhad

diedsuddenlyasaneurosurgeryintern,aftercontractingavirulentinfection,andso

she’d taken a maternal watch on my health. When I arrived, however, I found a

differentdoctorinheroffice—myclassmatewasonmaternityleave.

Dressed in a thin blue gown on a cold examining table, I described the

symptomstoher.“Ofcourse,”Isaid,“ifthiswereaboardsexamquestion—thirty-

five-year-oldwithunexplained weight loss and new-onsetback pain—the obvious

answerwouldbe(C)cancer.Butmaybeit’sjustthatI’mworkingtoohard.Idon’t

know.I’dliketogetanMRItobesure.”

“IthinkweshouldgetX-raysfirst,”shesaid.MRIsforbackpainareexpensive,

andunnecessaryimaginghad latelybecomeamajornationalpointofcost-saving

emphasis.Butthevalueofascanalsodependsonwhatyouarelookingfor:X-rays

are largelyuseless forcancer.Still,for manydocs,ordering anMRI at thisearly

stage is apostasy. She continued: “X-rays aren’t perfectly sensitive, but it makes

sensetostartthere.”

“Howaboutweget flexion-extension X-rays,then—maybe themorerealistic

diagnosishereisisthmicspondylolisthesis?”

Fromthereflectioninthewallmirror,Icouldseehergooglingit.

“It’saparsfractureaffectinguptofivepercentofpeopleandafrequentcause

ofbackpainintheyoung.”

“Okay,I’llorderthem,then.”

“Thanks,”Isaid.

WhywasIsoauthoritativeinasurgeon’scoatbutsomeekinapatient'sgown?

Thetruthwas,Iknewmoreaboutbackpainthanshedid—halfofmytrainingasa

neurosurgeonhadinvolveddisorders ofthespine.Butmaybe aspondy wasmore

likely.Itdidaffectasignificantpercentofyoungadults—andcancerinthespinein

yourthirties?Theoddsofthatcouldn’tbemorethanoneintenthousand.Evenifit

were one hundredtimesmorecommon than that,it’dstill belesscommon than a

spondy.MaybeIwasjustfreakingmyselfout.

The X-rays looked fine. We chalked the symptoms up to hard work and an

aging body, scheduled afollow-up appointment,andI wentback tofinishmy last

case of the day. The weight loss slowed, and the back pain became tolerable. A

healthydoseofibuprofengotmethroughtheday,andafterall,thereweren’tthat

manyofthesegrueling,fourteen-hourdaysleft.Myjourneyfrommedicalstudent

to professor of neurosurgery was almost complete: after ten years of relentless

training,Iwasdeterminedtopersevereforthenextfifteenmonths,untilresidency

ended.Ihadearnedtherespectofmyseniors,wonprestigiousnationalawards,and

was fielding job offers from several major universities. My program director at

Stanfordhadrecentlysatmedownandsaid,“Paul,Ithinkyou’llbethenumberone

candidateforanyjobyouapplyfor.JustasanFYI:we’llbestartingafacultysearch

forsomeonelikeyouhere.Nopromises,ofcourse,butit’ssomethingyoushould

consider.”

Atagethirty-six,Ihadreachedthemountaintop;IcouldseethePromisedLand,

from GileadtoJerichoto the Mediterranean Sea. Icould seea nicecatamaran on

that sea that Lucy, our hypothetical children, and I would take out on weekends. I

could see the tension in my back unwinding as my work schedule eased and life

became more manageable. I could see myself finally becoming the husband I’d

promisedtobe.

Then, a few weeks later, I began having bouts of severe chest pain. Had I

bumpedintosomethingatwork?Crackedaribsomehow?Somenights,I’dwakeup

on soaked sheets,drippingsweat. My weightbegandroppingagain, morerapidly

now,from175to145pounds.Idevelopedapersistentcough.Littledoubtremained.

One Saturday afternoon, Lucyand Iwere lyinginthesuninDolores Park in San

Francisco, waiting to meet her sister. She glimpsed my phone screen, which

displayedmedicaldatabasesearchresults:“frequencyofcancersinthirty-toforty-

year-olds.”

“What?”shesaid.“Ididn’trealizeyouwereactuallyworriedaboutthis.”

Ididn’trespond.Ididn’tknowwhattosay.

“Doyouwanttotellmeaboutit?”sheasked.

She was upset because she had been worried about it, too. She was upset

becauseIwasn’ttalkingtoheraboutit.ShewasupsetbecauseI’dpromisedherone

life,andgivenheranother.

“Canyoupleasetellmewhyyouaren’tconfidinginme?”sheasked.

Iturnedoffmyphone.“Let’sgetsomeicecream,”Isaid.

—

We were scheduled for a vacation the following week to visit some old college

friendsinNewYork.Maybeagoodnight’ssleepandafewcocktailswouldhelpus

reconnectabitanddecompressthepressurecookerofourmarriage.

But Lucy had another plan. “I’m not coming to New York with you,” she

announcedafewdaysbeforethetrip.Shewasgoingtomoveoutforaweek;she

wantedtimetoconsiderthestateofourmarriage.Shespokeineventones,which

onlyheightenedthevertigoIfelt.

“What?”Isaid.“No.”

“I love you so much, which is why this is so confusing,” she said. “But I’m

worriedwewantdifferentthingsfromourrelationship.Ifeellikewe’reconnected

halfway. Idon’twant to learn aboutyourworriesby accident.WhenI talkto you

aboutfeelingisolated,youdon'tseemtothinkit’saproblem.Ineedtodosomething

different.”

“Thingsaregoingtobeokay,”Isaid.“It’sjustresidency.”

Were thingsreallysobad? Neurosurgicaltraining, amongthemostrigorous

anddemandingofallmedicalspecialties,hadsurelyputastrainonourmarriage.

ThereweresomanynightswhenIcamehomelatefromwork,afterLucyhadgone

tobed,andcollapsedonthelivingroomfloor,exhausted,andsomanymornings

whenIleftforworkintheearlydark,beforeshe’dawoken.Butourcareerswere

peaking now—most universities wanted both of us: me in neurosurgery, Lucy in

internalmedicine.We’dsurvivedthemostdifficultpartofourjourney.Hadn’twe

discussedthisadozentimes?Didn’tsherealizethiswastheworstpossibletimefor

hertoblowthingsup?Didn’tsheseethatIhadonlyoneyearleftinresidency,thatI

lovedher,thatweweresoclosetothelifetogetherwe’dalwayswanted?

“Ifitwerejustresidency,Icouldmakeit,”shesaid.“We’vemadeitthisfar.But

the problem is, what if it’s not just residency? Do you really think things will be

betterwhenyou’reanacademicneurosurgeryattending?”

Iofferedtoskipthetrip,tobemoreopen,toseethecouplestherapistLucyhad

suggested a few months ago, but she insistedthat she needed time—alone. At that

point, the fuzziness of the confusion dissipated, leaving only a hard edge. Fine, I

said. If she decided to leave, then I would assume the relationship was over. If it

turnedoutthatIhadcancer,Iwouldn’ttellher—she’dbefreetolivewhateverlife

shechose.

Before leavingfor NewYork, Isnuck ina few medical appointmentstorule

out some common cancers in the young. (Testicular? No. Melanoma? No.

Leukemia? No.) The neurosurgical service was busy, as always. Thursday night

slipped into Friday morning as I was caught in the operating room for thirty-six

hoursstraight,inaseriesofdeeplycomplexcases:giantaneurysms,intracerebral

arterialbypasses,arteriovenousmalformations.Ibreathedasilentthankswhenthe

attendingcamein,allowingmeafewminutestoeasemybackagainstawall.The

onlytimetogetachestX-raywasasIwasleavingthehospital,onthewayhome

beforeheadingtotheairport.IfiguredeitherIhadcancer,inwhichcasethismight

be the last time I would see my friends, or I didn’t, in which case there was no

reasontocancelthetrip.

Irushedhometograbmybags.Lucydrovemetotheairportandtoldmeshe

hadscheduledusintocouplestherapy.

Fromthegate,Isentheratextmessage:“Iwishyouwerehere.”

Afewminuteslater,theresponsecameback:“Iloveyou.Iwillbeherewhen

yougetback.”

Mybackstiffenedterriblyduringtheflight,andbythetimeImadeittoGrand

Centraltocatchatraintomyfriends’placeupstate,mybodywasripplingwithpain.

Over the past few months, I’d had back spasms of varying ferocity, from simple

ignorablepain,topainthatmade meforsake speechtogrindmyteeth, topainso

severeIcurleduponthefloor,screaming.Thispainwastowardthe moresevere

endofthespectrum.Ilaydownonahardbenchinthewaitingarea,feelingmyback

musclescontort,breathingtocontrolthepain—theibuprofenwasn’ttouchingthis—

andnamingeachmuscleasitspasmedtostaveofftears:erectorspinae,rhomboid,

latissimus,piriformis…

Asecurityguardapproached.“Sir,youcan’tliedownhere.”

“I’msorry,”Isaid,gaspingoutthewords.“Bad…back…spasms.”

“Youstillcan’tliedownhere.”

I’msorry,butI’mdyingfromcancer.

Thewordslingeredonmytongue—butwhatifIwasn’t?Maybethiswasjust

whatpeoplewithbackpainlivewith.Iknewalotaboutbackpain—itsanatomy,its

physiology,thedifferentwordspatientsusedtodescribedifferentkindsofpain—

but I didn’t know what it felt like. Maybe that’s all this was. Maybe. Or maybe I

didn’twantthejinx.MaybeIjustdidn’twanttosaythewordcanceroutloud.

Ipulledmyselfupandhobbledtotheplatform.

ItwaslateafternoonwhenIreachedthehouseinColdSpring,fiftymilesnorth

ofManhattanontheHudsonRiver,andwasgreetedbyadozenofmyclosestfriends

from years past, their cheers of welcome mixed with the cacophony of young,

happychildren.Hugsensued,andanice-colddarkandstormymadeitswaytomy

hand.

“NoLucy?”

“Suddenworkthing,”Isaid.“Verylast-minute.”

“Oh,whatabummer!”

“Say,doyoumindifIputmybagsdownandrestabit?”

IhadhopedafewdaysoutoftheOR,withadequatesleep,rest,andrelaxation

—in short, a taste of a normal life—would bring my symptoms back into the

normalspectrumforbackpainandfatigue.Butafteradayortwo,itwasclearthere

wouldbenoreprieve.

I slept through breakfasts and shambled to the lunch table to stare at ample

platesofcassouletandcrablegsthatIcouldn’tbringmyselftoeat.Bydinner,Iwas

exhausted,readyforbedagain.SometimesIreadtothekids,butmostlytheyplayed

onandaroundme,leapingandyelling.(“Kids,IthinkUnclePaulneedsarest.Why

don’tyouplayoverthere?”)Irememberedadayoffasasummercampcounselor,

fifteen years prior, sitting on the shore of a lake in Northern California, with a

bunchofjoyouskidsusingmeasanobstacleinaconvolutedgameofCapturethe

Flag, while I read a book called Death and Philosophy. I used to laugh at the

incongruities of that moment: a twenty-year-old amid the splendor of trees, lake,

mountains,thechirpingofbirdsmixedwiththesquealofhappyfour-year-olds,his

noseburiedinasmallblackbookaboutdeath.Onlynow,inthismoment,Ifeltthe

parallels: instead of Lake Tahoe, it was the Hudson River; the children were not

strangers’,butmyfriends’;insteadofabookondeathseparatingmefromthelife

aroundme,itwasmyownbody,dying.

Onthethirdnight,IspoketoMike,ourhost,totellhimIwasgoingtocutthe

tripshortandheadhomethenextday.

“Youdon’tlooksogreat,”hesaid.“Everythingokay?”

“Whydon’twegrabsomescotchandhaveaseat?”Isaid.

Infrontofhisfireplace,Isaid,“Mike,IthinkIhavecancer.Andnotthegood

kind,either.”

ItwasthefirsttimeI’dsaiditoutloud.

“Okay,”hesaid.“Itakeitthisisnotsomeelaboratepracticaljoke?”

“No.”

Hepaused.“Idon’tknowexactlywhattoask.”

“Well, I suppose, first, I should say that I don’t know for a fact that I have

cancer.I’mjustprettysureofit—alotofthesymptomspointthatway.I’mgoingto

gohometomorrowandsortitout.Hopefully,I’mwrong.”

Mikeofferedtotakemyluggageandsendithomebymail,soIwouldn’thave

tocarryitwithme.Hedrovemetotheairportearlythenextmorning,andsixhours

laterIlandedinSanFrancisco.MyphonerangasIsteppedofftheplane.Itwasmy

primarycaredoctor,callingwiththechestX-rayresult:mylungs,insteadofbeing

clear, looked blurry, as if the camera aperture had been left open too long. The

doctorsaidshewasn’tsurewhatthatmeant.

Shelikelyknewwhatitmeant.

Iknew.

Lucypickedmeupfromtheairport,butIwaiteduntilwewerehometotellher.

We sat on the couch, and when I told her, she knew. She leaned her head on my

shoulder,andthedistancebetweenusvanished.

“Ineedyou,”Iwhispered.

“Iwillneverleaveyou,”shesaid.

We called a close friend, one of the attending neurosurgeons at the hospital,

andaskedhimtoadmitme.

I received the plastic arm bracelet all patients wear, put on the familiar light

bluehospitalgown,walkedpastthenursesIknewbyname,andwascheckedintoa

room—thesameroomwhereIhadseenhundredsofpatientsovertheyears.Inthis

room, I had sat with patients and explained terminal diagnoses and complex

operations; in this room, I had congratulated patients on being cured of a disease

and seen their happiness at being returned to their lives; in this room, I had

pronounced patients dead. I had sat in the chairs, washed my hands in the sink,

scrawled instructions on the marker board, changed the calendar. I had even, in

moments of utter exhaustion,longed to lie downin this bed and sleep. Now I lay

there,wideawake.

Ayoungnurse,oneIhadn’tmet,pokedherheadin.

“Thedoctorwillbeinsoon.”

Andwiththat,thefutureIhadimagined,theonejustabouttoberealized,the

culminationofdecadesofstriving,evaporated.

PARTI

InPerfectHealthIBegin

ThehandoftheLORDwasuponme,andcarriedmeoutinthespiritoftheLORD,andsetmedowninthe

midstofthevalleywhichwasfullofbones,

Andcausedmetopassbythemroundabout:and,behold,therewereverymanyintheopenvalley;and,

lo,theywereverydry.

Andhesaiduntome,Sonofman,cantheseboneslive?

—Ezekiel37:1–3,KingJamestranslation

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planned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.

Ilaythereinthedirt,awashinsunlightandmemory,feelingtheshrinkingsize

ofthistownoffifteenthousand,sixhundredmilesfrommynewcollegedormitory

atStanfordandallitspromise.

I knew medicine only by its absence—specifically, the absence of a father

growingup,onewhowenttoworkbeforedawnandreturnedinthedarktoaplate

of reheated dinner. When I was ten, my father had moved us—three boys, ages

fourteen, ten, and eight—from Bronxville, New York, a compact, affluent suburb

just north of Manhattan, to Kingman, Arizona, in a desert valley ringed by two

mountain ranges, known primarily to the outside world as a place to get gas en

routetosomewhereelse.Hewasdrawnbythesun,bythecostofliving—howelse

would he pay for his sons to attend the colleges he aspired to?—and by the

opportunity to establisharegionalcardiologypracticeofhisown.Hisunyielding

dedication to his patients soon made him a respected member of the community.

When we didsee him,lateat night oronweekends,he was anamalgamof sweet

affections and austere diktats, hugs and kisses mixed with stony pronouncements:

“It’sveryeasyto benumberone:findtheguywhoisnumberone,andscore one

point higher than he does.” He had reached some compromise in his mind that

fatherhood could be distilled; short, concentrated (but sincere) bursts of high

intensitycouldequal…whateveritwasthatotherfathersdid.AllIknewwas,ifthat

wasthepriceofmedicine,itwassimplytoohigh.

Frommydesertplateau,Icouldseeourhouse,justbeyondthecitylimits,atthe

base of the Cerbat Mountains, amid red-rock desert speckled with mesquite,

tumbleweeds, and paddle-shaped cacti. Out here, dust devils swirled up from

nothing,blurringyourvision,thendisappeared.Spacesstretchedon,thenfellaway

into the distance. Our two dogs, Max and Nip, never grew tired of the freedom.

Everyday,they’dventureforthandbringhomesomenewdeserttreasure:thelegof

adeer,unfinishedbitsofjackrabbittoeatlater,thesun-bleachedskullofahorse,the

jawboneofacoyote.

My friends and I loved the freedom, too, and we spent our afternoons

exploring,walking,scavengingforbonesandraredesertcreeks.Havingspentmy

previousyearsinalightlyforestedsuburbintheNortheast,withatree-linedmain

street anda candy store, Ifound the wild, windy desert alien andalluring.On my

firsttrekalone,asaten-year-old,Idiscoveredanoldirrigationgrate.Iprieditopen

withmyfingers,lifteditup,andthere,afewinchesfrommyface,werethreewhite

silkenwebs,andineach,marchingalongonspindledlegs,wasaglisteningblack

bulbous body, bearing in its shine the dreaded blood-red hourglass. Near to each

spider a pale, pulsating sac breathed with the imminent birth of countless more

blackwidows.Horrorletthegratecrashshut.Istumbledback.Thehorrorcameina

mix of “country facts” (Nothing is more deadly than the bite of the black widow

spider) and the inhuman posture and the black shine and the red hourglass. I had

nightmaresforyears.

Thedesertofferedapantheonofterrors:tarantulas,wolfspiders,fiddlebacks,

bark scorpions, whip scorpions, centipedes, diamondbacks, sidewinders, Mojave

greens. Eventually we grew familiar, even comfortable, with these creatures. For

fun,whenmyfriendsandIdiscoveredawolfspider ’snest,we’ddropanantontoits

outer limits and watch as its entangled escape attempts sent quivers down the silk

strands,intothespider ’sdarkcentralhole,anticipatingthatfatalmomentwhenthe

spider would burst from its hollows and seize the doomed ant in its mandibles.

“Countryfacts”becamemytermfortheruralcousinoftheurbanlegend.AsIfirst

learnedthem, country facts grantedfairy powersto desert creatures, making,say,

theGilamonsternolessanactualmonsterthantheGorgon.Onlyafterlivingoutin

thedesertforawhiledidwerealizethatsomecountryfacts,liketheexistenceofthe

jackalope,hadbeendeliberatelycreatedtoconfusecityfolkandamusethelocals.I

oncespentanhourconvincingagroupofexchangestudentsfromBerlinthat,yes,

therewas a particular species of coyote that lived inside cacti and could leap ten

yards to attack its prey (like, well, unsuspecting Germans). Yet no one precisely

knewwherethetruthlayamidthewhirlingsand;foreverycountryfactthatseemed

preposterous, there was one that felt solid and true. Always check your shoes for

scorpions,forexample,seemedplaingoodsense.

When I was sixteen, I was supposed to drive my younger brother, Jeevan, to

school. One morning, as usual, I was running late, and as Jeevan was standing

impatientlyinthefoyer,yellingthathedidn’twanttogetdetentionagainbecauseof

mytardiness,socouldIpleasehurrythehellup,Iraceddownthestairs,threwopen

the front door…and nearly stepped on a snoozing six-foot rattlesnake. It was

anothercountryfactthatifyoukilledarattlesnakeonyourdoorstep,itsmateand

offspring would come and make a permanent nest there, like Grendel’s mother

seekingherrevenge.SoJeevanandIdrewstraws:theluckyonegrabbedashovel,

the unluckyoneapairof thick gardening gloves anda pillowcase, andthrough a

seriocomicdance, wemanagedtoget thesnake intothepillowcase. Then,like an

Olympic hammer thrower, I hurled the whole out into the desert, with plans to

retrieve the pillowcase later that afternoon, so as not to get in trouble with our

mother.

—

Of our many childhood mysteries, chief among them was not why our father

decidedtobringhisfamilytothedeserttownofKingman,Arizona,whichwegrew

to cherish, but how he ever convinced my mother to join him there. They had

eloped, in love, across the world, from southern India to New York City (he a

Christian, she a Hindu, their marriage was condemned on both sides, and led to

yearsof familial rifts—mymother ’s mother never acknowledged my name, Paul,

instead insisting I be called by my middle name, Sudhir) to Arizona, where my

mother was forced to confront an intractable mortal fear of snakes. Even the

smallest,cutest,mostharmlessredracerwouldsendherscreamingintothehouse,

whereshe’dlockthedoorsandarmherselfwiththenearestlarge,sharpimplement

—rake,cleaver,ax.

Thesnakeswereaconstantsourceofanxiety,butitwasherchildren’sfuture

thatmymotherfearedformostofall.Beforewemoved,myolderbrother,Suman,

hadnearlycompletedhighschoolinWestchesterCounty,whereelitecollegeswere

theexpectation.HewasacceptedtoStanfordshortlyafterarrivinginKingmanand

leftthehousesoonthereafter.ButKingman,welearned,wasnotWestchester.Asmy

mothersurveyedtheMohaveCountypublicschoolsystem,shebecamedistraught.

The U.S. census had recently identified Kingman as the least educated district in

America. The high school dropout rate was somewhere north of 30 percent. Few

studentswentontocollege,andcertainlynonetoHarvard,myfather ’sstandardof

excellence. Looking for advice, my mother called her friends and relatives from

wealthy East Coast suburbs and found some sympathetic, others gleeful that their

childrennolongerhadtocompetewiththesuddenlyeducation-starvedKalanithis.

Atnight,shebrokeintotears,sobbingaloneinherbed.Mymother,afraidthe

impoverished school system would hobble her children, acquired, from

somewhere, a “college prep reading list.” Trained in India to be a physiologist,

married at twenty-three, and preoccupied with raising three kids in a country that

was not her own,she had notread many of the books on the listherself. But she

wouldmakesureherkidswerenotdeprived.Shemademeread1984whenIwasten

yearsold;Iwasscandalizedbythesex,butitalsoinstilledinmeadeeploveof,and

carefor,language.

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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.

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.

Becausethemedschool applicationcycletakeseighteenmonths,Ihad afree

yearoncemyclasseswereover.SeveralprofessorshadsuggestedIpursueadegree

in the history and philosophy of science and medicine before deciding to leave

academia for good. So I applied for, and was accepted into, the HPS program at

Cambridge.IspentthenextyearinclassroomsintheEnglishcountryside,whereI

found myself increasingly often arguing that direct experience of life-and-death

questionswasessentialtogeneratingsubstantialmoralopinionsaboutthem.Words

begantofeelasweightlessasthebreaththatcarriedthem.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. I finished my degree and

headedbacktotheStates.IwasgoingtoYaleformedicalschool.

—

Youwouldthinkthatthefirsttimeyoucutupadeadperson,you’dfeelabitfunny

aboutit.Strangely,though,everythingfeelsnormal.Thebrightlights,stainlesssteel

tables, and bow-tied professors lend an air of propriety. Even so, that first cut,

runningfromthenapeoftheneckdowntothesmalloftheback,isunforgettable.

The scalpel is so sharp it doesn’t so much cut the skin as unzip it, revealing the

hiddenandforbiddensinewbeneath,anddespiteyourpreparation, youarecaught

unawares,ashamedandexcited.Cadaverdissectionisamedicalriteofpassageand

a trespass on the sacrosanct, engendering a legion of feelings: from revulsion,

exhilaration, nausea, frustration, and awe to, as time passes, the mere tedium of

academic exercise. 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. Eventually, as you complete your

assignmentsby dissecting the median nerve, sawingthe pelvisinhalf, andslicing

opentheheart,thebathossupersedes:thesacredviolationtakesonthecharacterof

youraveragecollegeclass,repletewithpedants,classclowns,andtherest.Cadaver

dissection epitomizes, for many, the transformation of the somber, respectful

studentintothecallous,arrogantdoctor.

The enormity of the moral mission of medicine lent my early days of med

school a severe gravity. The first day, before we got to the cadavers, was CPR

training,mysecondtimedoingit.Thefirsttime,backincollege,hadbeenfarcical,

unserious, everyone laughing: the terribly acted videos and limbless plastic

mannequinscouldn’thavebeenmoreartificial.Butnowthelurkingpossibilitythat

wewouldhavetoemploytheseskillssomedayanimatedeverything.AsIrepeatedly

slammed my palm into the chest of a tiny plastic child, I couldn’t help but hear,

alongwithmyfellowstudents’jokes,realribscracking.

Cadavers reverse the polarity. The mannequins you pretend are real; the

cadavers youpretendare fake. But that first day, you just can’t. When I faced my

cadaver, slightly blue and bloated, his total deadness and total humanness were

undeniable.TheknowledgethatinfourmonthsIwouldbebisectingthisman’shead

withahacksawseemedunconscionable.

Yetthereareanatomyprofessors.Andtheadvicetheygaveuswastotakeone

goodlookatourcadaver ’sfaceandthenleaveitcovered;itmakestheworkeasier.

Justasweprepared,withdeepbreathsandearnestlooks,tounwrapourcadaver ’s

head, a surgeon stopped by to chat, leaning with his elbows on the corpse’s face.

Pointing out various marks and scars on the naked torso, he reconstructed the

patient’shistory.Thisscarisfromaninguinalherniaoperation,thisoneacarotid

endarterectomy; these marks here indicate scratching, possibly jaundice, high

bilirubin;heprobablydiedofpancreaticcancer,thoughnoscarforthat—killedhim

tooquick.Meanwhile,Icouldnothelpbutstareattheshiftingelbowsthat,witheach

medicalhypothesisandvocabularylesson,rolledoverthiscoveredhead.Ithought:

Prosopagnosiaisaneurologicaldisorderwhereinonelosestheabilitytoseefaces.

PrettysoonIwouldhaveit,hacksawinhand.

Because after a few weeks, the drama dissipated. In conversations with non–

medicalstudents,tellingcadaverstories,Ifoundmyselfhighlightingthegrotesque,

macabre, and absurd, asif toreassure them thatI was normal, even though I was

spending six hours a week carving up a corpse. Sometimes I told of the moment

when I turned around and saw a classmate, the sort of woman who had a mug

decoratedwithpuffypaint,tiptoeingonastool,cheerfullyhammeringachiselinto

a woman’s backbone, splinters flying through the air. I told this story as if to

distance myself from it,but my kinship was undeniable. After all, hadn’t I just as

eagerlydisassembledaman’sribcagewithapairofboltcutters?Evenworkingon

the dead, with their faces covered, their names a mystery, you find that their

humanity pops up at you—in opening my cadaver ’s stomach, I found two

undigested morphine pills, meaning that he had died in pain, perhaps alone and

fumblingwiththecapofapillbottle.

Ofcourse,thecadavers,inlife,donatedthemselvesfreelytothisfate,andthe

languagesurroundingthebodiesinfrontofussoonchangedtoreflectthatfact.We

wereinstructedtonolongercallthem“cadavers”;“donors”wasthepreferredterm.

And yes, the transgressive element of dissectionhad certainly decreased from the

badolddays.(Studentsnolongerhadtobringtheirownbodies,forstarters,asthey

didinthenineteenthcentury.Andmedicalschoolshaddiscontinuedtheirsupportof

the practice of robbing graves to procure cadavers—that looting itself a vast

improvementovermurder,ameansoncecommonenoughtowarrantitsownverb:

burke,whichtheOEDdefinesas“tokillsecretlybysuffocationorstrangulation,or

forthepurposeofsellingthevictim’sbodyfordissection.”)Yetthebest-informed

people—doctors—almost never donated their bodies. How informed were the

donors,then?Asoneanatomyprofessor putittome,“Youwouldn’ttellapatient

thegorydetailsofasurgeryifthatwouldmakethemnotconsent.”

Even if donors were informed enough—and they might well have been,

notwithstanding one anatomy professor ’s hedging—it wasn’t so much thethought

ofbeingdissectedthatgalled.Itwasthethoughtofyourmother,yourfather,your

grandparentsbeinghackedtopiecesbywisecrackingtwenty-two-year-oldmedical

students.EverytimeIreadthepre-labandsawatermlike“bonesaw,”Iwonderedif

thiswouldbethesessioninwhichIfinallyvomited.YetIwasrarelytroubledinlab,

even when I found that the “bone saw” in question was nothing more than a

common,rustywoodsaw.TheclosestIevercame tovomitingwasnowherenear

the lab but on a visit to my grandmother’s grave in New York, on the twentieth

anniversary of her death. I found myself doubled over, almost crying, and

apologizing—nottomycadaverbuttomycadaver ’sgrandchildren.Inthemidstof

ourlab,infact,asonrequestedhismother’shalf-dissectedbodyback.Yes,shehad

consented,buthecouldn’tlivewiththat.IknewI’ddothesame.(Theremainswere

returned.)

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throughinconvenient

muscles,pulledoutthelungs,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.

Itwasnotasimpleevil,however.Allofmedicine,notjustcadaverdissection,

trespasses into sacred spheres. Doctors invade the body in every way imaginable.

Theyseepeopleattheirmostvulnerable,theirmostscared,theirmostprivate.They

escort them into the world, and then back out. Seeing the body as matter and

mechanism is the flip side to easing the most profound human suffering. By the

sametoken,themostprofoundhumansufferingbecomesamerepedagogicaltool.

Anatomy professors are perhaps the extreme end of this relationship, yet their

kinship to the cadavers remains. Early on,whenImadea long, quickcutthrough

mydonor’sdiaphragminordertoeasefindingthesplenicartery,ourproctorwas

both livid and horrified. Not because I had destroyed an important structure or

misunderstoodakeyconceptorruinedafuturedissectionbutbecauseIhadseemed

socavalieraboutit.Thelookonhisface,hisinabilitytovocalizehissadness,taught

memoreaboutmedicinethananylectureIwouldeverattend.WhenIexplainedthat

another anatomy professor had told me to make the cut, our proctor ’s sadness

turned to rage, and suddenly red-faced professors were being dragged into the

hallway.

Othertimes,thekinshipwasmuchsimpler.Once,whileshowingustheruinsof

ourdonor ’spancreaticcancer,theprofessorasked,“Howoldisthisfellow?”

“Seventy-four,”wereplied.

“That’smyage,”hesaid,setdowntheprobe,andwalkedaway.

—

Medicalschool sharpenedmyunderstandingof therelationship betweenmeaning,

life,anddeath.IsawthehumanrelationalityIhadwrittenaboutasanundergraduate

realizedinthedoctor-patientrelationship.Asmedicalstudents,wewereconfronted

by death, suffering, and the work entailed in patient care, while being

simultaneouslyshieldedfromtherealbruntofresponsibility,thoughwecouldspot

its specter. Med students spend the first two years in classrooms, socializing,

studying, and reading; it was easy to treat the work as a mere extension of

undergraduate studies. But my girlfriend, Lucy, whom I met in the first year of

medicalschool(andwhowouldlaterbecome my wife),understoodthesubtextof

theacademics.Hercapacitytolovewasbarelyfinite,andalessontome.Onenight

onthesofainmyapartment,whilestudyingthereamsofwavylinesthatmakeup

EKGs,shepuzzledover,thencorrectlyidentified,afatalarrhythmia.Allatonce,it

dawnedonherandshebegantocry:whereverthis“practiceEKG”hadcomefrom,

the patienthad not survived. The squiggly lines on that page were more than just

lines; they were ventricular fibrillation deteriorating to asystole, and they could

bringyoutotears.

Lucy and I attended the Yale School of Medicine when Shep Nuland still

lectured there, but I knew him only in my capacity as a reader. Nuland was a

renownedsurgeon-philosopherwhoseseminalbookaboutmortality,HowWeDie,

hadcomeoutwhenIwasinhighschoolbutmadeitintomyhandsonlyinmedical

school.FewbooksIhadreadsodirectlyandwhollyaddressedthatfundamentalfact

ofexistence:allorganisms,whethergoldfishorgrandchild,die.Iporedoveritin

myroomatnight,andrememberinparticularhisdescriptionofhisgrandmother’s

illness, and how that one passage so perfectly illuminated the ways in which the

personal,medical,andspiritualallintermingled.Nulandrecalledhow,asachild,he

wouldplayagameinwhich,usinghisfinger,heindentedhisgrandmother’sskinto

see how long ittook to resume its shape—a part of the aging process that,along

withher newfoundshortness ofbreath,showedher“gradualslideinto congestive

heart failure…the significant decline in the amount of oxygen that aged blood is

capableoftakingupfromtheagedtissuesoftheagedlung.” But“whatwas most

evident,”hecontinued,“wastheslowdrawingawayfromlife….BythetimeBubbeh

stoppedpraying,shehadstoppedvirtuallyeverythingelseaswell.”Withherfatal

stroke,NulandrememberedSirThomasBrowne’sReligioMedici:“Withwhatstrife

andpainswecomeintotheworldweknownot,but’tiscommonlynoeasymatterto

getoutofit.”

I had spent so much time studying literature at Stanford and the history of

medicine at Cambridge, in an attempt to better understand the particularities of

death, only to come away feeling like they were still unknowable to me.

DescriptionslikeNuland’sconvincedmethatsuchthingscouldbeknownonlyface-

to-face.Iwaspursuingmedicinetobearwitnesstothetwinnedmysteriesofdeath,

its experiential and biological manifestations: at once deeply personal and utterly

impersonal.

I remember Nuland, in the opening chapters of How We Die, writing about

being a young medical student alone in the OR with a patient whose heart had

stopped.Inanactofdesperation,hecutopenthepatient’schestandtriedtopumphis

heartmanually,triedtoliterallysqueezethelifebackintohim.Thepatientdied,and

Nulandwasfoundbyhissupervisor,coveredinbloodandfailure.

MedicalschoolhadchangedbythetimeIgotthere,tothepointwheresucha

scenewassimplyunthinkable:asmedicalstudents,wewerebarelyallowedtotouch

patients,letaloneopentheirchests.Whathadnotchanged,though,wastheheroic

spiritofresponsibilityamidbloodandfailure.Thisstruckmeasthetrueimageofa

doctor.

—

ThefirstbirthIwitnessedwasalsothefirstdeath.

I had recently taken Step 1of my medical boards, wrappingup two yearsof

intensive study buried in books, deep in libraries, poring over lecture notes in

coffee shops, reviewing hand-made flash cards while lying in bed. The next two

years,then,Iwouldspendinthehospitalandclinic,finallyputtingthattheoretical

knowledgetousetorelieveconcretesuffering,withpatients,notabstractions,asmy

primary focus. I started in ob-gyn, working the graveyard shift in the labor and

deliveryward.

Walkingintothe building as the sun descended, Itried to recallthe stages of

labor, the corresponding dilation of the cervix, the names of the “stations” that

indicatedthebaby’sdescent—anythingthatmightprovehelpfulwhenthetimecame.

Asamedicalstudent,mytaskwastolearnbyobservationandavoidgettinginthe

way.Residents,whohadfinishedmedicalschoolandwerenowcompletingtraining

in a chosen specialty, and nurses, with their years of clinical experience, would

serveasmyprimaryinstructors.Butthefearstilllurked—Icouldfeelitsfluttering

—thatthroughaccidentorexpectation,I’dbecalledontodeliverachildbymyself,

andfail.

I made my way to the doctors’ lounge where I was to meet the resident. I

walked in and saw a dark-haired young woman lying on a couch, chomping

furiously at a sandwich while watching TV and reading a journal article. I

introducedmyself.

“Oh,hi,”shesaid.“I’mMelissa.I’llbeinhereorinthecallroomifyouneed

me.ProbablythebestthingforyoutodoiskeepaneyeonpatientGarcia.She’sa

twenty-two-year-old, here with preterm labor and twins. Everyone else is pretty

standard.”

Between bites, Melissa briefed me, a barrage of facts and information: The

twins were only twenty-three and a half weeks old; the hope was to keep the

pregnancy going until they were more developed, however long that might be;

twenty-fourweekswasconsideredthecuspofviability,andeveryextradaymadea

difference; the patient was getting various drugs to control her contractions.

Melissa’spagerwentoff.

“Okay,” she said, swingingherlegs offthecouch. “Igottago.Youcanhang

outhere,ifyoulike.Wehavegoodcablechannels.Oryoucancomewithme.”

I followed Melissa to the nurses’ station. One wall was lined with monitors,

displayingwavytelemetrylines.

“What’sthat?”Iasked.

“That’stheoutputofthetocometersandthefetalheartrates.Letmeshowyou

thepatient.Shedoesn’tspeakEnglish.DoyouspeakSpanish?”

Ishookmyhead.Melissabroughtmetotheroom.Itwasdark.Themotherlay

in a bed, resting, quiet, monitor bands wrapped around her belly, tracking her

contractionsandthetwins’heartratesandsendingthesignaltothescreensI’dseen

atthenurses’station.Thefatherstoodatthebedsideholdinghiswife’shand,worry

etchedonhisbrow.MelissawhisperedsomethingtotheminSpanish,thenescorted

meout.

For the next several hours, things progressed smoothly. Melissa slept in the

lounge. I trieddecodingtheindecipherable scribblesin Garcia’s chart, which was

likereadinghieroglyphics,andcameawaywiththeknowledgethatherfirstname

was Elena,this was hersecondpregnancy,she hadreceived no prenatal care, and

shehadnoinsurance.Iwrotedownthenamesofthedrugsshewasgettingandmade

a note to look them up later. I read a little about premature labor in a textbook I

foundinthedoctors’ lounge.Preemies, if theysurvived, apparentlyincurredhigh

rates of brain hemorrhages and cerebral palsy. Then again, my older brother,

Suman,hadbeenbornalmosteightweekspremature,threedecadesearlier,andhe

wasnowapracticingneurologist.Iwalkedovertothenurseandaskedhertoteach

mehowtoreadthoselittlesquigglesonthemonitor,whichwerenoclearertome

than the doctors’ handwriting but could apparently foretell calm or disaster. She

nodded and began talking me through reading a contraction and the fetal hearts’

reactiontoit,theway,ifyoulookedclosely,youcouldsee—

Shestopped.Worryflashedacrossherface.Withoutaword,shegotupandran

into Elena’s room, then burst back out, grabbed the phone, and paged Melissa. A

minutelater,Melissaarrived,bleary-eyed,glancedatthestrips,andrushedintothe

patient’sroom,withmetrailingbehind.Sheflippedopenhercellphoneandcalled

theattending,rapidlytalkinginajargonIonlypartiallyunderstood.Thetwinswere

indistress,Igathered,andtheironlyshotatsurvivalwasanemergencyC-section.

I was carried along with the commotion into the operating room. They got

Elenasupineonthetable,drugsrunningintoherveins.Anursefranticallypainted

the woman’sswollen abdomenwith anantiseptic solution,while theattending,the

resident, and I splashed alcohol cleanser on our hands and forearms. I mimicked

their urgent strokes, standing silently as they cursed under their breath. The

anesthesiologists intubated the patient while the senior surgeon, the attending,

fidgeted.

“C’mon,”hesaid.“Wedon’thavealotoftime.Weneedtomovefaster!”

I was standing next to the attending as he sliced open the woman’s belly,

makinga single longcurvilinear incisionbeneath her bellybutton,just belowthe

apex of her protuberant womb. I tried to follow every movement, digging in my

brainfortextbookanatomicalsketches.Theskinslidapartatthescalpel’stouch.He

sliced confidently through thetoughwhiterectus fasciacovering the muscle,then

splitthefasciaandtheunderlyingmusclewithhishands,revealingthefirstglimpse

ofthemelon-likeuterus.Heslicedthatopenaswell,andasmallfaceappeared,then

disappearedamidtheblood.Inplungedthedoctor’shands,pullingoutone,thentwo

purplebabies,barelymoving,eyesfusedshut,liketinybirdsfallentoosoonfroma

nest. With their bones visible through translucent skin, they looked more like the

preparatorysketchesofchildrenthanchildrenthemselves.Toosmalltocradle,not

much bigger than the surgeon’s hands, they were rapidly passed to the waiting

neonatalintensivists,whorushedthemtotheneonatalICU.

With the immediate danger averted, the pace of the operation slowed, frenzy

turning to something resembling calm. The odor of burnt flesh wafted up as the

cautery arrested little spurts of blood. The uterus was sutured back together, the

stitcheslikearowofteeth,bitingclosedtheopenwound.

“Professor, do you want the peritoneum closed?” Melissa asked. “I read

recentlythatitdoesn’tneedtobe.”

“LetnomanputasunderwhatGodhasjoined,”theattendingsaid.“Atleast,no

morethantemporarily.IliketoleavethingsthewayIfoundthem—let’ssewitback

up.”

Theperitoneumisamembranethatsurroundstheabdominalcavity.Somehow

I had completely missed its opening, and I couldn’t see it at all now. To me, the

wound looked like a mass of disorganized tissue, yet to the surgeons it had an

appreciableorder,likeablockofmarbletoasculptor.

Melissacalledfortheperitonealstitch,reachedherforcepsintothewound,and

pulledupatransparentlayeroftissuebetweenthemuscleandtheuterus.Suddenly

theperitoneum,andthegapingholeinit,wasclear.Sheseweditclosedandmoved

ontothemuscleandfascia,puttingthembacktogetherwithalargeneedleandafew

big looping stitches. The attending left, and finally the skin was sutured together.

MelissaaskedmeifIwantedtoplacethelasttwostitches.

My hands shook as I passed the needle through the subcutaneous tissue. As I

tighteneddownthesuture,Isawthattheneedlewasslightlybent.Theskinhadcome

togetherlopsided,agloboffatpokingthrough.

Melissa sighed.“That’suneven,”shesaid.“Youhavetojust catch thedermal

layer—youseethisthinwhitestripe?”

Idid.Notonlywouldmymindhavetobetrained,myeyeswould,too.

“Scissors!”Melissacutoutmyamateurknots,resuturedthewound,appliedthe

dressing,andthepatientwastakentorecovery.

AsMelissahadtoldmeearlier,twenty-fourweeksinuterowasconsideredthe

edgeofviability.Thetwinshadlastedtwenty-threeweeksandsixdays.Theirorgans

werepresent,butperhapsnotyetreadyfortheresponsibilityofsustaininglife.They

wereowednearlyfourmoremonthsofprotecteddevelopmentinthewomb,where

oxygenated blood and nutrients came to them through the umbilical cord. Now

oxygenwouldhave to comethroughthelungs,and thelungswerenotcapableof

thecomplexexpansionandgastransferthatwasrespiration.Iwenttoseethemin

theNICU,eachtwinencasedinaclearplasticincubator,dwarfedbylarge,beeping

machines,barelyvisibleamidthetangleofwiresandtubes.Theincubatorhadsmall

sideportsthroughwhichtheparentscouldstraintoreachandgentlystrokealegor

arm,providingvitalhumancontact.

Thesunwasup,myshiftover.Iwassenthome,theimageofthetwinsbeing

extracted from the uterus interrupting my sleep. Like a premature lung, I felt

unreadyfortheresponsibilityofsustaininglife.

When I returned to work that night,I was assigned to a newmother. No one

anticipatedproblemswiththispregnancy.Thingswereasroutineaspossible;today

wasevenheractualduedate.Alongwiththenurse,Ifollowedthemother ’ssteady

progress, contractions racking her body with increasing regularity. The nurse

reportedthedilationofthecervix,fromthreecentimeterstofivetoten.

“Okay,it’stimetopushnow,”thenursesaid.

Turning tome, she said, “Don’t worry—we’ll page you whenthedeliveryis

close.”

I found Melissa in the doctors’ lounge. After some time, the OB team was

called into the room: delivery was near. Outside the door, Melissa handed me a

gown,gloves,andapairoflongbootcovers.

“Itgetsmessy,”shesaid.

Weenteredtheroom.IstoodawkwardlyofftothesideuntilMelissapushedme

tothefront,betweenthepatient’slegs,justinfrontoftheattending.

“Push!” the nurse encouraged. “Now again: just like that, only without the

screaming.”

Thescreamingdidn’tstop,andwassoonaccompaniedbyagushofbloodand

otherfluids.TheneatnessofmedicaldiagramsdidnothingtorepresentNature,red

notonlyintoothandclawbutinbirthaswell.(AnAnneGeddesphotothiswasnot.)

Itwasbecomingclearthatlearningtobeadoctorinpracticewasgoingtobeavery

differenteducationfrombeingamedicalstudentintheclassroom.Readingbooks

and answering multiple-choice questions bore little resemblance to taking action,

withitsconcomitantresponsibility.Knowingyouneedtobejudiciouswhenpulling

ontheheadtofacilitatedeliveryoftheshoulderisnotthesameasdoingit.WhatifI

pulledtoohard?(Irreversiblenerve injury, my brain shouted.) The head appeared

with each push and then retracted with each break, three steps forward, two steps

back. I waited. The human brain has rendered the organism’s most basic task,

reproduction, a treacherous affair. That same brain made things like labor and

deliveryunits,cardiotocometers,epidurals,andemergencyC-sectionsbothpossible

andnecessary.

Istoodstill,unsurewhentoactorwhattodo.Theattending’svoiceguidedmy

hands to the emerging head, and on the next push, I gently guided the baby’s

shouldersasshecameout.Shewaslarge,plump,andwet,easilythreetimesthesize

ofthebirdlikecreaturesfromthe previousnight.Melissaclamped thecord,andI

cut it. The child’s eyes opened and she began to cry. I held the baby a moment

longer,feelingherweightandsubstance,thenpassedhertothenurse,whobrought

hertothemother.

Iwalkedoutto thewaitingroomtoinform the extendedfamily ofthehappy

news.Thedozenorsofamilymembersgatheredthereleaptuptocelebrate,ariotof

handshakesandhugs.Iwasaprophetreturningfromthemountaintopwithnewsof

ajoyousnewcovenant!Allthemessinessofthebirth disappeared;hereIhadjust

beenholdingthenewestmemberofthisfamily,thisman’sniece,thisgirl’scousin.

Returningtotheward,ebullient,IranintoMelissa.

“Hey,doyouknowhowlastnight’stwinsaredoing?”Iasked.

Shedarkened.BabyAdied yesterdayafternoon; Baby Bmanagedto live not

quitetwenty-fourhours,thenpassedawayaroundthetimeIwasdeliveringthenew

baby.Inthatmoment, Icould onlythink of SamuelBeckett,themetaphors that, in

thosetwins,reachedtheirterminallimit:“Onedaywewereborn,onedayweshall

die,thesame day, thesamesecond….Birth astrideof agrave,the light gleamsan

instant,thenit’snightoncemore.”Ihadstoodnextto“thegravedigger”withhis

“forceps.”Whathadtheselivesamountedto?

“Youthinkthat’sbad?”shecontinued.“Mostmotherswithstillbornsstillhave

to go through labor and deliver. Can you imagine? At least these guys had a

chance.”

A match flickers but does not light. The mother ’s wailing in room 543, the

searingredrimsofthefather’slowereyelids,tearssilentlystreakinghisface:this

flip side of joy, the unbearable, unjust, unexpected presence of death…What

possiblesensecouldbemade,whatwordswerethereforcomfort?

“Wasittherightchoice,todoanemergencyC-section?”Iasked.

“Noquestion,”shesaid.“Itwastheonlyshottheyhad.”

“Whathappensifyoudon’t?”

“Probably,theydie.Abnormalfetalhearttracingsshowwhenthefetalbloodis

turningacidemic;thecordiscompromisedsomehow,orsomethingelseseriously

badishappening.”

“Buthowdoyouknowwhenthetracinglooksbadenough?Whichisworse,

beingborntooearlyorwaitingtoolongtodeliver?”

“Judgmentcall.”

What a call to make. In my life, had I ever made a decision harder than

choosingbetweenaFrenchdipandaReuben?HowcouldIeverlearntomake,and

live with, such judgment calls? I still had a lot of practical medicine to learn, but

would knowledge alone be enough, with life and death hanging in the balance?

Surely intelligence wasn’t enough; moral clarity was needed as well. Somehow, I

hadtobelieve,Iwouldgainnotonlyknowledgebutwisdom,too.Afterall,whenI

had walked intothehospital just one daybefore, birthanddeath hadbeenmerely

abstract concepts. Now I had seen them both up close. Maybe Beckett’s Pozzo is

right.Maybelifeismerelyan“instant,”toobrieftoconsider.Butmyfocuswould

have to be on my imminent role, intimately involved with the when and how of

death—thegravediggerwiththeforceps.

Not long after, my ob-gyn rotation ended, and it was immediately on to

surgicaloncology.Mari, afellowmedstudent, andIwould rotatetogether.Afew

weeksin,afterasleeplessnight,shewasassignedtoassistinaWhipple,acomplex

operationthatinvolvesrearrangingmostabdominalorgansinanattempttoresect

pancreaticcancer,anoperationinwhichamedicalstudenttypicallystandsstill—or,

atbest,retracts—foruptoninehoursstraight.It’sconsideredtheplumoperationto

beselectedtohelpwith,becauseofitsextremecomplexity—onlychiefresidentsare

allowed to actively participate. But it is grueling, the ultimate test of a general

surgeon’sskill.Fifteenminutesaftertheoperationstarted,IsawMariinthehallway,

crying.ThesurgeonalwaysbeginsaWhipplebyinsertingasmallcamerathrougha

tiny incision to look for metastases, as widespread cancer renders the operation

useless and causes its cancellation. Standingthere, waiting in the OR witha nine-

hoursurgerystretchingoutbeforeher,Marihadawhisperofathought:I’msotired

—please God, let there be mets. There were. The patient was sewn back up, the

procedure called off. First came relief, then a gnawing, deepening shame. Mari

burstoutoftheOR,where,needingaconfessor,shesawme,andIbecameone.

—

In the fourth year of medical school, I watched as, one by one, many of my

classmateselectedtospecializeinlessdemandingareas(radiologyordermatology,

forexample)andappliedfortheirresidencies.Puzzledbythis,Igathereddatafrom

severalelite medical schoolsandsawthatthetrendswerethesame:bytheend of

medicalschool,moststudentstendedtofocuson“lifestyle”specialties—thosewith

more humane hours, higher salaries, and lower pressures—the idealism of their

med school application essays tempered or lost. As graduation neared and we sat

down, in a Yale tradition, to rewrite our commencement oath—a melding of the

words of Hippocrates, Maimonides, Osler, along with a few other great medical

forefathers—severalstudentsarguedfortheremovaloflanguageinsistingthatwe

place our patients’ interests above our own. (The rest of us didn’t allow this

discussiontocontinueforlong.Thewordsstayed.Thiskindofegotismstruckme

asantitheticaltomedicineand,itshouldbenoted,entirelyreasonable.Indeed,thisis

how99percentofpeopleselecttheirjobs:pay,workenvironment,hours.Butthat’s

thepoint.Puttinglifestylefirstishowyoufindajob—notacalling.)

Asforme,Iwouldchooseneurosurgeryasmyspecialty.Thechoice,whichI

hadbeencontemplatingforsometime,wascementedonenightinaroomjustoff

theOR,whenIlistenedinquietaweasapediatricneurosurgeonsatdownwiththe

parentsofachildwithalargebraintumorwhohadcomeinthatnightcomplaining

ofheadaches.Henotonlydeliveredtheclinicalfactsbutaddressedthehumanfacts

as well, acknowledging thetragedy of the situation and providing guidance. As it

happened,thechild’s mother was aradiologist.Thetumor looked malignant—the

mother had already studied the scans, and now she sat in a plastic chair, under

fluorescentlight,devastated.

“Now,Claire,”thesurgeonbegan,softly.

“Isitasbadasitlooks?”themotherinterrupted.“Doyouthinkit’scancer?”

“Idon’tknow.WhatIdoknow—andIknowyouknowthesethings,too—isthat

yourlifeisaboutto—italreadyhaschanged.Thisisgoingtobealonghaul,you

understand?Youhavegottobethereforeachother,butyoualsohavetogetyour

restwhenyouneedit.Thiskindofillnesscaneitherbringyoutogether,oritcan

tearyouapart.Nowmorethanever,youhavetobethereforeachother.Idon’twant

either of you staying up all night at the bedside or never leaving the hospital.

Okay?”

He went on to describe the planned operation, the likely outcomes and

possibilities, what decisions needed to be made now, what decisions they should

start thinking about but didn’t need to decide on immediately, and what sorts of

decisionstheyshouldnotworryaboutatallyet.Bytheendoftheconversation,the

family was notat ease, but they seemed able to face the future. I had watched the

parents’faces—atfirstwan,dull,almostotherworldly—sharpenandfocus.AndasI

satthere,Irealizedthatthequestionsintersectinglife,death,andmeaning,questions

thatallpeople face at somepoint, usually arisein amedical context. Inthe actual

situations where one encounters these questions, it becomes a necessarily

philosophical and biological exercise. Humans are organisms, subject to physical

laws, including, alas, the one that says entropy always increases. Diseases are

moleculesmisbehaving; the basicrequirementof lifeismetabolism,and death its

cessation.

While all doctors treat diseases, neurosurgeons work in the crucible of

identity: every operation on the brain is, by necessity, a manipulation of the

substance of our selves, and every conversation with a patient undergoing brain

surgerycannothelpbutconfrontthisfact.Inaddition,tothepatientandfamily,the

brainsurgeryisusuallythemostdramaticeventtheyhaveeverfacedand,assuch,

hastheimpactofanymajorlifeevent.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 eliminating the small

possibilityofafatalbrainhemorrhage?Yourrighthand’sfunctiontostopseizures?

Howmuchneurologic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compelledbyneurosurgery,withitsunforgivingcalltoperfection;like

theancientGreekconceptarete,Ithought,virtuerequiredmoral,emotional,mental,

andphysicalexcellence.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:neurosurgery,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.

—

Aftermedicalschool,LucyandI,newlymarried,headedtoCaliforniatobeginour

residencies, me at Stanford, Lucy just up the road at UCSF. Medical school was

officially behind us—now real responsibility lay in wait. In short order, I made

severalclosefriendsinthehospital,inparticularVictoria,myco-resident,andJeff,

a general surgery resident a few years senior to us. Over the next seven years of

training, we would grow from bearing witness to medical dramas to becoming

leadingactorsinthem.

Asaninterninthefirstyearofresidency,oneislittlemorethanapaperpusher

againstabackdropoflifeanddeath—though,eventhen,theworkloadisenormous.

Myfirstdayinthehospital,thechiefresidentsaidtome,“Neurosurgeryresidents

aren’t just the best surgeons—we’re the best doctors in the hospital. That’s your

goal. Make us proud.” Thechairman, passingthrough theward:“Alwayseat with

yourlefthand.You’vegottolearntobeambidextrous.”Oneoftheseniorresidents:

“Just a heads-up—the chief is going through a divorce, so he’s really throwing

himself into his work right now. Don’t make small talk with him.” The outgoing

internwhowassupposedtoorientmebutinsteadjusthandedmealistofforty-three

patients: “Theonly thingI havetotell youis:they canalwayshurtyou more,but

theycan’tstoptheclock.”Andthenhewalkedaway.

I didn’t leave the hospital for the first two days, but before long, the

impossible-seeming,day-killingmoundsofpaperworkwereonlyanhour ’swork.

Still, whenyouwork in ahospital,thepapersyou file aren’t justpapers:they are

fragments of narratives filled with risks and triumphs. An eight-year-old named

Matthew,forexample,cameinonedaycomplainingofheadachesonlytolearnthat

he had a tumor abutting his hypothalamus. The hypothalamus regulates our basic

drives:sleep,hunger,thirst,sex.LeavinganytumorbehindwouldsubjectMatthew

toalifeofradiation,furthersurgeries,braincatheters…inshort,itwouldconsume

hischildhood.Completeremovalcouldpreventthat,butattheriskofdamaginghis

hypothalamus, rendering him a slave to his appetites. The surgeon got to work,

passedasmallendoscopethroughMatthew’snose,anddrilledoffthefloorofhis

skull.Onceinside, hesawa clear planeand removedthetumor.Afewdayslater,

Matthewwasboppingaroundtheward,sneakingcandiesfromthenurses,readyto

go home. That night, I happily filled out the endless pages of his discharge

paperwork.

IlostmyfirstpatientonaTuesday.

Shewasaneighty-two-year-old woman, smallandtrim,thehealthiestperson

onthegeneralsurgeryservice,whereIspentamonthasanintern.(Atherautopsy,

thepathologistwouldbeshockedtolearnherage:“Shehastheorgansofafifty-

year-old!”)Shehadbeenadmittedforconstipationfromamildbowelobstruction.

After six days of hoping her bowels would untangle themselves, we did a minor

operationtohelp sortthingsout. Aroundeight P.M.Mondaynight,I stoppedby to

checkonher,andshewasalert,doingfine.Aswetalked,Ipulledfrommypocket

mylistoftheday’sworkandcrossedoffthelastitem(post-opcheck,Mrs.Harvey).

Itwastimetogohomeandgetsomerest.

Sometime after midnight,thephone rang. The patientwas crashing. With the

complacencyofbureaucraticworksuddenlytornaway,Isatupinbedandspatout

orders:“OneliterbolusofLR,EKG,chestX-ray,stat—I’monmywayin.”Icalled

mychief,andshetoldmetoaddlabsandtocallherbackwhenIhadabettersense

ofthings.IspedtothehospitalandfoundMrs.Harveystrugglingforair,herheart

racing, her blood pressure collapsing. She wasn’t getting better no matter what I

did; and as I was the only general surgery intern on call, my pager was buzzing

relentlessly,withcallsIcoulddispensewith(patientsneedingsleepmedication)and

onesIcouldn’t(arupturingaorticaneurysmintheER).Iwasdrowning,outofmy

depth, pulled in a thousand directions, and Mrs. Harvey was still not improving. I

arrangedatransfertotheICU,whereweblastedherwithdrugsandfluidstokeep

her from dying, and I spent the next few hours running between my patient

threateningtodieintheERandmypatientactivelydyingintheICU.By5:45A.M.,

the patient in the ER was on his way to the OR, and Mrs. Harvey was relatively

stable.She’dneededtwelvelitersoffluid,twounitsofblood,aventilator,andthree

differentpressorstostayalive.

When Ifinally left thehospital, at fiveP.M. on Tuesday evening,Mrs. Harvey

wasn’t getting better—or worse. At seven P.M., the phone rang: Mrs. Harvey had

coded,andtheICUteamwasattemptingCPR.Iracedbacktothehospital,andonce

again, she pulled through. Barely. This time, instead of going home, I grabbed

dinnernearthehospital,justincase.

AteightP.M.,myphonerang:Mrs.Harveyhaddied.

Iwenthometosleep.

I was somewhere between angry and sad. For whatever reason, Mrs. Harvey

had burst through the layers of paperwork to become my patient. The next day, I

attendedherautopsy,watchedthepathologistsopenherupandremoveherorgans.I

inspectedthemmyself,ranmyhandsoverthem,checkedtheknotsIhadtiedinher

intestines.Fromthatpointon,Iresolvedtotreatallmypaperworkaspatients,and

notviceversa.

Inthatfirstyear,Iwouldglimpsemyshareofdeath.Isometimessawitwhile

peekingaroundcorners,othertimeswhilefeelingembarrassedtobecaughtinthe

sameroom.HerewereafewofthepeopleIsawdie:

1.Analcoholic,hisbloodnolongerabletoclot,whobledtodeathintohisjoints

andunderhisskin.Everyday,thebruiseswouldspread.Beforehebecame

delirious,helookedupatmeandsaid,“It’snotfair—I’vebeendilutingmy

drinkswithwater.”

2.Apathologist,dyingofpneumonia,wheezingherdeathrattlebeforeheading

downtobeautopsied—herfinaltriptothepathologylab,whereshehadspent

somanyyearsofherlife.

3.Amanwho’dhadaminorneurosurgicalproceduretotreatlightningboltsof

painthatwereshootingthroughhisface:atinydropofliquidcementhadbeen

placedonthesuspectednervetokeepaveinfrompressingonit.Aweeklater,

hedevelopedmassiveheadaches.Nearlyeverytestwasrun,butnodiagnosis

waseveridentified.

4.Dozensofcasesofheadtrauma:suicides,gunshots,barfights,motorcycle

accidents,carcrashes.Amooseattack.

Atmoments,theweightofitallbecamepalpable.Itwasintheair,thestressand

misery. Normally, you breathed it in, without noticing it. But some days, like a

humidmuggyday,ithadasuffocatingweightofitsown.Somedays,thisishowit

feltwhenIwasinthehospital:trappedinanendlessjunglesummer,wetwithsweat,

therainoftearsofthefamiliesofthedyingpouringdown.

—

In the second year of training, you’re the first to arrive in an emergency. Some

patients you can’tsave. Others you can:the first time I rushed a comatose patient

fromtheERtotheOR,drainedthebloodfromhisskull,andthenwatchedhimwake

up,starttalkingtohisfamily,andcomplainabouttheincisiononhishead,Igotlost

inaeuphoricdaze,promenadingaroundthehospitalattwoA.M.untilIhadnosense

ofwhereIwas.Ittookmeforty-fiveminutestofindmywaybackout.

The schedule took a toll. As residents, we were working as much as one

hundred hours a week; though regulations officially capped our hours at eighty-

eight,therewasalwaysmoreworktobedone.Myeyeswatered,myheadthrobbed,

IdownedenergydrinksattwoA.M.Atwork,Icouldkeepittogether,butassoonasI

walked out of the hospital, the exhaustion would hit me. I staggered through the

parkinglot,oftennappinginmycarbeforedrivingthefifteenminuteshometobed.

Not all residents could stand the pressure. One was simply unable to accept

blame or responsibility. He was a talented surgeon, but he could not admit when

he’dmadeamistake.Isatwithhimonedayintheloungeashebeggedmetohelp

himsavehiscareer.

“Allyouhavetodo,”Isaid,“islookmeintheeyeandsay,‘I’msorry.What

happenedwasmyfault,andIwon’tletithappenagain.’ ”

“Butitwasthenursewho—”

“No.Youhavetobeabletosayitandmeanit.Tryagain.”

“But—”

“No.Sayit.”

ThiswentonforanhourbeforeIknewhewasdoomed.

Thestressdroveanotherresidentoutofthefieldentirely;sheelectedtoleave

foralesstaxingjobinconsulting.

Otherswouldpayevenhigherprices.

Asmyskillsincreased,sotoodidmyresponsibility.Learningtojudgewhose

lives could be saved, whose couldn’t be, and whose shouldn’t be requires an

unattainableprognosticability.Imademistakes.RushingapatienttotheORtosave

onlyenoughbrainthathisheartbeatsbuthecanneverspeak,heeatsthroughatube,

andheiscondemnedtoanexistencehewouldneverwant…Icametoseethisasa

moreegregiousfailurethanthepatientdying.Thetwilightexistenceofunconscious

metabolismbecomesanunbearableburden,usuallylefttoaninstitution,wherethe

family,unabletoattainclosure,visitswithincreasingrarity,untiltheinevitablefatal

bedsoreor pneumoniasetsin.Someinsistonthislifeandembraceitspossibility,

eyes open. But many do not, or cannot, and the neurosurgeon must learn to

adjudicate.

Ihadstartedinthiscareer,inpart,topursuedeath:tograspit,uncloakit,and

see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its

intertwiningof brain and consciousness as for its intertwiningof life anddeath. I

hadthoughtthatalifespentinthespacebetweenthetwowouldgrantmenotmerely

astageforcompassionateactionbutanelevationofmyownbeing:gettingasfar

awayfrompettymaterialism,fromself-importanttrivia,gettingrightthere,tothe

heartofthematter,totrulylife-and-deathdecisionsandstruggles…surelyakindof

transcendencewouldbefoundthere?

Butinresidency,somethingelsewasgraduallyunfolding.Inthemidstofthis

endlessbarrageofheadinjuries,Ibegantosuspectthatbeingsoclosetothefiery

light of such moments only blinded me to their nature, like trying to learn

astronomybystaringdirectlyatthesun.Iwasnotyetwithpatientsintheirpivotal

moments, I was merely at those pivotal moments. I observed a lot of suffering;

worse,Ibecameinuredtoit.Drowning,eveninblood,oneadapts,learnstofloat,to

swim, even to enjoy life, bonding with the nurses, doctors, and others who are

clingingtothesameraft,caughtinthesametide.

My fellow resident Jeff and I worked traumas together. When he called me

down to the trauma bay because of a concurrent head injury, we were always in

sync.He’dassesstheabdomen,thenaskformyprognosisonapatient’scognitive

function.“Well,hecouldstillbeasenator,”Ioncereplied,“butonlyfromasmall

state.” Jeff laughed, and from that moment on, state population became our

barometerforhead-injuryseverity.“IsheaWyomingoraCalifornia?”Jeffwould

ask,tryingtodeterminehowintensivehiscareplanshouldbe.OrI’dsay,“Jeff,I

knowhisbloodpressureislabile,butIgottagethimtotheORorhe’sgonnago

fromWashingtontoIdaho—canyougethimstabilized?”

Inthecafeteriaoneday,asIwasgrabbingmytypicallunch—aDietCokeand

anicecreamsandwich—mypagerannouncedanincomingmajortrauma.Iranto

the trauma bay, tucking my ice cream sandwich behind a computer just as the

paramedicsarrived,pushingthegurney,recitingthedetails:“Twenty-two-year-old

male, motorcycle accident, forty miles per hour, possible brain coming out his

nose…”

Iwentstraighttowork,callingforanintubationtray,assessinghisothervital

functions.Oncehewassafelyintubated,Isurveyedhisvariousinjuries:thebruised

face, the road rash, the dilated pupils. We pumped him full of mannitol to reduce

brain swelling and rushed him to the scanner: a shattered skull, heavy diffuse

bleeding. In my mind, I was already planningthescalp incision, howI’d drill the

bone, evacuate the blood. His blood pressure suddenly dropped. We rushed him

back to the trauma bay, and just as the rest of the trauma team arrived, his heart

stopped. A whirlwind of activity surrounded him: catheters were slipped into his

femoralarteries,tubesshoveddeepintohischest,drugspushedintohisIVs,andall

thewhile,fistspoundedonhishearttokeepthebloodflowing.Afterthirtyminutes,

we let him finish dying. With that kind of head injury, we all murmured in

agreement,deathwastobepreferred.

I slipped out of the trauma bay just as the family was broughtin to viewthe

body. Then I remembered: my Diet Coke, my ice cream sandwich…and the

swelteringheatofthetraumabay.WithoneoftheERresidentscoveringforme,I

slippedbackin,ghostlike,tosavetheicecreamsandwichinfrontofthecorpseof

thesonIcouldnot.

Thirtyminutesinthefreezerresuscitatedthesandwich.Prettytasty,Ithought,

picking chocolate chips out of my teeth as the family said its last goodbyes. I

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

strides.

Afewdayslater,IheardthatLaurie,afriendfrommedicalschool,hadbeenhit

by a car and that a neurosurgeon had performed an operation to try to save her.

She’d coded, was revived, and then died the following day. I didn’twant to know

more. The days when someone was simply “killed in a car accident” were long

gone. Now those words opened a Pandora’s box, out of which emerged all the

images:therollofthegurney,thebloodonthetraumabayfloor,thetubeshoved

downherthroat, the pounding onher chest.Icould seehands,myhands, shaving

Laurie’sscalp,thescalpelcuttingopenherhead,couldhearthefrenzyofthedrill

andsmelltheburningbone,itsdustwhirling,thecrackasIpriedoffasectionof

herskull.Herhairhalfshaven,herheaddeformed.Shefailedtoresembleherselfat

all;shebecameastrangertoherfriendsandfamily.Maybetherewerechesttubes,

andalegwasintraction…

Ididn’taskfordetails.Ialreadyhadtoomany.

Inthatmoment,allmyoccasionsoffailedempathycamerushingbacktome:

thetimesIhadpusheddischargeoverpatientworries,ignoredpatients’painwhen

other demands pressed. The people whose suffering I saw, noted, and neatly

packagedintovariousdiagnoses,thesignificanceofwhichIfailedtorecognize—

theyallreturned,vengeful,angry,andinexorable.

I feared I was on the way to becoming Tolstoy’s stereotype of a doctor,

preoccupiedwithemptyformalism,focused ontherotetreatmentofdisease—and

utterlymissingthelargerhumansignificance.(“Doctorscametoseehersinglyand

inconsultation,talkedmuchinFrench,German,andLatin,blamedoneanother,and

prescribedagreatvarietyofmedicinesforallthediseasesknowntothem,butthe

simple idea never occurred to any of them that they could not know the disease

Natasha was sufferingfrom.”) Amother came tome, newlydiagnosed withbrain

cancer. She was confused, scared, overcome by uncertainty. I was exhausted,

disconnected.I rushed throughher questions,assuredher thatsurgery wouldbe a

success,andassuredmyselfthattherewasn’tenoughtimetoanswerherquestions

fairly.Butwhydidn’tImakethetime?Atruculentvetrefusedtheadviceandcoaxing

of doctors, nurses, and physical therapists for weeks; as a result, his back wound

brokedown,justaswehadwarnedhimitwould.CalledoutoftheOR,Istitchedthe

dehiscentwoundasheyelpedinpain,tellingmyselfhe’dhaditcoming.

Nobodyhasitcoming.

I took meager solace in knowing that William Carlos Williams and Richard

Selzerhadconfessedtodoingworse,andIsworetodobetter.Amidthetragedies

and failures, I feared I was losing sight of the singular importance of human

relationships,notbetweenpatientsandtheirfamiliesbutbetweendoctorandpatient.

Technicalexcellencewasnotenough.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.Whenapatientcomesinwithafatalheadbleed,

that first conversation with a neurosurgeon may forever color how the family

remembers the death, from a peaceful letting go (“Maybe it was his time”) to an

open sore of regret (“Those doctors didn’t listen! They didn’t even try to save

him!”).Whenthere’snoplaceforthescalpel,wordsarethesurgeon’sonlytool.

Foramidthatuniquesufferinginvokedbyseverebraindamage,thesuffering

oftenfeltmorebyfamiliesthanbypatients,itisnotmerelythephysicianswhodo

notseethefullsignificance.The familieswho gatheraroundtheir beloved—their

belovedwhoseshearedheadscontainedbatteredbrains—donotusuallyrecognize

the full significance, either. They see the past, the accumulation of memories, the

freshlyfeltlove,allrepresentedbythebodybeforethem.Iseethepossiblefutures,

thebreathingmachinesconnectedthroughasurgicalopeningintheneck,thepasty

liquiddrippinginthroughaholeinthebelly,thepossiblelong,painful,andonly

partial recovery—or, sometimes more likely, no return at all of the person they

remember.Inthesemoments,Iactednot,asImostoftendid,asdeath’senemy,but

asitsambassador.Ihadtohelpthosefamiliesunderstandthatthepersontheyknew

—the full, vital independent human—now lived only in the past and that Ineeded

theirinputtounderstandwhatsortoffutureheorshewouldwant:aneasydeathor

tobestrungbetweenbagsoffluidsgoingin,otherscomingout,topersistdespite

beingunabletostruggle.

HadIbeenmorereligiousin my youth,I mighthavebecomea pastor,forit

wasthepastoralroleI’dsought.

—

With my renewed focus, informed consent—the ritual by which a patient signs a

pieceofpaper,authorizingsurgery—becamenotajuridicalexerciseinnamingall

the risks as quickly as possible, like the voiceover in an ad for a new

pharmaceutical,butanopportunitytoforgeacovenantwithasufferingcompatriot:

Herewearetogether,andherearethewaysthrough—Ipromisetoguideyou,asbest

asIcan,totheotherside.

By this point in my residency, I was more efficient and experienced. I could

finallybreathealittle,nolongertryingtohangonformyowndearlife.Iwasnow

acceptingfullresponsibilityformypatients’well-being.

Mythoughtsturnedtomyfather.Asmedicalstudents,LucyandIhadattended

his hospitalroundsinKingman,watchingashe broughtcomfortand levity to his

patients.Toonewoman,whowasrecoveringfromacardiacprocedure:“Areyou

hungry?WhatcanIgetyoutoeat?”

“Anything,”shesaid.“I’mstarving.”

“Well, how about lobster and steak?” He picked up the phone and called the

nursingstation.“Mypatientneedslobsterandsteak—rightaway!”Turningbackto

her, he said, with a smile: “It’s on the way, but it may look more like a turkey

sandwich.”

The easy human connections he formed, the trust he instilled in his patients,

wereaninspirationtome.

Athirty-five-year-oldsatinherICUbed,asheenofterroronherface.Shehad

beenshoppingforhersister ’sbirthdaywhenshe’dhadaseizure.Ascanshowedthat

abenignbraintumorwaspressingonherrightfrontallobe.Intermsofoperative

risk, it was the best kind of tumor to have, and the best place to have it; surgery

would almost certainly eliminate her seizures. The alternative was a lifetime on

toxicantiseizuremedications.ButIcouldseethattheideaofbrainsurgeryterrified

her,morethanmost.Shewaslonesomeandinastrangeplace,havingbeenswept

outofthefamiliarhubbubofashoppingmallandintothealienbeepsandalarms

andantisepticsmellsofanICU.ShewouldlikelyrefusesurgeryifIlaunchedintoa

detached spiel detailing all the risks and possible complications. I could do so,

documentherrefusalinthechart,considermydutydischarged,andmoveontothe

nexttask.Instead,withherpermission,Igatheredherfamilywithher,andtogether

wecalmlytalkedthroughtheoptions.Aswetalked,Icouldseetheenormousnessof

thechoiceshefaceddwindleintoadifficultbutunderstandabledecision.Ihadmet

herinaspacewhereshewasaperson,insteadofaproblemtobesolved.Shechose

surgery. The operation went smoothly. She went home two days later, and never

seizedagain.

Anymajorillnesstransformsapatient’s—really,anentirefamily’s—life.But

braindiseaseshavetheadditionalstrangenessoftheesoteric.Ason’sdeathalready

defiestheparents’ordereduniverse;howmuchmoreincomprehensibleisitwhen

thepatientisbrain-dead,hisbodywarm,hisheartstillbeating?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.Sometimesthenewssoshocksthemind

that the brain suffers an electrical short. This phenomenon is known as a

“psychogenic” syndrome, a severe version of the swoon some experience after

hearingbadnews.Whenmymother,aloneatcollege,heardthatherfather,whohad

championedherrighttoaneducationinrural1960sIndia,hadfinallydiedaftera

long hospitalization, she had a psychogenic seizure—which continued until she

returnedhometoattendthefuneral.Oneofmypatients,uponbeingdiagnosedwith

braincancer,fellsuddenlyintoacoma.Iorderedabatteryoflabs,scans,andEEGs,

searchingforacause,withoutresult.Thedefinitivetestwasthesimplest:Iraisedthe

patient’sarmabovehisfaceandletgo.Apatientinapsychogeniccomaretainsjust

enough volition to avoid hitting himself. The treatment consists in speaking

reassuringly,untilyourwordsconnectandthepatientawakens.

Cancerofthebraincomesintwovarieties:primarycancers,whicharebornin

the brain,and metastases,whichemigratefrom somewhereelsein thebody,most

commonly fromthelungs.Surgerydoesnotcurethe disease, butitdoesprolong

life;formostpeople,cancerinthebrainsuggestsdeathwithinayear,maybetwo.

Mrs. Lee was in her late fifties, with pale green eyes, and had transferred to my

servicetwodaysearlierfromahospitalnearherhome,ahundredmilesaway.Her

husband,hisplaidshirttuckedintocrispjeans,stoodbyherbedside,fidgetingwith

hisweddingring.Iintroducedmyselfandsatdown,andshetoldmeherstory:For

thepastfewdays,shehadfeltatinglinginherrighthand,andthenshe’dbegunto

lose control of it, until she could nolonger button her blouse. She’d gone to her

localER,fearingshewashavingastroke.AnMRIwasobtainedthere,andshewas

senthere.

“DidanyonetellyouwhattheMRIshowed?”Iasked.

“No.”Thebuckhadbeenpassed,asitoftenwaswithdifficultnews.Oftentimes,

we’dhaveaspatwiththeoncologistoverwhosejobitwastobreakthenews.How

manytimeshadIdonethesame?Well,Ifigured,itcanstophere.

“Okay,”Isaid.“Wehavealottotalkabout.Ifyoudon’tmind,canyoutellme

whatyouunderstandishappening?It’salwayshelpfulformetohear,tomakesureI

don’tleaveanythingunanswered.”

“Well,IthoughtIwashavingastroke,butIguess…I’mnot?”

“That’sright.Youaren’thavingastroke.”Ipaused.Icouldseethevastnessof

thechasmbetweenthelifeshe’dhadlastweekandtheoneshewasabouttoenter.

She and her husband didn’t seem ready to hear brain cancer—is anyone?—so I

beganacouplestepsback.“TheMRIshowsamassinyourbrain,whichiscausing

yoursymptoms.”

Silence.

“DoyouwanttoseetheMRI?”

“Yes.”

Ibroughtuptheimagesonthebedsidecomputer,pointingouthernose,eyes,

and ears to orient her. Then I scrolled up to the tumor, a lumpy white ring

surroundingablacknecroticcore.

“What’sthat?”sheasked.

Couldbeanything.Maybeaninfection.Wewon’tknowtillaftersurgery.

Myinclinationtododgethequestionstillpersisted,tolettheirobviousworries

floatintheirheads,unpinned.

“Wecan’tbesureuntilaftersurgery,”Ibegan,“butitlooksverymuchlikea

braintumor.”

“Isitcancer?”

“Again, we won’t know for certain until it is removed and examined by our

pathologists,but,ifIhadtoguess,Iwouldsayyes.”

Basedonthescan,therewasnodoubtinmymindthatthiswasglioblastoma—

anaggressivebrain cancer, theworstkind. Yet Iproceededsoftly, takingmycues

fromMrs.Leeandherhusband.Havingintroducedthepossibilityofbraincancer,I

doubtedthey would recall much else. A tureen of tragedy was bestallotted by the

spoonful. Only a few patients demanded the whole at once; most needed time to

digest. They didn’t ask about prognosis—unlike in trauma, where you have only

about ten minutes to explain and make a major decision, here I could let things

settle. I discussed in detail what to expect over the next couple of days: what the

surgery entailed; how we’d shave only a small strip of her hair to keep it

cosmeticallyappealing;howherarmwouldlikelygetalittleweakerafterwardbut

thenstrongeragain;thatifallwentwell,she’dbeoutofthehospitalinthreedays;

thatthiswasjustthefirststepinamarathon;thatgettingrestwasimportant;andthat

Ididn’texpectthemtoretainanythingIhadjustsaidandwe’dgoovereverything

again.

After surgery, we talked again, this time discussing chemo, radiation, and

prognosis. By this point, I had learned a couple of basic rules. First, detailed

statistics are for research halls, not hospital rooms. The standard statistic, the

Kaplan-Meiercurve,measuresthenumberofpatientssurvivingovertime.Itisthe

metric by which we gauge progress, by which we understand the ferocity of a

disease. For glioblastoma, the curve drops sharply until only about 5 percent of

patientsarealiveattwoyears.Second,itisimportanttobeaccurate,butyoumust

alwaysleavesomeroomforhope.Ratherthansaying,“Mediansurvivaliseleven

months”or“Youhaveaninety-fivepercentchanceofbeingdeadintwoyears,”I’d

say,“Mostpatientslivemanymonthstoacoupleofyears.”Thiswas,tome,amore

honestdescription.Theproblemisthatyoucan’ttellanindividualpatientwhereshe

sits on the curve:Will she die in six months or sixty? I came to believe that it is

irresponsible to be more precise than you can be accurate. Those apocryphal

doctorswhogavespecificnumbers(“ThedoctortoldmeIhadsixmonthstolive”):

Whowerethey,Iwondered,andwhotaughtthemstatistics?

Patients, when hearing the news, mostly remain mute. (One of the early

meanings of patient, after all, is “one who endures hardship without complaint.”)

Whetheroutofdignityorshock,silenceusuallyreigns,andsoholdingapatient’s

handbecomesthemodeofcommunication.Afewimmediatelyharden(usuallythe

spouse,rather thanthepatient): “We’regonna fightand beat this thing,Doc.”The

armamentvaries,fromprayertowealthtoherbstostemcells.Tome,thathardness

alwaysseems brittle,unrealisticoptimismtheonlyalternativeto crushingdespair.

Inanycase,intheimmediacyofsurgery,awarlikeattitudefit.IntheOR,thedark

grayrottingtumorseemedaninvaderinthefleshypeachconvolutionsofthebrain,

and I felt real anger (Got you, you fucker, I muttered). Removing the tumor was

satisfying—even though I knew that microscopic cancer cells had already spread

throughout that healthy-looking brain. The nearly inevitable recurrence was a

problemforanotherday.Aspoonfulatatime.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.

Yetopennesstohumanrelationalityalsocarriedaprice.

Oneeveninginmythirdyear,IranintoJeff,myfriendingeneralsurgery,a

similarly intense and demanding profession. We each noted the other ’s

despondency.“Yougofirst,”hesaid.AndIdescribedthedeathofachild,shotinthe

headforwearingthewrongcolorshoes,buthehadbeensoclosetomakingit…

Amidarecentspateoffatal,inoperablebraintumors,myhopeshadbeenpinnedon

thiskidpullingthrough,andhehadn’t.Jeffpaused,andIawaitedhisstory.Instead,

helaughed,punchedmeinthearm,andsaid,“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.”

Driving home later that night, after gently explaining to a mother that her

newborn had been born without a brain and would die shortly, I switched on the

radio;NPRwasreportingonthecontinuingdroughtinCalifornia.Suddenly,tears

werestreamingdownmyface.

Being with 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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.

—

Midwaythroughresidency,timeissetasideforadditionaltraining.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otherfieldsaswell.Sometimesthis

isverypublic,asinthecaseoftheneurosurgeon-journalistSanjayGupta,butmost

oftenthedoctor’sfocusisonarelatedfield.Themostrigorousandprestigiouspath

isthatoftheneurosurgeon-neuroscientist.

In my fourth year, I began work in a Stanford lab dedicated to basic motor

neuroscienceandthedevelopmentofneuralprosthetictechnologythatwouldallow,

say,paralyzedpeopletomentallycontrolacomputercursororrobotarm.Thehead

ofthelab,aprofessorofelectricalengineeringandneurobiology,afellowsecond-

generation Indian, was affectionately called “V” by everyone. V was seven years

older than I, but we got on like brothers. His lab had become a world leader in

readingout brainsignals, but withhis blessingI embarked on aprojectto do the

reverse:towritesignalsintothebrain.Afterall,ifyourrobotarmcan’tfeelhow

hardit’sgraspingawineglass,youwillbreakalotofwineglasses.Theimplications

of writing signals into the brain, or “neuromodulation,” however, were far more

wide-reaching than that: being able to control neural firing would conceivably

allow treatment of a host of currently untreatable or intractable neurological and

psychiatric diseases, from major depression to Huntington’s to schizophrenia to

Tourette’stoOCD…thepossibilitieswerelimitless.Puttingsurgeryasidenow,Iset

toworklearningtoapplynewtechniquesingenetherapyinaseriesof“firstofits

kind”experiments.

After I’d been there for a year, V and I sat down for one of our weekly

meetings.Ihadgrowntolovethesechats.VwasnotlikeotherscientistsIknew.He

was soft-spoken and cared deeply about people and the clinical mission, and he

often confessed tome that he wished he’d been a surgeon himself. Science, I had

cometolearn,isaspolitical,competitive,andfierceacareerasyoucanfind,fullof

thetemptationtofindeasypaths.

One could counton Vto alwayschoosethe honest(and, often,self-effacing)

way forward. While most scientists connived to publish in the most prestigious

journalsandgettheirnamesoutthere,Vmaintainedthatouronlyobligationwasto

be authentic to the scientific story and to tell it uncompromisingly. I’d never met

someone so successful who was also so committed to goodness. V was an actual

paragon.

InsteadofsmilingasIsatdownacrossfromhim,helookedpained.Hesighed

andsaid,“Ineedyoutowearyourdoctorhatrightnow.”

“Okay.”

“TheytellmeIhavepancreaticcancer.”

“V…okay.Tellmethestory.”

Helaidouthisgradualweightloss,indigestion,andhisrecent“precautionary”

CTscan—atrulynonstandardprocedureatthispoint—whichshowedapancreatic

mass. We discussed the way forward, the dreaded Whipple operation in his near

future (“You are going to feel like a truck hit you,” I told him), who the best

surgeonswere,theimpacttheillnesswouldhaveonhiswifeandchildren,andhow

to run the lab during his prolonged absence. Pancreatic cancer has a dismal

prognosis,butofcoursetherewasnowaytoknowwhatthatmeantforV.

Hepaused.“Paul,”hesaid,“doyouthinkmylifehasmeaning?DidImakethe

rightchoices?”

It was stunning: even someone I considered a moral exemplar had these

questionsinthefaceofmortality.

V’ssurgery,chemotherapy,andradiationtreatmentsweretrying,butasuccess.

Hewasbackatworkayearlater,justasIwasreturningtomyclinicaldutiesinthe

hospital. His hair had thinned and whitened, and the spark in his eyes had dulled.

Duringourfinalweeklychat,heturnedtomeandsaid,“Youknow,todayisthefirst

dayitallseemsworthit.Imean,obviously,Iwould’vegonethroughanythingfor

mykids,buttodayisthefirstdaythatallthesufferingseemsworthit.”

Howlittledodoctorsunderstandthehellsthroughwhichweputpatients.

—

In my sixth year, I returned to the hospital full-time, my research in V’s lab now

relegatedtodaysoffandidlemoments,suchastheywere.Mostpeople,evenyour

closest colleagues, don’t quite understand the black hole that is neurosurgical

residency.Oneofmyfavoritenurses,afterstickingarounduntiltenP.M.onenightto

helpusfinish alonganddifficult case,saidtome,“Thank God Ihave tomorrow

off.Doyou,too?”

“Um,no.”

“Butatleastyoucancomeinlaterorsomething,right?Whendoyouusually

getin?”

“SixA.M.”

“No.Really?”

“Yep.”

“Everyday?”

“Everyday.”

“Weekends,too?”

“Don’task.”

In residency, there’s a saying: The days are long, but the years are short. In

neurosurgical residency, the day usually began at six A.M. and lasted until the

operatingwasdone,whichdepended,inpart,onhowquickyouwereintheOR.

Aresident’ssurgicalskillisjudgedbyhistechniqueandhisspeed.Youcan’tbe

sloppy, and you can’t be slow.From your firstwound closure onward, spend too

muchtimebeingpreciseandthescrubtechwillannounce,“Lookslikewe’vegota

plastic surgeon on our hands!” Or: “I get your strategy: by the time you finish

sewingthetophalfofthewound,thebottomwillhavehealedonitsown!Halfthe

work—verysmart!”Achiefresidentwilladviseajunior,“Learntobefastnow.You

canlearntobegoodlater.”IntheOR,everyone’seyesarealwaysontheclock.For

thepatient’ssake:Howlonghashebeenunderanesthesia?Duringlongprocedures,

nerves can get damaged,muscles can break down,kidneys can fail. For everyone

else’ssake:Whattimearewegettingoutofheretonight?

Icouldseethatthereweretwostrategiestocuttingthetimeshort,perhapsbest

exemplifiedbythetortoiseandthehare.Theharemovesasfastaspossible,handsa

blur,instrumentsclattering,fallingtothefloor;theskinslipsopenlikeacurtain,the

skullflapisonthetraybeforethebonedustsettles.Asaresult,theopeningmight

need to be expanded a centimeter here or there because it’s not optimally placed.

Thetortoise,ontheotherhand,proceedsdeliberately,withnowastedmovements,

measuringtwice,cuttingonce.Nostepoftheoperationneedsrevisiting;everything

movesinaprecise,orderlyfashion.Iftheharemakestoomanyminormisstepsand

has to keep adjusting, the tortoise wins. If the tortoise spends too much time

planningeachstep,theharewins.

ThefunnythingabouttimeintheOR,whetheryouracefreneticallyorproceed

steadily,isthatyouhavenosenseofitpassing.Ifboredomis,asHeideggerargued,

theawarenessoftimepassing,thensurgeryfeltliketheopposite:theintensefocus

made the arms of the clock seem arbitrarily placed. Two hours could feel like a

minute. Once the final stitch was placed and the wound was dressed, normal time

suddenly restarted. You could almost hear an audible whoosh. Then you started

wondering: How long until the patientwakes up? How long until the next case is

rolledin?AndwhattimewillIgethometonight?

Itwasn’tuntilthelastcasefinishedthatIfeltthelengthoftheday,thedragin

my step. Those last fewadministrative tasks before leavingthehospital were like

anvils.

Coulditwaituntiltomorrow?

No.

Asigh,andEarthcontinuedtorotatebacktowardthesun.

—

As a chief resident, nearly all responsibility fell on my shoulders, and the

opportunitiestosucceed—orfail—weregreaterthanever.Thepainoffailurehad

led me to understand that technical excellence was a moral requirement. Good

intentions were not enough, not when so much depended on my skills, when the

differencebetweentragedyandtriumphwasdefinedbyoneortwomillimeters.

One day, Matthew, the little boy with the brain tumor who had charmed the

wardafewyearsback,wasreadmitted.Hishypothalamushad,infact,beenslightly

damagedduringtheoperationtoremovehistumor;theadorableeight-year-oldwas

nowatwelve-year-oldmonster.Heneverstoppedeating;hethrewviolentfits.His

mother’s arms were scarred with purple scratches. Eventually Matthew was

institutionalized:hehadbecomeademon,summonedbyonemillimeterofdamage.

Foreverysurgery,afamilyandasurgeondecidetogetherthatthebenefitsoutweigh

the risks, but this was still heartbreaking. No one wanted to think about what

Matthewwouldbelikeasathree-hundred-poundtwenty-year-old.

Anotherday,Iplacedanelectrodeninecentimetersdeepinapatient’sbrainto

treataParkinson’stremor.Thetargetwasthesubthalamicnucleus,atinyalmond-

shapedstructuredeepinthebrain.Differentpartsofitsubservedifferentfunctions:

movement,cognition,emotion.Intheoperatingroom,weturnedonthecurrentto

assessthetremor.Withalloureyesonthepatient’slefthand,weagreedthetremor

lookedbetter.

Then the patient’s voice, confused, rose above our affirmative murmurs: “I

feel…overwhelminglysad.”

“Currentoff!”Isaid.

“Oh,nowthefeelingisgoingaway,”thepatientsaid.

“Let’srecheckthecurrentandimpedance,okay?Okay.Currenton…”

“No,everything…itjustfeels…sosad.Justdarkand,and…sad.”

“Electrodeout!”

Wepulled theelectrodeoutand reinserted it,this timetwo millimeterstothe

right.Thetremorwentaway.Thepatientfelt,thankfully,fine.

Once,Iwasdoingalate-nightcasewithoneoftheneurosurgeryattendings,a

suboccipital craniectomy for a brain-stem malformation. It’s one of the most

elegantsurgeries,inperhapsthemostdifficultpartofthebody—justgettingthereis

tricky,nomatterhowexperiencedyouare.Butthatnight,Ifeltfluid:theinstruments

were like extensions of my fingers; the skin, muscle, and bone seemed to unzip

themselves;andthereIwas,staringatayellow,glisteningbulge,amassdeepinthe

brainstem.Suddenly,theattendingstoppedme.

“Paul,whathappensifyoucuttwomillimetersdeeperrighthere?”Hepointed.

Neuroanatomyslideswhirredthroughmyhead.

“Doublevision?”

“No,”hesaid.“Locked-insyndrome.”Anothertwomillimeters,andthepatient

wouldbecompletelyparalyzed,savefortheabilitytoblink.Hedidn’tlookupfrom

themicroscope.“AndIknowthisbecausethethirdtimeIdidthisoperation,that’s

exactlywhathappened.”

Neurosurgery requires a commitment to one’s own excellence and a

commitment to another ’s identity. The decision to operate at all involves an

appraisal of one’sown abilities, as well as adeep sense ofwho the patient is and

what she holds dear. 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.

Usuallylocatedontheleftside,theyarecalledWernicke’sandBroca’sareas;oneis

forunderstandinglanguageandtheotherforproducingit.DamagetoBroca’sarea

results in an inability to speak or write, though the patient can easily understand

language.DamagetoWernicke’sarearesultsinaninabilitytounderstandlanguage;

though the patient can still speak, the language she produces is a stream of

unconnected words, phrases, and images, a grammar without semantics. If both

areas are damaged, the patient becomes an isolate, something central to her

humanity stolen forever. After someone suffers a head trauma or a stroke, the

destructionoftheseareasoftenrestrainsthesurgeon’simpulsetosavealife:What

kindoflifeexistswithoutlanguage?

WhenIwasamedstudent,thefirstpatientImetwiththissortofproblemwasa

sixty-two-year-oldmanwithabraintumor.Westrolledintohisroomonmorning

rounds,andtheresidentaskedhim,“Mr.Michaels,howareyoufeelingtoday?”

“Foursixoneeightnineteen!”hereplied,somewhataffably.

The tumor had interrupted his speech circuitry, so he could speak only in

streams of numbers, but he still had prosody, he could still emote: smile, scowl,

sigh. He recited another series of numbers, this time with urgency. There was

somethinghewantedtotellus,butthedigitscouldcommunicatenothingotherthan

hisfearandfury.Theteampreparedtoleavetheroom;forsomereason,Ilingered.

“Fourteenonetwoeight,”hepleadedwithme,holdingmyhand.“Fourteenone

twoeight.”

“I’msorry.”

“Fourteenonetwoeight,”hesaidmournfully,staringintomyeyes.

AndthenIlefttocatchuptotheteam.Hediedafewmonthslater,buriedwith

whatevermessagehehadfortheworld.

When tumors or malformations abut these language areas, the surgeon takes

numerous precautions, ordering a host of different scans, a detailed

neuropsychologicalexamination.Critically,however,thesurgeryisperformedwith

the patient awake and talking. Once the brain is exposed, but before the tumor

excision,thesurgeonusesahand-heldball-tipelectrodetodeliverelectricalcurrent

tostuna smallarea of the cortexwhile thepatientperforms various verbal tasks:

namingobjects,recitingthealphabet,andsoon.Whentheelectrodesendscurrent

intoacriticalpieceofcortex,itdisruptsthepatient’sspeech:“ABCDEguhguh

guhrrrr…FGHI…”Thebrainandthetumorarethusmappedtodeterminewhat

can be resected safely, and the patient is kept awake throughout, occupied with a

combinationofformalverbaltasksandsmalltalk.

Oneevening,asIwaspreppingforoneofthesecases,Ireviewedthepatient’s

MRI andnoted thatthe tumor completely coveredthelanguage areas.Notagood

sign.Reviewingthenotes,Isawthatthehospital’stumorboard—anexpertpanelof

surgeons, oncologists, radiologists, and pathologists—had deemed the case too

dangerousforsurgery.Howcould thesurgeonhaveoptedtoproceed?I became a

littleindignant:atacertainpoint,itwasourjobtosayno.Thepatientwaswheeled

intotheroom.Hefixedhiseyesonmeandpointedtohishead.“Iwantthisthingout

ofmyfuckingbrain.Gotit?”

Theattendingstrolledinandsawtheexpressiononmyface.“Iknow,”hesaid.

“Itriedtalkinghimoutofthisforabouttwohours.Don’tbother.Readytogo?”

Instead of the usual alphabet recital or counting exercise, we were treated,

throughoutthesurgery,toalitanyofprofanityandexhortation.

“Is that fucking thing out of my head yet? Why are you slowing down? Go

faster!Iwantitout.Icanstayhereallfuckingday,Idon’tcare,justgetitout!”

Islowlyremovedtheenormoustumor,attentivetotheslightesthintofspeech

difficulty. With the patient’s monologue unceasing, the tumor now sat on a petri

dish,hiscleanbraingleaming.

“Why’dyoustop?Yousomekindaasshole?ItoldyouIwantthefuckingthing

gone!”

“It’sdone,”Isaid.“It’sout.”

Howwashestilltalking?Giventhesizeandlocationofthetumor,itseemed

impossible.Profanitysupposedlyranonaslightlydifferentcircuitfromtherestof

language.Perhapsthetumorhadcausedhisbraintorewiresomehow…

Buttheskullwasn’tgoingtocloseitself.Therewouldbetimeforspeculation

tomorrow.

—

I had reached the pinnacle of residency. I had mastered the core operations. My

researchhadgarneredthehighestawards.Jobinterestwastricklinginfromallover

the country.Stanford launcheda searchforapositionthatfitmyinterestsexactly,

foraneurosurgeon-neuroscientistfocusedontechniquesofneuralmodulation.One

of myjunior residents came up to me and said, “I justheard from the bosses—if

theyhireyou,you’regoingtobemyfacultymentor!”

“Shhhh,”Isaid.“Don’tjinxit.”

It felt to me as if the individual strands of biology, morality, life, and death

were finally beginning to weave themselves into, if not a perfectmoral system, a

coherentworldviewandasenseofmyplaceinit.Doctorsinhighlychargedfields

met patients at inflected moments, the most authentic moments, where life and

identity were under threat; their duty included learning what made that particular

patient’slifeworthliving,andplanningtosavethosethingsifpossible—ortoallow

thepeaceofdeathifnot.Suchpowerrequireddeepresponsibility,sharinginguilt

andrecrimination.

I was at a conference in San Diego when my phone rang. My co-resident,

Victoria.

“Paul?”

Somethingwaswrong.Mystomachtightened.

“What’sup?”Isaid.

Silence.

“Vic?”

“It’sJeff.Hekilledhimself.”

“What?”

JeffwasfinishinghissurgicalfellowshipintheMidwest,andwewerebothso

punishingly busy…we’d lost touch. I tried to recall our last conversation and

couldn’t.

“He,uh—heapparentlyhadadifficultcomplication,andhispatientdied.Last

nighthe climbed onto the roof of a building and jumped off. I don’treally know

anythingelse.”

I searched for a question to bring understanding. None was forthcoming. I

couldonlyimaginetheoverwhelmingguilt,likeatidalwave,thathadliftedhimup

andoffthatbuilding.

Iwished,desperately,thatIcould’vebeenwalkingwithhimoutthedoorofthe

hospitalthatevening.Iwishedwecould’vecommiseratedasweusedto.IwishedI

couldhavetoldJeffwhatIhadcometounderstandaboutlife,andourchosenway

oflife,ifonlytohearhiswise,clevercounsel.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a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.

PARTII

CeaseNottillDeath

IfIwereawriterofbooks,Iwouldcompilearegister,withacomment,ofthevariousdeathsofmen:he

whoshouldteachmentodiewouldatthesametimeteachthemtolive.

—MicheldeMontaigne,“ThattoStudyPhilosophyIstoLearntoDie”

LYINGNEXTTOLUCYinthehospitalbed,bothofuscrying,theCTscanimagesstill

glowing on the computer screen, that identity as a physician—my identity—no

longer mattered. With the cancer having invaded multiple organ systems, the

diagnosiswasclear.Theroomwasquiet.Lucytoldmeshelovedme.“Idon’twant

todie,” Isaid. Itold her toremarry, that I couldn’t bear the thought of her being

alone.Itoldherweshouldrefinancethemortgageimmediately.Westartedcalling

familymembers.Atsomepoint,Victoriacamebytheroom,andwediscussedthe

scanandthelikelyfuturetreatments.Whenshebroughtupthelogisticsofreturning

toresidency,Istoppedher.

“Victoria,” Isaid,“I’mnevercoming back to this hospitalasa doctor.Don’t

youthink?”

One chapter of my life seemed to have ended; perhaps the whole book was

closing.Insteadofbeingthepastoralfigureaidingalifetransition,Ifoundmyself

the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-

shattering.Itfeltlesslikeanepiphany—apiercingburstoflight,illuminatingWhat

ReallyMatters—andmorelikesomeonehadjustfirebombedthepathforward.Now

Iwouldhavetoworkaroundit.

MybrotherJeevanhadarrivedatmybedside.“You’veaccomplishedsomuch,”

hesaid.“Youknowthat,don’tyou?”

Isighed.Hemeantwell,butthewordsranghollow.Mylifehadbeenbuilding

potential,potentialthatwouldnowgounrealized.Ihadplannedtodosomuch,andI

had come so close. I was physically debilitated, my imagined future and my

personalidentitycollapsed,andIfacedthesameexistentialquandariesmypatients

faced. The lung cancer diagnosis was confirmed. My carefully planned and hard-

wonfuturenolongerexisted.Death,sofamiliartomeinmywork,wasnowpaying

apersonalvisit.Herewewere,finallyface-to-face,andyetnothingaboutitseemed

recognizable.StandingatthecrossroadswhereIshouldhavebeenabletoseeand

follow the footprints of the countless patients I had treated over the years, I saw

insteadonlyablank,aharsh,vacant,gleamingwhitedesert,asifasandstormhad

erasedalltraceoffamiliarity.

The sun was setting. I would be discharged the next morning. An oncology

appointmentwassetforlaterintheweek,butthenursetoldmemyoncologistwas

goingtodropbythatnight,beforeleavingtopickupherkids.HernamewasEmma

Hayward,andshewantedtosayhellobeforetheinitialofficevisit.IknewEmmaa

little—Ihadtreatedsomeofherpatientsbefore—butwehadneverspokenbeyond

passing professional courtesies. My parents and brothers were scattered about the

room, not saying much, while Lucy sat by the bed, holding my hand. The door

openedandin shewalked,herwhitecoat showingthe wearofa longdaybuther

smilefresh.Trailingbehindherwereherfellowandaresident.Emmawasonlya

fewyearsolderthanI,herhairlonganddark,butasiscommontoallthosewho

spendtimewithdeath,streakedwithgray.Shepulledupachair.

“Hi,mynameisEmma,”shesaid.“I’msorrytohavetobesobrieftoday,butI

wantedtocomebyandintroducemyself.”

Weshookhands,myarmentangledintheIVline.

“Thanksforstoppingby,”Isaid.“Iknowyouhavekidstopickup.Thisismy

family.”ShenoddedhelloatLucy,atmybrothersandparents.

“I’msorrythisishappeningtoyou,”shesaid.“Toallofyou.Therewillbea

lotoftimetotalkinacoupledays.Iwentaheadandhadthelabstartrunningsome

tests on your tumor sample, which will help guide therapy. Treatment may be

chemotherapyornot,dependingonthetests.”

Eighteen months earlier, I’d been in the hospital with appendicitis. Then I’d

beentreatednotasapatientbutasacolleague,almostlikeaconsultantonmyown

case.Iexpectedthesamehere.“Iknownow’snotthetime,”Iproceeded,“butIwill

wanttotalkabouttheKaplan-Meiersurvivalcurves.”

“No,”shesaid.“Absolutelynot.”

Abriefsilence.Howdareshe?Ithought.Thisishowdoctors—doctorslikeme

—understandprognostication.Ihavearighttoknow.

“We can talk about therapies later,” she said. “We can talk about your going

back to work, too, if that’s what you’d like to do. The traditional chemotherapy

combination—cisplatin,pemetrexed,possiblywithAvastin,too—hasahighrateof

peripheralneuropathy,sowe’dprobablyswitchthecisplatinforcarboplatin,which

willprotectyournervesbetter,sinceyou’reasurgeon.”

Gobacktowork?Whatisshetalkingabout?Isshedelusional?OramIdead

wrongaboutmyprognosis?Andhowcanwetalkaboutanyofthiswithoutarealistic

estimateofsurvival?Theground,havingalreadybuckledandroiledoverthepast

fewdays,didsoagain.

“We can do details later,” she continued, “as I know this is a lot to absorb.

Mostly, I just wanted to meet you all before our appointment Thursday. Is there

anythingIcando,oranswer—besidessurvivalcurves—today?”

“No,” I said, my mind reeling. “Thanks so much for stopping by. I really

appreciateit.”

“Here’smycard,”shesaid,“andthere’stheclinicnumber.Feelfreetocallif

anythingcomesupbeforeweseeyouintwodays.”

My family and friends quickly wired through our network of medical

colleagues to find out who the best lung cancer oncologists in the country were.

Houston and New York had major cancer centers; was that where I should be

treated?Thelogisticsofmovingortemporarilyrelocatingorwhathaveyou—that

could be sorted out later. The replies came back quickly, and more or less

unanimously: Emma not only was one of the best—a world-renowned oncologist

whoservedasthelungcancerexpertononeofthemajornationalcanceradvisory

boards—butshewasalsoknowntobecompassionate,someonewhoknewwhento

pushandwhentoholdback.Ibrieflywonderedatthestringofeventsthathadsent

meloopingthroughtheworld,myresidencydeterminedbyacomputerizedmatch

process,onlytoendupassignedhere,withafreakdiagnosis,inthehandsofoneof

thefinestdoctorstotreatit.

Having spent the better part of the week bedridden, with the cancer

progressing,Ihadgrownnoticeablyweaker.Mybody,andtheidentitytiedtoit,had

radicallychanged.Nolongerwasgettinginandoutofbedtogotothebathrooman

automated subcortical motor program; it took effort and planning. The physical

therapistslefta listof items toease mytransitionhome: acane, amodifiedtoilet

seat,foamblocksforlegsupportwhileresting.Abevyofnewpainmedicationswas

prescribed.AsIhobbledoutofthehospital,Iwonderedhow,justsixdaysago,Ihad

spentnearlythirty-sixstraighthoursintheoperatingroom.HadIgrownthatmuch

sickerinaweek?Yes,inpart.ButIhadalsousedanumberoftricksandhelpfrom

co-surgeons to get through those thirty-six hours—and, even so, I had suffered

excruciating pain. Had the confirmation of my fears—in the CT scan, in the lab

results,bothshowingnotmerelycancerbutabodyoverwhelmed,nearingdeath—

releasedmefromthedutytoserve,frommydutytopatients,toneurosurgery,tothe

pursuit of goodness? Yes, I thought, and therein was the paradox: like a runner

crossingthefinishlineonlytocollapse,withoutthatdutytocarefortheillpushing

meforward,Ibecameaninvalid.

UsuallywhenIhadapatientwithastrangecondition,Iconsultedtherelevant

specialistandspenttimereadingaboutit.Thisseemednodifferent,butasIstarted

readingaboutchemo,whichincludedawholevarietyofagents,andaraftofmore

modern novel treatments that targeted specific mutations, the sheer number of

questions I had prevented any useful directed study. (Alexander Pope: “A little

learning is a dangerous thing; / Drink deep, or taste not the Pierian spring.”)

Withoutappropriatemedicalexperience,Icouldn’tplacemyselfinthisnewworld

of information, couldn’t find my spot on the Kaplan-Meier curve. I waited,

expectantly,formyclinicvisit.

Butmostly,Irested.

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.MyfriendLauriehadhadafiancéwhenshe’ddiedin

acaraccident—wasthisanycrueler?

Myfamilyengagedinaflurryofactivitytotransformmylifefromthatofa

doctor to that of a patient. We set up an account with a mail-order pharmacy,

orderedabedrail,andboughtanergonomicmattresstohelpalleviatethesearing

backpain.Ourfinancialplan,whichafewdaysbeforehadbankedonmyincome

increasing sixfold in the next year, now looked precarious, and a variety of new

financial instruments seemed necessary to protect Lucy. My father declared that

thesemodificationswerecapitulationstothedisease:Iwasgoingtobeatthisthing,I

wouldsomehowbecured.HowoftenhadIheardapatient’sfamilymembermake

similardeclarations?Ineverknewwhattosaytothemthen,andIdidn’tknowwhat

tosaytomyfathernow.

Whatwasthealternatestory?

—

Two days later, Lucy and I met Emma in the clinic. My parents hovered in the

waiting room. The medical assistant took my vitals. Emma and her nurse

practitionerwereremarkablypunctual,andEmmapulledupachairinfrontofme,

totalkface-to-face,eye-to-eye.

“Helloagain,”shesaid.“ThisisAlexis,myrighthand.”ShegesturedtotheNP,

whosatatthecomputertakingnotes.“Iknowthere’salottodiscuss,butfirst:How

areyoudoing?”

“Okay, all things considered,” I said. “Enjoying my ‘vacation,’ I guess. How

areyou?”

“Oh,I’mokay.”Shepaused—patientsdon’ttypicallyaskhowtheirdoctorsare

doing,butEmmawasalsoacolleague.“I’mrunningtheinpatientservicethisweek,

soyouknowhowthat is.”Shesmiled.LucyandIdid know.Outpatientspecialists

rotated on the inpatient service periodically, adding several hours of work in an

alreadyjam-packedday.

Aftermorepleasantries,wesettledintoacomfortablediscussiononthestateof

lung cancer research. There were two paths forward, she said. The traditional

method was chemotherapy, which generically targeted rapidly dividing cells—

primarilycancercellsbutalsocellsinyourbonemarrow,hairfollicles,intestines,

andsoforth.Emmareviewedthedataandoptions,lecturingasiftoanotherdoctor

—but again with the exception of any mention of Kaplan-Meier survival curves.

Newertherapieshadbeendeveloped,however,targetingspecificmoleculardefects

in the cancer itself. I had heard rumors of such efforts—it had long been a holy

grail in cancer work—and was surprised to learn how much progress had been

made.Thesetreatments,itseemed,hadledtolong-termsurvivalin“some”patients.

“Mostofyourtestsareback,”Emmasaid.“YouhaveaPI3Kmutation,butno

one’ssurewhatthatmeansyet.Thetestforthemostcommonmutationinpatients

likeyou,EGFR,isstillpending.I’mbettingthat’swhatyouhave,andifso,there’sa

pillcalledTarcevathatyoucantakeinsteadofchemotherapy.Thatresultshouldbe

back tomorrow, Friday, but you’re sick enough that I’ve set you up for chemo

startingMondayincasetheEGFRtestisnegative.”

Iimmediatelyfeltakinship.ThiswasexactlyhowIapproachedneurosurgery:

haveaplanA,B,andCatalltimes.

“Withchemo,ourmaindecisionwillbecarboplatinversuscisplatin.Inisolated

studies,head-to-head,carboplatinisbettertolerated.Cisplatinhaspotentiallybetter

resultsbutmuchworsetoxicity,especiallyforthenerves,thoughallthedataisold,

andthere’snodirectcomparisonwithinourmodernchemoregimens.Doyouhave

anythoughts?”

“I’mlessworriedaboutprotectingmyhandsforsurgery,”Isaid.“There’salot

I can do withmy life. If I lose my hands, I can find another job, or notwork, or

something.”

Shepaused.“Letmeaskthis:Issurgeryimportanttoyou?Isitsomethingyou

wanttodo?”

“Well,yes,I’vespentalmostathirdofmylifepreparingforit.”

“Okay,thenI’mgoingtosuggestwestickwiththecarboplatin.Idon’tthinkit

willchangesurvival,andIdothinkitcoulddramaticallychangeyourqualityoflife.

Doyouhaveanyotherquestions?”

Sheseemedclearthatthiswasthewaytogo,andIwashappytofollow.Maybe,

I began to let myself believe, performing surgery again was a possibility. I felt

myselfrelaxalittle.

“CanIstartsmoking?”Ijoked.

Lucylaughed,andEmmarolledhereyes.

“No.Anyseriousquestions?”

“TheKaplan-Meier—”

“We’renotdiscussingthat,”shesaid.

Ididn’tunderstandherresistance.Afterall,Iwasadoctorfamiliarwiththese

statistics.Icouldlookthemupmyself…sothat’swhatIwouldhavetodo.

“Okay,” I said, “then I think everything is pretty clear. We’ll hear from you

tomorrowabouttheEGFRresults.Ifyes,thenwe’llstartapill,Tarceva.Ifno,then

westartchemotherapyMonday.”

“Right.TheotherthingIwantyoutoknowisthis:Iamyourdoctornow.Any

problemyouhave,fromprimarycaretowhatever,youcometousfirst.”

Again,Ifeltapangofkinship.

“Thanks,”Isaid.“Andgoodluckontheinpatientwards.”

Shelefttheroom,onlytopopherheadbackinasecondlater.“Feelfreetosay

notothis,buttherearesomelungcancerfundraiserswhowouldlovetomeetyou.

Don’tanswernow—thinkaboutit,andletAlexisknowifyoumightbeinterested.

Don’tdoanythingyoudon’twantto.”

Asweleft,Lucyremarked,“She’sgreat.She’sagoodfitforyou.Although…”

Shesmiled.“Ithinkshelikesyou.”

“And?”

“Well,there’sthatstudy thatsaysdoctorsdoa worsejobprognosticatingfor

patientsthey’repersonallyinvestedin.”

“Onourlistofthingstoworryabout,”Isaid,withalaugh,“Ithinkthat’sinthe

bottomquartile.”

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.

—

Slowlythemedicalfogwasclearing—atleastnowIhadenoughinformationtodive

intotheliterature.Whilethenumberswerefuzzy,havinganEGFRmutationseemed

toaddaroundayearoflifeonaverage,withthepotentialforlong-termsurvival;

nothavingitsuggestedan80percentchanceofdeathwithintwoyears.Clarifying

therestofmylifewasgoingtobeaprocess.

The next day, Lucy and I went to the sperm bank, to preserve gametes and

options.Wehadalwaysplannedtohavekidsattheendofmyresidency,butnow…

Thecancerdrugswouldhaveanunknowneffectonmysperm,sotokeepachance

ofhavingchildren,we’dhavetofreezespermbeforeIstartedtreatment.Ayoung

womanwalkedusthroughavarietyofpaymentplansandoptionsforstorageand

legal forms for ownership. On her desk were a multitude of colorful pamphlets

about various social outings for young people with cancer: improv groups, a

cappellagroups,open-mikenights,andsoon.Ienviedtheirhappyfaces,knowing

that, statistically, they all probably had highly treatable forms of cancer, and

reasonable life expectancies. Only 0.0012 percent of thirty-six-year-olds get lung

cancer. Yes, all cancer patients are unlucky, but there’s cancer, and then there’s

CANCER,andyouhavetobereallyunluckytohavethelatter.Whensheaskedusto

specify what would happen to the sperm if one of us “were to die”—who would

legallyownthemintheeventofdeath—tearsbeganrollingdownLucy’sface.

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.

Duringmyresidency,Ihadsatwithcountlesspatientsandfamiliestodiscuss

grim prognoses; it’soneof themost importantjobsyouhave,asa physician. It’s

easierwhenthepatientisninety-four, inthe laststagesofdementia,withasevere

brain bleed. But for someone like me—a thirty-six-year-old given a diagnosis of

terminalcancer—therearen’treallywords.

The reason doctors don’t give patients specific prognoses is not merely

becausetheycannot.Certainly,ifapatient’sexpectationsarewayoutofthebounds

of probability—someone expecting to live to 130, say, or someone thinking his

benignskinspotsaresignsofimminentdeath—doctorsareentrustedtobringthat

person’sexpectationsintotherealmofreasonablepossibility.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.

Whenwearrivedhomefromthespermbank,IgotaphonecallsayingthatI

did, in fact, have a treatable mutation (EGFR). Chemo was off, thankfully, and

Tarceva,alittlewhitepill,becamemytreatment.Isoonbegantofeelstronger.And

eventhoughInolongerreallyknewwhatitwas,Ifeltit:adropofhope.Thefog

surrounding my life rolled back another inch, and a sliver of blue sky peeked

through.Intheweeksthatfollowed,myappetitereturned.Iputonalittleweight.I

developedthecharacteristicsevereacnethatcorrelateswithagoodresponse.Lucy

hadalwayslovedmysmoothskin,butnowitwaspockmarkedand,withmyblood

thinners, constantly bleeding. Anypartof me thatidentified withbeing handsome

was slowly beingerased—though,in fairness, I was happyto be uglier and alive.

Lucysaidshelovedmyskinjustthesame,acneandall,butwhileIknewthatour

identitiesderivenotjustfromthebrain,Iwaslivingitsembodiednature.Theman

wholovedhiking,camping,andrunning,whoexpressedhislovethroughgigantic

hugs,whothrewhisgigglingniecehighintheair—thatwasamanInolongerwas.

Atbest,Icouldaimtobehimagain.

At our first of several biweekly appointments, Emma’s and my discussion

tendedfromthemedical(“How’stherash?”)tothemoreexistential.Thetraditional

cancernarrative—thatoneoughttorecede,spendtimewithfamily,andsettleone’s

toesinthepeat—wasoneoption.

“Manypeople,oncediagnosed,quitworkentirely,”shesaid.“Othersfocuson

itheavily.Eitherwayisokay.”

“Ihadmappedoutthiswholeforty-yearcareerformyself—thefirsttwentyas

asurgeon-scientist,thelasttwentyasawriter.ButnowthatIamlikelywellintomy

lasttwentyyears,Idon’tknowwhichcareerIshouldbepursuing.”

“Well,Ican’ttellyouthat,”shesaid.“Icanonlysaythatyoucangetbackto

surgeryifyouwant,butyouhavetofigureoutwhat’smostimportanttoyou.”

“IfIhadsomesenseofhowmuchtimeIhaveleft,it’dbeeasier.IfIhadtwo

years,I’dwrite.IfIhadten,I’dgetbacktosurgeryandscience.”

“YouknowIcan’tgiveyouanumber.”

Yes, I knew. It was up to me, to quote her oft-repeated refrain, to find my

values. Part of me felt this was a cop-out: okay, fine, I never gave out specific

numberstopatients,either,butdidn’tIalwayshaveasenseofhowthepatientwould

do? HowelsedidImakelife-and-death decisions?ThenIrecalledthetimesIhad

beenwrong:thetimeIhadcounseledafamilytowithdrawlifesupportfortheirson,

onlyfortheparentstoappeartwoyearslater,showingmeaYouTubevideoofhim

playingpiano,anddeliveringcupcakesinthanksforsavinghislife.

My oncology appointments were the most important of many new

appointmentswithavarietyofhealthcareproviders,buttheyweren’ttheonlyones.

AtLucy’sinsistence,webeganseeingacouplestherapistwhospecializedincancer

patients. Sitting in her windowless office, in side-by-side armchairs, Lucy and I

detailedthewaysinwhichourlives,presentandfuture,hadbeenfracturedbymy

diagnosis, and the pain of knowing and not knowing the future, the difficulty in

planning,thenecessityofbeingthereforeachother.Intruth,cancerhadhelpedsave

ourmarriage.

“Well, you two are coping with this better than any couple I’ve seen,” the

therapist said at the end of our first session. “I’m not sure I have any advice for

you.”

Ilaughedaswewalkedout—atleast Iwasexcellingat somethingagain.The

yearsofministeringtoterminallyillpatientshadbornesomefruit!IturnedtoLucy,

expectingtoseeasmile;instead,shewasshakingherhead.

“Don’tyougetit?”shesaid,takingmyhandinhers.“Ifwe’rethebestatthis,

thatmeansitdoesn’tgetbetterthanthis.”

If the weight of mortality does not grow lighter, does it at least get more

familiar?

OnceIhadbeendiagnosedwith aterminalillness, Ibegantoview theworld

throughtwoperspectives;Iwasstartingtoseedeathasbothdoctorandpatient.Asa

doctor, I knewnot to declare “Cancer is abattle I’m goingto win!” or ask “Why

me?”(Answer:Whynotme?)Iknewalotaboutmedicalcare,complications,and

treatmentalgorithms.Iquicklylearnedfrommyoncologistandmyownstudythat

stageIVlungcancertodaywasadiseasewhosestorymightbechanging,likeAIDS

inthelate1980s:stillarapidlyfatalillnessbutwithemergingtherapiesthatwere,

forthefirsttime,providingyearsoflife.

Whilebeingtrainedasaphysicianandscientisthadhelpedmeprocessthedata

and accept the limits of what that data could reveal about my prognosis, it didn’t

helpmeasapatient.Itdidn’ttellLucyandmewhetherweshouldgoaheadandhave

achild,orwhatitmeanttonurtureanewlifewhileminefaded.Nordidittellme

whether to fight for my career, to reclaim the ambitions I had single-mindedly

pursuedforsolong,butwithoutthesuretyofthetimetocompletethem.

Like my own patients, I had to face my mortality and try to understandwhat

mademylifeworthliving—andIneededEmma’shelptodoso.Tornbetweenbeing

a doctor and being a patient, delving into medical science and turning back to

literature for answers, I struggled, while facing my owndeath, to rebuild my old

life—orperhapsfindanewone.

—

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eleven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thirty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sixwobblymiles.Itwasafar

cryfromthebreezy,thirty-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. 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 fourteenth-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,

afterall,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.

BecauseofthemedicationsIwason,assistedreproductionappearedtobethe

onlyrouteforward.Sowevisitedaspecialistatareproductiveendocrinologyclinic

inPaloAlto.Shewasefficientandprofessional,butherlackofexperiencedealing

with terminally ill, as opposed to infertile, patients was obvious. She plowed

throughherspiel,eyesonherclipboard:

“Howlonghaveyoubeentrying?”

“Well,wehaven’tyet.”

“Oh,right.Ofcourse.”

Finally she asked, “Given your, uh, situation, I assume you want to get

pregnantfast?”

“Yes,”Lucysaid.“We’dliketostartrightaway.”

“I’dsuggestyoubeginwithIVF,then,”shesaid.

WhenImentionedthatwe’dratherminimizehowmanyembryoswerecreated

and destroyed, she looked slightly confused. Most people who came here prized

expedienceaboveall.ButIwasdeterminedtoavoidthesituationwhere,afterIdied,

Lucyhadresponsibilityforahalfdozenembryos—thelastremnantsofourshared

genomes,mylastpresenceonthisearth—stuckinafreezersomewhere,toopainful

todestroy,impossibletobringtofullhumanity:technologicalartifactsthatnoone

knewhow to relate to. But after several trials of intrauterine insemination, it was

clearweneededahigherleveloftechnology:wewouldneedtocreateatleastafew

embryosinvitro andimplantthehealthiest.Theotherswould die. Even in having

childreninthisnewlife,deathplayeditspart.

—

Six weeks after starting treatment, I was due for my firstCT scan to measure the

efficacyoftheTarceva.AsIhoppedoutofthescanner,theCTtechlookedatme.

“Well,Doc,”heoffered,“I’mnotsupposedtosaythis,butthere’sacomputerback

thereifyouwanttotakealook.”Iloadeduptheimagesontheviewer,typinginmy

ownname.

Theacnewasareassuringsign.Mystrengthhadalsoimproved,thoughIwas

stilllimitedbybackpainandfatigue.Sittingthere,IremindedmyselfofwhatEmma

hadsaid:evenasmallamountoftumorgrowth,solongasitwassmall,wouldbe

consideredasuccess.(Myfather,ofcourse,hadpredictedthatallthecancerwould

be gone. “Your scan will be clear, Pubby!” he’d declared, using my family

nickname.) I repeated to myself that even small growth was good news, took a

breath,andclicked.Theimagesmaterializedonthescreen.Mylungs,speckledwith

innumerable tumors before, were clear except for a one-centimeter nodule in the

rightupper lobe. I could make out my spine beginning to heal. There had been a

clear,dramaticreductionintumorburden.

Reliefwashedoverme.

Mycancerwasstable.

When we met Emma the next day she still refused to talk prognosis, but she

said, “You’re well enough that we can meet every six weeks now. Next time we

meet,wecanstarttotalkaboutwhatyourlifemightbelike.”Icouldfeelthechaos

ofthepastmonthsreceding,asenseofanewordersettlingin.Mycontractedsense

ofthefuturebegantorelax.

A local meeting of former Stanford neurosurgery graduates was happening

thatweekend,andIlookedforwardtothechancetoreconnectwithmyformerself.

Yet being there merely heightenedthe surrealcontrast ofwhatmylife wasnow.I

was surrounded by success and possibility and ambition, by peers and seniors

whoseliveswererunningalongatrajectorythatwasnolongermine,whosebodies

couldstilltoleratestandingforagruelingeight-hoursurgery.Ifelttrappedinsidea

reversed Christmas carol: Victoria was opening the happy present—grants, job

offers, publications—I should be sharing. My senior peers were living the future

thatwasnolongermine:earlycareerawards,promotions,newhouses.

No one asked about my plans, which was a relief, since I had none. While I

could now walk without a cane, a paralytic uncertainty loomed: Who would I be,

going forward, and for how long? Invalid, scientist, teacher? Bioethicist?

Neurosurgeononceagain,asEmmahadimplied?Stay-at-homedad?Writer?Who

could,orshould,Ibe?Asadoctor,Ihadhadsomesenseofwhatpatientswithlife-

changingillnessesfaced—anditwasexactlythesemomentsIhadwantedtoexplore

withthem.Shouldn’tterminalillness,then,betheperfectgifttothatyoungmanwho

hadwantedtounderstanddeath?Whatbetterwaytounderstanditthantoliveit?But

I’dhadnoideahowharditwouldbe,howmuch terrainIwouldhave to explore,

map,settle.I’dalwaysimaginedthedoctor’sworkassomethinglikeconnectingtwo

piecesofrailroadtrack,allowingasmoothjourneyforthepatient.Ihadn’texpected

the prospect of facing my own mortality to be so disorienting, so dislocating. I

thoughtbacktomyyoungerself,whomight’vewantedto“forgeinthesmithyof

mysoultheuncreatedconscienceofmyrace”;lookingintomyownsoul,Ifound

thetoolstoobrittle,thefiretooweak,toforgeevenmyownconscience.

Lostinafeaturelesswastelandofmyownmortality,andfindingnotractionin

thereamsofscientificstudies,intracellularmolecularpathways,andendlesscurves

ofsurvivalstatistics,Ibeganreadingliteratureagain:Solzhenitsyn’sCancerWard,

B.S.Johnson’sTheUnfortunates,Tolstoy’sIvanIlyich,Nagel’sMindandCosmos,

Woolf,Kafka,Montaigne,Frost,Greville,memoirsofcancerpatients—anythingby

anyonewhohadeverwrittenaboutmortality.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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. The

monolithic uncertainty of my future was deadening; everywhere I turned, the

shadowofdeathobscuredthemeaningofanyaction.Irememberthemomentwhen

my overwhelming unease yielded, when that seemingly impassable sea of

uncertainty parted. I woke up in pain, facing another day—no project beyond

breakfast seemed tenable. I can’t go on, I thought, and immediately, its antiphon

responded,completingSamuelBeckett’ssevenwords,wordsIhadlearnedlongago

asanundergraduate:I’llgoon.Igotoutofbedandtookastepforward,repeating

thephraseoverandover:“Ican’tgoon.I’llgoon.”

That morning, I made a decision: I would push myself to return to the OR.

Why?BecauseIcould.Becausethat’swhoIwas.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dying,untilIactuallydie,Iamstillliving.

—

Overthenextsixweeks,Ialteredmyphysicaltherapyprogram,focusingnowon

building strength specifically for operating: long hours of standing,

micromanipulationofsmallobjects,pronationforplacingpediclescrews.

Another CT scan followed.Thetumorhadshrunkslightlymore.Goingover

theimageswithme,Emmasaid,“Idon’tknowhowlongyou’vegot,butIwillsay

this: the patient I saw just before you today has been on Tarceva for seven years

withoutaproblem.You’vestillgotawaystogobeforewe’rethatcomfortablewith

yourcancer.But,lookingatyou,thinkingaboutlivingtenyearsisnotcrazy.You

mightnotmakeit,butit’snotcrazy.”

Here was the prognostication—no, not prognostication: justification.

Justificationofmydecisiontoreturntoneurosurgery,toreturntolife.Onepartof

meexultedattheprospectoftenyears.Anotherpartwishedshe’dsaid,“Goingback

tobeinganeurosurgeoniscrazyforyou—picksomethingeasier.”Iwasstartledto

realizethatinspiteofeverything,thelastfewmonthshadhadoneareaoflightness:

not having to bear the tremendous weight of the responsibility neurosurgery

demanded—andpartofmewantedtobeexcusedfrompickinguptheyokeagain.

Neurosurgeryisreallyhardwork,andnoonewouldhavefaultedmefornotgoing

back.(Peopleoftenaskifitisacalling,andmyanswerisalwaysyes.Youcan’tsee

itasajob,becauseifit’sajob,it’soneoftheworstjobsthereis.)Acoupleofmy

professors actively discouraged the idea: “Shouldn’t you be spending time with

yourfamily?”(“Shouldn’tyou?”Iwondered.Iwasmakingthedecisiontodothis

workbecausethiswork,tome,wasasacredthing.)LucyandIhadjustreachedthe

top of the hill, the landmarks of Silicon Valley, buildings bearing the names of

everybiomedicalandtechnologicaltransformationofthelastgeneration,unfolding

belowus.Eventually,though,theitchtoholdasurgicaldrillagainhadbecometoo

compelling.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.Lucywas

fullysupportive.

I called up the program director to tell him I was ready to return. He was

thrilled.VictoriaandItalkedabouthowbesttoreintroducemeandgetmebackup

tospeed.Irequestedthatafellowresidentbeavailabletobackmeupatalltimesin

case something went awry. Furthermore, I would do only one case per day. I

wouldn’t manage the patients outside the OR or be on call. We’d proceed

conservatively. The OR schedule came out, and I was assigned to a temporal

lobectomy, one of my favorite operations. Commonly, epilepsy is caused by a

misfiringhippocampus,whichislocateddeepinthetemporallobe.Removingthe

hippocampuscancuretheepilepsy,butthe operation iscomplex,requiringgentle

dissectionof the hippocampusoffthepia,thedelicatetransparent coveringof the

brain,rightnearthebrainstem.

I spent the night prior poring through surgical textbooks, reviewing the

anatomyandstepsoftheoperation.Isleptrestlessly,seeingtheangleofthehead,

thesawagainsttheskull,thewaythelightreflectsoffthepiaoncethetemporallobe

isremoved.Igotoutofbedandputonashirtandtie.(Ihadreturnedallmyscrubs

months ago, assuming I’d never need them again.) I arrived at the hospital and

changed into the familiar blue garb for the first time in eighteen weeks. I chatted

with the patient to make sure there were no last-minute questions, then began the

process of setting up the OR. The patient was intubated, the attending and I were

scrubbedandreadytobegin.Ipickedupthescalpelandincisedtheskinjustabove

the ear, proceeding slowly, trying to make sure I forgot nothing and made no

mistakes.Withtheelectrocautery,Ideepenedtheincisiontothebone,thenelevated

theskinflapwithhooks.Everythingfeltfamiliar,musclememorykickingin.Itook

thedrillandmadethreeholesintheskull.Theattendingsquirtedwatertokeepthe

drill cool asIworked.Switching tothe craniotome, asideways-cuttingdrill bit, I

connectedtheholes,freeingup alargepiece of bone. Withacrack,I priedit off.

There lay the silvery dura. Happily, I hadn’t damaged it withthe drill, a common

beginner ’smistake.Iusedasharpknifetoopenthedurawithoutinjuringthebrain.

Successagain.Ibegantorelax.Itackedbackthedurawithsmallstitchestokeepit

outofthewayofthemainsurgery.Thebraingentlypulsedandglistened.Thehuge

Sylvianveinsranacrossthetopofthetemporallobe,pristine.Thefamiliarpeach

convolutionsofthebrainbeckoned.

Suddenly, the edges of my vision dimmed. I put down my instruments and

stepped back from the table. The blackness encroached farther as a feeling of

lightnessovercameme.

“Sorry,sir,”Itoldtheattending,“I’mfeelingalittlefaint.IthinkIneedtolie

down.Jack,myjuniorresident,willfinishthecase.”

Jackarrivedquickly,andIexcusedmyself.Isippedsomeorangejuiceinthe

lounge, lying on the couch. After twenty minutes, I began to feel better.

“Neurocardiogenicsyncope,”Iwhisperedtomyself.Theautonomicnervoussystem

briefly shutting down the heart. Or, as it’s more commonly known, a case of the

nerves.Arookieproblem.ThiswasnothowI’denvisionedmyreturntotheOR.I

went to the locker room, threw my dirty scrubs in the laundry, and put on my

civilianclothes.Onthewayout,Igrabbedastackofcleanscrubs.Tomorrow,Itold

myself,wouldbeabetterday.

Itwas.Everyday,eachcasefeltfamiliarbutmovedalittlemoreslowly.Onday

three, I was removing a degenerated disc from a patient’s spine. I stared at the

bulging disc, not remembering my exact move. The fellow supervising me

suggestedtakingsmallbiteswitharongeur.

“Yeah, I know that’s how it’s usually done,” I mumbled, “but there’s another

way…”

I nibbled away for twenty minutes, my brain searching for the more elegant

wayIhadlearnedtodothis.Atthenextspinallevel,itcamebacktomeinaflash.

“Cobbinstrument!”Icalledout.“Mallet.Kerrison.”

Ihadthewholediscremovedinthirtyseconds.“That’showIdothis,”Isaid.

Over thenextcoupleofweeks, my strengthcontinued to improve,asdidmy

fluencyandtechnique.Myhandsrelearnedhowtomanipulatesubmillimeterblood

vessels without injury, my fingers conjuringup theoldtricksthey’d once known.

Afteramonth,Iwasoperatinganearlyfullload.

Ikeptmyselflimitedtooperating,leavingtheadministration,patientcare,and

night and weekend calls to Victoria and the other senior residents. I had already

mastered those skills, anyway, and needed to learn only the nuances of complex

operationstofeelcomplete.Iendedmydaysexhaustedbeyondmeasure,muscleson

fire,slowlyimproving.Butthetruthwas,itwasjoyless. Thevisceralpleasure I’d

once found in operating was gone, replaced by an iron focus on overcoming the

nausea,thepain,thefatigue.Cominghomeeachnight,Iwouldscarfdownahandful

of pain pills, then crawl into bed next to Lucy, who had returned to a full work

scheduleaswell.Shewasnowinthefirsttrimesterofpregnancy,withthebabydue

in June, when I would complete residency. We had a photo of our child as a

blastocyst, taken just before implantation. (“She has your cell membrane,” I

remarkedtoLucy.)Still,Iwasdeterminedtorestoremylifetoitspriortrajectory.

Anotherstablescansixmonthsafterdiagnosispassed,andIreopenedmyjob

search.Withmycancerundercontrol,Imighthaveseveralyearsleft.Itseemedthe

career I had worked for years to attain, which had disappeared amid disease, was

nowbackinreach.Icouldalmostheartrumpetssoundingavictoryfanfare.

—

DuringmynextvisitwithEmma,wetalkedaboutlifeandwhereitwastakingme.I

recalled Henry Adams trying to compare the scientific force of the combustion

engine and the existential force of the Virgin Mary. The scientific questions were

settledfornow,allowingtheexistentialonesfullplay,yetbothwereinthedoctor’s

purview.I hadrecently learnedthatthesurgeon-scientist positionatStanford—the

jobforwhichIhadbeenheirapparent—hadbeenfilledwhileIwasoutsick.Iwas

crushed,andtoldherso.

“Well,” she said, “this doctor-professor thing can be a real grind. But you

knowthatalready.I’msorry.”

“Yeah, I guess the science that excited me was about twenty-year projects.

Without that kind of time frame, I’m not sure I’m all that interested in being a

scientist.”Itriedtoconsolemyself.“Youcan’tgetmuchdoneinacoupleofyears.”

“Right.Andjustremember,you’redoinggreat.You’reworkingagain.You’ve

gotababyontheway.You’refindingyourvalues,andthat’snoteasy.”

Later that day one of the younger professors, a former resident and close

friend,stoppedmeinthehallway.

“Hey,” she said. “There’s been a lot of discussion in faculty meetings about

whattodowithyou.”

“Whattodowithme,how?”

“Ithinksomeprofessorsareconcernedaboutyougraduating.”

Graduationfromresidencyrequiredtwothings:meetingasetofnationaland

localrequirements,whichI’dalreadydone,andtheblessingofthefaculty.

“What?”Isaid.“Idon’tmeantosoundcocky,butI’magoodsurgeon,justas

goodas—”

“Iknow.Ithinktheyprobablyjustwanttoseeyouperformingthefullloadofa

chief.It’sbecausetheylikeyou.Seriously.”

Irealized itwastrue:For thepastfewmonths,Ihadbeenactingmerelyasa

surgical technician. I had been using cancer as an excuse not to take full

responsibilityformypatients.Ontheotherhand,itwasagoodexcuse,damnit.But

now I started coming in earlier, staying later, fully caring for the patients again,

addinganotherfourhourstoatwelve-hourday.Itputthepatientsbackinthecenter

ofmymindatalltimes.ThefirsttwodaysIthoughtIwouldhavetoquit,battling

wavesofnausea,pain,andfatigue,retreatingtoanunusedbedindownmomentsto

sleep.Butbythethirdday,I hadbeguntoenjoyitagain,despite thewreckofmy

body. Reconnecting with patients brought back the meaning of this work. I took

antiemeticsandnonsteroidalanti-inflammatorydrugs(NSAIDs)betweencasesand

justbeforerounds.Iwassuffering,butIwasfullyback.Insteadoffindinganunused

bed,Istartedrestingonthejuniorresidents’couch,supervisingthemonthecareof

mypatients,lecturingasIrodeawaveofbackspasms.Themoretorturedmybody

became, the more I relished having donethework. At theend of the first week, I

sleptforfortyhoursstraight.

ButIwascallingtheshots:

“Hey,boss,”Isaid,“Iwasjustreviewingcasesfortomorrow,andIknowthe

firstcaseisbookedinterhemispheric,butIthinkitwillbemuchsaferandeasierif

wecomeparietaltranscortical.”

“Really?” the attending said. “Let me look at the films….You know what?

You’reright.Canyouchangethebooking?”

Thenextday:“Hi,sir,it’sPaul.IjustsawMr.FandhisfamilyintheICU—I

thinkwe’llneedtotakehimtomorrowforanACDF.OkayifIbookit?Whenare

youfree?”

AndIwasbacktofullspeedintheOR:

“Nurse,canyoupageDr.S?I’mgoingtobedonewiththiscasebeforehegets

here.”

“I’vegothimonthephone.Hesaysyoucan’tpossiblybedoneyet.”

Theattendingcamerunningin,outofbreath,scrubbed,andpeeredthroughthe

microscope.

“Itookaslightlyacuteangletoavoidthesinus,”Isaid,“butthewholetumor ’s

out.”

“Youavoidedthesinus?”

“Yes,sir.”

“Yougotitoutinonepiece?”

“Yes,sir,it’sonthetablesoyoucanhavealook.”

“Looksgood.Reallygood.Whendidyougettobesofast?SorryIwasn’there

earlier.”

“Notrouble.”

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terminalillnessisaprocess.

ItstruckmethatIhadtraversedthefivestagesofgrief—the“Denial→Anger

→Bargaining→Depression→Acceptance”cliché—butIhaddoneitallbackward.

Ondiagnosis,I’dbeenpreparedfordeath.I’devenfeltgoodaboutit.I’dacceptedit.

I’dbeenready.ThenIslumpedintoadepression,asitbecameclearthatImightnot

bedyingsosoonafterall,whichis,ofcourse,goodnews,butalsoconfusingand

strangely enervating. The rapidity of the cancer science, and the nature of the

statistics,meantImightliveanothertwelvemonths,oranother120.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?

At some point, then, I began to do a little bargaining—or not exactly

bargaining.Morelike:“God,IhavereadJob,andIdon’tunderstandit,butifthisis

a test of faith, you now realize my faith is fairly weak, and probably leaving the

spicymustardoffthepastramisandwichwouldhavealsotestedit?Youdidn’thave

to go nuclear on me, you know…” Then, after the bargaining, came flashes of

anger:“Iworkmywholelifetogettothispoint,andthenyougivemecancer?”

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.

—

Iwasoperatinguntillateatnightorintotheearlymorning,fixatedongraduation,

mydiagnosisninemonthsinthepast.Mybodywastakingabeating.Iwastootired

toeatwhenIgothome.IhadbeenslowlyuppingthedoseofTylenolandNSAIDs

andantiemetics.Ihaddevelopedapersistentcough,presumablycausedbyscarring

from the deadtumorin my lungs. Ionly hadtokeepupthis relentless pace fora

couplemoremonths,Itoldmyself,andthenIwouldgraduatefromresidencyand

settleintothecomparativelycalmerroleofaprofessor.

In February, I flew to Wisconsin for a job interview. They were offering

everythingIwanted:millionsofdollarstostartaneurosciencelab,headofmyown

clinicalservice,flexibilityifIneededitformyhealth,atenure-trackprofessorship,

appealing job options for Lucy, high salary, beautiful scenery, idyllic town, the

perfect boss. “I understand about your health, and you probably have a strong

connectionwithyouroncologist,”thedepartmentchairmantoldme.“Soifyouwant

tokeepyourcarethere,wecanflyyoubackandforth—thoughwedohaveatop-

notchcancercenterhere,ifyouwanttoexploreit.IsthereanythingelseIcandoto

makethisjobmoreattractive?”

I thought about what Emma had told me. I had gone from being unable to

believeIcouldbeasurgeontobeingone,atransformationthatcarriedtheforceof

religious conversion. She had always kept this part of my identity in mind, even

whenIcouldn’t.ShehaddonewhatIhadchallengedmyselftodoasadoctoryears

earlier:acceptedmortalresponsibilityformysoulandreturnedmetoapointwhere

Icouldreturntomyself.Ihadattainedtheheightsoftheneurosurgicaltrainee,setto

become not only a neurosurgeon but a surgeon-scientist. Every trainee aspires to

thisgoal;almostnonemakeit.

That night, the chairman was driving me back to my hotel after dinner. He

stoppedthecarandpulledover.“Letmeshowyousomething,”hesaid.Wegotout

andstoodinfrontofthehospital,lookingoverafrozenlake,itsfaredgeluminous

withspecksoflightleakingfromfacultyhouses.“Insummer,youcanswimorsail

towork.Inwinter,youcanskiorice-skate.”

Itwaslikeafantasy.Andinthatmoment,ithitme:itwasafantasy.Wecould

nevermovetoWisconsin.WhatifIhadaseriousrelapseintwoyears?Lucywould

be isolated, stripped of her friends and family, alone, caringfora dying husband

and new child. As furiously as I had tried to resist it, I realized that cancer had

changedthecalculus.Forthelastseveralmonths,Ihadstrivenwitheveryounceto

restoremylifetoitsprecancertrajectory,tryingtodenycanceranypurchaseonmy

life.AsdesperatelyasInowwantedtofeeltriumphant,insteadIfelttheclawsofthe

crabholdingmeback.Thecurseofcancercreatedastrangeandstrainedexistence,

challengingmetobeneitherblindto,norboundby,death’sapproach.Evenwhen

thecancerwasinretreat,itcastlongshadows.

WhenI’dfirstlosttheprofessorshipatStanford,I’dconsoledmyselfwiththe

ideathatrunningalabmadesenseonlyonatwenty-yeartimescale.NowIsawthat

thiswas,infact,true.Freudstartedhiscareerasasuccessfulneuroscientist.When

he realized neuroscience would need at least a century to catch up with his true

ambition of understanding the mind, he set aside his microscope. I think I felt

somethingsimilar.Transformingneurosurgerythroughmyresearchwasagamble

whose odds had been made too long by my diagnosis; the lab wasn’t the place I

wantedtoplunktheremainderofmychips.

IcouldhearEmma’svoiceagain:Youhavetofigureoutwhat’smostimportant

toyou.

If I no longer sought to fly on the highest trajectory of neurosurgeon and

neuroscientist,whatdidIwant?

Tobeafather?

Tobeaneurosurgeon?

Toteach?

I didn’t know. But if I did not know what I wanted, 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liveshavedisintegratedandworkuntiltheycanstandback

upandface,andmakesenseof,theirownexistence.

Myownhubrisasasurgeonstoodnakedtomenow:asmuchasIfocusedon

my responsibility and power over patients’ lives, it was at best a temporary

responsibility,afleetingpower.Onceanacutecrisishasbeenresolved,thepatient

awakened,extubated,andthendischarged,thepatientandfamilygoonliving—and

thingsareneverquitethesame.Aphysician’swordscaneasethemind,justasthe

neurosurgeon’s scalpel can ease a disease of the brain. Yet their uncertainties and

morbidities,whetheremotionalorphysical,remaintobegrappledwith.

Emma hadn’t given me back my old identity. She’d protected my ability to

forgeanewone.And,finally,IknewIwouldhaveto.

—

On a crystalline spring morning on the third Sunday of Lent,Lucy and Iwent to

churchwithmyparents,whohadflowninfromArizonaforaweekendvisit.Wesat

together ina longwoodenpew,and mymother struck up aconversationwith the

family sitting next to us, first complimenting the mother on her baby daughter ’s

eyes,thenquicklymovingontomattersofgreatersubstance,herskillsasalistener,

confidante, and connector fully evident. During the pastor ’s Scripture reading, I

suddenlyfoundmyselfchuckling.ItfeaturedafrustratedJesuswhosemetaphorical

languagereceivesliteralinterpretationfromhisfollowers:

Jesusansweredandsaidtoher,“Everyonewhodrinksthiswaterwillbethirsty

again; but whoever drinks the water I shall givewill never thirst; the waterI

shallgivewillbecomeinhimaspringofwaterwellinguptoeternallife.”The

womansaidtohim,“Sir,givemethiswater,sothatImaynotbethirstyorhave

tokeepcomingheretodrawwater.”

…Meanwhile,thedisciplesurgedhim,“Rabbi,eat.”Buthesaidtothem,“I

have food to eat of which you do not know.” So the disciples said to one

another,“Couldsomeonehavebroughthimsomethingtoeat?”

Itwaspassageslikethese,wherethereisaclearmockingofliteralistreadings

ofScripture,that hadbrought mebackaroundto Christianityafteralongstretch,

followingcollege,whenmy notionof God and Jesus hadgrown,to put itgently,

tenuous.Duringmysojourninironcladatheism,theprimaryarsenalleveledagainst

Christianity had been its failure on empirical grounds. Surely enlightened reason

offered amorecoherentcosmos. SurelyOccam’s razorcut thefaithful freefrom

blind faith. There is no proof of God; therefore, it is unreasonable to believe in

God.

Although I had been raised in a devout Christian family, where prayer and

Scripturereadingswereanightlyritual,I,likemostscientifictypes,cametobelieve

in the possibility of a material conception of reality, an ultimately scientific

worldviewthatwouldgrantacompletemetaphysics,minusoutmodedconceptslike

souls,God,andbeardedwhitemeninrobes.Ispentagoodchunkofmytwenties

trying to build a frame for such an endeavor. 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.

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.

Betweenthesecorepassionsandscientifictheory,therewillalwaysbeagap.

Nosystem ofthoughtcan containthefullnessofhuman experience. Therealmof

metaphysics remains the province of revelation (this, not atheism, is what Occam

argued, after all). And atheism can be justified only on these grounds. The

prototypicalatheist,then,isGrahamGreene’scommandantfromThePowerandthe

Glory,whoseatheismcomesfromarevelationoftheabsenceofGod.Theonlyreal

atheismmustbegroundedinaworld-makingvision.Thefavoritequoteofmanyan

atheist,fromtheNobelPrize–winningFrenchbiologistJacquesMonod,beliesthis

revelatoryaspect: “The ancientcovenantisin pieces; man at lastknowsthat heis

aloneintheunfeelingimmensityoftheuniverse,outofwhichheemergedonlyby

chance.”

Yet I returned to the central values of Christianity—sacrifice, redemption,

forgiveness—becauseIfoundthemso compelling.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.

Notonlythat,butmaybethebasicmessageoforiginalsinisn’t“Feelguiltyall

thetime.”Maybeitismorealongtheselines:“Weallhaveanotionofwhatitmeans

tobegood,andwecan’tliveuptoitallthetime.”Maybethat’swhatthemessageof

the New Testament is, after all. Even if you have a notion as well defined as

Leviticus,youcan’tlivethatway.It’snotjustimpossible,it’sinsane.

About God I could say nothing definitive, of course, but the basic reality of

human life stands compellingly against blind determinism. Moreover, no one,

myself included, credits revelation with any epistemic authority. We are all

reasonablepeople—revelationisnotgoodenough.EvenifGodspoketous,we’d

discountitasdelusional.

Sowhat,Iwonder,istheaspiringmetaphysiciantodo?

Giveup?

Almost.

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a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 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 sows 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theirwork.

—

IhoppedoutoftheCTscanner,sevenmonthssinceIhadreturnedtosurgery.This

wouldbemylastscanbeforefinishingresidency,beforebecomingafather,before

myfuturebecamereal.

“Wannatakealook,Doc?”thetechsaid.

“Notrightnow,”Isaid.“I’vegotalotofworktodotoday.”

It was already six P.M. I had to go see patients, organize tomorrow’s OR

schedule, review films, dictate my clinic notes, check on my post-ops, and so on.

AroundeightP.M.,Isatdownintheneurosurgeryoffice,nexttoaradiologyviewing

station. I turned it on, looked at my patients’ scans for the next day—two simple

spinecases—and,finally,typedinmyownname.Izippedthroughtheimagesasif

theywereakid’sflip-book,comparingthenewscantothelast.Everythinglooked

thesame,theoldtumorsremainedexactlythesame…except,wait.

Irolledbacktheimages.Lookedagain.

Thereitwas.Anewtumor,large,fillingmyrightmiddlelobe.Itlooked,oddly,

likeafullmoonhavingalmostclearedthehorizon.Goingbacktotheoldimages,I

couldmakeoutthefaintesttraceofit,aghostlyharbingernowbroughtfullyinto

theworld.

Iwasneitherangrynorscared.Itsimplywas.Itwasafactabouttheworld,like

thedistancefromthesuntotheearth.IdrovehomeandtoldLucy.ItwasaThursday

night,andwewouldn’tseeEmmaagainuntilMonday,butLucyandIsatdowninthe

living room, with our laptops, and mapped out the next steps: biopsies, tests,

chemotherapy. The treatments this time around would be tougher to endure, the

possibilityofalonglifemoreremote.Eliotagain:“ButatmybackinacoldblastI

hear / the rattle of the bones, and chuckle spread from ear to ear.” Neurosurgery

wouldbeimpossibleforacoupleofweeks,perhapsmonths,perhapsforever.But

wedecidedthatallofthatcouldwaittoberealuntilMonday.TodaywasThursday,

andI’dalreadymadetomorrow’sORassignments;Iplannedonhavingonelastday

asaresident.

As I stepped out of my car at the hospital at five-twenty the next morning, I

inhaled deeply, smelling the eucalyptus and…was that pine? Hadn’t noticed that

before. I met the resident team, assembled for morning rounds. We reviewed

overnightevents,newadmissions,new scans,thenwenttoseeour patientsbefore

M&M, or morbidity and mortality conference, a regular meeting in which the

neurosurgeonsgatheredtoreviewmistakes thathad beenmadeandcasesthathad

gonewrong.Afterward,Ispentanextracoupleofminuteswithapatient,Mr.R.He

haddevelopedararesyndrome,calledGerstmann’s,where,afterI’d removedhis

braintumor, he’d begunshowingseveralspecificdeficits:aninability to write,to

namefingers,todoarithmetic,totellleftfromright.I’dseenitonlyoncebefore,as

a medicalstudent eightyears ago,ononeof the first patients I’dfollowedonthe

neurosurgicalservice.Likehim,Mr.Rwaseuphoric—Iwonderedifthatwaspartof

thesyndromethatnoonehaddescribedbefore.Mr.Rwasgettingbetter,though:his

speechhadreturnedalmosttonormal,andhisarithmeticwasonlyslightlyoff.He’d

likelymakeafullrecovery.

Themorningpassed,andIscrubbedformylastcase.Suddenlythemomentfelt

enormous.Mylasttimescrubbing?Perhapsthiswasit.Iwatchedthesudsdripoff

myarms,thendownthedrain.IenteredtheOR,gownedup,anddrapedthepatient,

making sure the corners were sharp and neat. I wanted this case to be perfect. I

opened the skin of his lower back. He was an elderly man whose spine had

degenerated,compressinghisnerverootsandcausingseverepain.Ipulledawaythe

fatuntilthefasciaappearedandIcouldfeelthetipsofhisvertebrae.Iopenedthe

fascia and smoothly dissected the muscle away, until only the wide, glistening

vertebrae showed up through the wound, clean and bloodless. The attending

wanderedinasIbegantoremovethelamina,thebackwallofthevertebrae,whose

bonyovergrowths,alongwithligamentsbeneath,werecompressingthenerves.

“Looksgood,”hesaid.“Ifyouwanttogototoday’sconference,Icanhavethe

fellowcomeinandfinish.”

Mybackwasbeginningtoache.Whyhadn’tItakenanextradoseofNSAIDs

beforehand?Thiscaseshouldbequick,though.Iwasalmostthere.

“Naw,”Isaid.“Iwanttofinishthecase.”

The attending scrubbed in, and together we completed the bony removal. He

began topick away at the ligaments, beneath which lay the dura, which contained

spinalfluidandthenerveroots.Themostcommonerroratthisstageistearinga

holeinthedura.Iworkedontheoppositeside.Outofthecornerofmyeye,Isaw

nearhisinstrumentaflashofblue—thedurastartingtopeekthrough.

“Watchout!”Isaid,justasthemouthofhisinstrumentbitintothedura.Clear

spinalfluidbegantofillthewound.Ihadn’thadaleakinoneofmycasesinmore

thanayear.Repairingitwouldtakeanotherhour.

“Getthemicrosetout,”Isaid.“Wehavealeak.”

Bythetimewefinishedtherepairandremovedthecompressivesofttissue,my

shoulders burned. The attending broke scrub, offered his apologies and said his

thanks,andleftmetoclose.Thelayerscametogethernicely.Ibegantosuturethe

skin,usingarunningnylonstitch.Mostsurgeonsusedstaples,butIwasconvinced

thatnylonhadlowerinfectionrates,andwewoulddothisone,thisfinalclosure,my

way. The skin came together perfectly, without tension, as if there had been no

surgeryatall.

Good.Onegoodthing.

Asweuncoveredthepatient,thescrubnurse,onewithwhomIhadn’tworked

before,said,“Youoncallthisweekend,Doc?”

“Nope.”Andpossiblyneveragain.

“Gotanymorecasestoday?”

“Nope.”Andpossiblyneveragain.

“Shit,well,Iguessthatmeansthisisahappyending!Work’sdone.Ilikehappy

endings,don’tyou,Doc?”

“Yeah.Yeah,Ilikehappyendings.”

I sat down by the computer to enter orders as the nurses cleaned and the

anesthesiologists began to wake the patient. I had always jokingly threatened that

whenIwasincharge,insteadofthehigh-energypopmusiceveryonelikedtoplay

intheOR,we’dlistenexclusivelytobossanova.Iput Getz/Gilberto on the radio,

andthesoft,sonoroussoundsofasaxophonefilledtheroom.

I left the OR shortly after, then gathered my things, which had accumulated

over seven years of work—extra sets of clothes for the nights you don’t leave,

toothbrushes,barsofsoap,phonechargers,snacks,myskullmodelandcollection

of neurosurgery books, and so on. On second thought, I left my books behind.

They’dbeofmoreusehere.

Onmywayouttotheparkinglot,afellowapproachedtoaskmesomething,

buthispagerwentoff.Helookedatit,waved,turned,andranbackintothehospital

—“I’llcatchyoulater!”hecalledoverhisshoulder.TearswelledupasIsatinthe

car, turned the key, and slowly pulled out into the street. I drove home, walked

throughthefrontdoor,hungupmywhitecoat,andtookoffmyIDbadge.Ipulled

thebatteryoutofmypager.Ipeeledoffmyscrubsandtookalongshower.

Laterthatnight,IcalledVictoriaandtoldherIwouldn’tbeinonMonday,or

possiblyeveragain,andwouldn’tbesettingtheORschedule.

“You know, I’ve been having this recurring nightmare that this day was

coming,”shesaid.“Idon’tknowhowyoudidthisforsolong.”

—

Lucy and I met with Emma on Monday. She confirmed the plan we’d envisioned:

bronchoscopic biopsy, look for targetable mutations, otherwise chemo. The real

reasonIwasthere,though,wasforherguidance.ItoldherIwastakingleavefrom

neurosurgery.

“Okay,”shesaid.“That’sfine.Youcanstopneurosurgeryif,say,youwantto

focus on something that matters more to you. But not because you are sick. You

aren’tanysickerthanyouwereaweekago.Thisisabumpintheroad,butyoucan

keepyourcurrenttrajectory.Neurosurgerywasimportanttoyou.”

Onceagain,Ihadtraversedthelinefromdoctortopatient,fromactortoacted

upon,fromsubjecttodirectobject.Mylifeupuntilmyillnesscouldbeunderstood

as the linear sumof my choices.Asinmost modern narratives, acharacter ’s fate

dependedonhumanactions,hisandothers.KingLear’sGloucestermaycomplain

abouthumanfateas“fliestowantonboys,”butit’sLear ’svanitythatsetsinmotion

the dramatic arc of the play. From the Enlightenment onward, the individual

occupied center stage. But now I lived in a different world, a more ancient one,

wherehumanactionpaledagainstsuperhumanforces,aworldthatwasmoreGreek

tragedy than Shakespeare. No amount of effort can help Oedipus and his parents

escapetheirfates;theironlyaccesstotheforcescontrollingtheirlivesisthrough

the oracles and seers, those given divine vision. What I had come for was not a

treatment plan—I had read enough to know the medical ways forward—but the

comfortoforacularwisdom.

“Thisis not the end,”shesaid, aline she must haveuseda thousand times—

after all, did I not use similar speeches to my own patients?—to those seeking

impossibleanswers.“Oreventhebeginningoftheend.Thisis just theendofthe

beginning.”

AndIfeltbetter.

Aweekafter thebiopsy,Alexis,the nurse practitioner, called. Therewereno

newtargetablemutations,sochemotherapywastheonlyoption,anditwasbeingset

up for Monday. I asked about the specific agents and was told I’d have to talk to

Emma.ShewasenroutetoLakeTahoewithherkids,butshe’dgivemeacallover

theweekend.

The next day, a Saturday, Emma called. I asked her what she thought about

chemotherapyagents.

“Well,”shesaid.“Doyouhavespecificthoughts?”

“I guessthemainquestionis whethertoincludeAvastin,” Isaid. “Iknow the

data is mixed and that it adds potential side effects, and some cancer centers are

turningawayfromit.Inmymind,though,sincetherearealotofstudiessupporting

itsuse,I’dleantowardincludingit.WecandiscontinueitifIhaveabadreactionto

it.Ifthatseemssensibletoyou.”

“Yeah,thatsoundsaboutright.Insurancecompaniesalsomakeithardtoaddit

later,sothat’sanotherreasontouseitupfront.”

“Thanksforcalling.I’llletyougetbacktoenjoyingthelake.”

“Okay.But there’s onething.” Shepaused.“I’m totallyhappyforus tomake

your medical plan together; obviously, you’re a doctor, you know what you’re

talkingabout,andit’syourlife.Butifyoueverwantmetojustbethedoctor,I’m

happytodothat,too.”

Ihadn’teverconsideredthatIcouldreleasemyselffromtheresponsibilityof

my own medical care. I’d just assumed all patients became experts at their own

diseases.Irememberedhow,asagreenmedicalstudent,knowingnothing,Iwould

oftenendupaskingpatientstoexplaintheirdiseasesandtreatmentstome,theirblue

toes and pink pills. But as a doctor, I never expected patients to make decisions

alone;Iboreresponsibilityforthepatient.AndIrealizedIwastryingtodothesame

thing now, my doctor-self remaining responsible for my patient-self. Maybe I’d

been cursed by a Greek god, but abdicating control seemed irresponsible, if not

impossible.

—

ChemotherapybeganonMonday.Lucy,mymother,andIwenttotheinfusioncenter

together.IhadanIVplaced,settledintoaneasychair,andwaited.Thedrugcocktail

wouldtakefourandahalfhourstoinfuse.Ipassedthetimenapping,reading,and

sometimes blankly staring, with Lucyand my mothernextto me, interruptingthe

silencewithoccasionalsmalltalk.Theotheroccupantsoftheroomwereinvarious

states of health—some bald, some well-coiffed, some withered, some sprightly,

somedisheveled,somedapper.Alllaystill,silent,withIVtubingdrippingpoison

intooutstretchedarms.Iwastoreturneverythreeweeksfortreatment.

I began to feel the effects the next day, a deep fatigue, a profound bone-

wearinesssettingin.Eating,normallyasourceofgreatpleasure,waslikedrinking

seawater.Suddenly,allofmyjoysweresalted.Forbreakfast,Lucymademeabagel

withcreamcheese;ittastedlikeasaltlick.Isetitaside.Readingwasexhausting.I

hadagreedtowriteafewchaptersonthetherapeuticpotentialofmyresearchwith

V for two major neurosurgical textbooks. That,too, I setaside. The days passed,

television and forced feedings marking the time. A pattern developed over the

weeks:themalaisewouldslowlyease,normalcyreturningjustintimeforthenext

treatment.

The cycles continued; I shuffled in and out of the hospital with minor

complications, which were just enough to preclude any return to work. The

neurosurgerydepartmentdeterminedthatIhadmetallnationalandlocalcriteriafor

graduation; the ceremony was scheduled for a Saturday, about two weeks before

Lucy’sduedate.

The day arrived. As I stood in our bedroom, dressing for graduation—the

culmination of seven years of residency—a piercing nausea struck me. This was

unliketheusualnauseaofchemotherapy,whichwashedoveryoulikeawaveand,

likeawave,couldberidden.Ibeganuncontrollablyvomitinggreenbile,itschalky

tastedistinctfromstomachacid.Thiswasfromdeepinmygut.

Iwouldnotbegoingtograduation,afterall.

Ineeded IV fluidsto avoid dehydration,soLucydroveme to the emergency

departmentandrehydrationbegan.Thevomitinggavewaytodiarrhea.Themedical

resident,Brad,andIchattedamicably,andIrelayedmymedicalhistory,covering

all my medications, and we ended up discussing advances in molecular therapies,

especiallyTarceva,whichIwasstilltaking.Themedicalplanwassimple:keepme

hydratedwithintravenousfluidsuntilIcoulddrinkenoughbymouth.Thatevening,

Iwasadmittedtoahospitalroom.Butwhenthenursereviewedmymedicationlist,I

noticed Tarceva was not on it. I asked her to call the resident to correct the

oversight.Thesethingshappen.Iwastakingadozenmedications,afterall.Keeping

trackwasnoteasy.

ItwaswellpastmidnightwhenBradappeared.

“Iheardyouhadaquestionaboutyourmedications?”heasked.

“Yeah,”Isaid.“Tarcevawasn’tordered.Doyoumindorderingit?”

“Idecidedtotakeyouoffit.”

“Whyisthat?”

“Yourliverenzymesaretoohightotakeit.”

I was confused. My liver enzymes had been high for months; if this was an

issue, why hadn’t we discussed it before? In any case, this was clearly a mistake.

“Emma—myoncologist,yourboss—hasseenthesenumbers,andshewantstokeep

meonit.”

Residents routinely have to make medical decisions without the attending’s

input.ButnowthathehadEmma’sopinion,surelyhewouldcapitulate.

“ButitmightbecausingyourGIproblems.”

My confusion deepened. Usually invoking the attending’s orders ends the

discussion.“I’vebeentakingitforayearwithoutanyproblems,”Isaid.“Youthink

Tarcevaiscausingthisallofasudden,andnotthechemotherapy?”

“Maybe,yeah.”

Confusionyieldedtoanger.Somekidtwoyearsoutofmedschool,noolder

thanmyjuniorresidents,wasreallyarguingwithme?It’dbeonethingifhewere

right, but he wasn’t making any sense. “Um, didn’t I mention this afternoon that

withoutthatpill,mybonemetastasesbecomeactiveandproduceexcruciatingpain?

Idon’tmeantosounddramatic,butI’vebrokenbonesboxing,andthisisfarmore

painful.Asin,ten-out-of-tenpain.Asin,I-Will-Actually-Soon-Be-Screamingpain.”

“Well,giventhehalf-lifeofthedrug,thatprobablywon’thappenforadayor

so.”

IcouldseethatinBrad’seyesIwasnotapatient,Iwasaproblem:aboxtobe

checkedoff.

“Look,” he continued, “if you weren’t you, we wouldn’t even be having this

conversation.I’djuststopthedrugandmakeyouproveitcausesallthispain.”

Whathadhappenedtoouramicablechatthisafternoon?Ithoughtbacktomed

school,whenapatienthadtoldmethatshealwaysworehermostexpensivesocksto

thedoctor ’soffice,sothatwhenshewasinapatient’sgownandshoeless,thedoctor

would see the socks and know she was a person of substance, to be treated with

respect.(Ah,there’stheproblem—Iwaswearinghospital-issuesocks,whichIhad

beenstealingforyears!)

“Anyway, Tarceva is a special drug, and it requires a fellow or attending to

signoffonit.Doyoureallywantmetowakesomeoneupforthis?Can’titwaittill

morning?”

Andthereitwas.

Meetinghisobligationtomemeantaddingonemorethingtohisto-dolist:an

embarrassing phone call with his boss, revealing his error. He was working the

night shift. Residency education regulations had forced most programs to adopt

shift work. And along with shift work comes a kind of shiftiness, a subtle

undercutting of responsibility.If hecould just pushitoff forafewmorehours, I

wouldbecomesomebodyelse’sproblem.

“I usually take it at five A.M.,” I said. “And you know as well as I do that

‘waiting till morning’ means letting someone deal with it after morning rounds,

whichwillbemoreliketheafternoon.Right?”

“Okay,fine,”hesaid,andlefttheroom.

Whenmorningarrived,Idiscoveredthathehadnotorderedthemedication.

Emma dropped in to say hello and told me she would sort out the Tarceva

order. She wished me a speedy recovery and apologized for thefact that she was

headingoutoftownforaweek.OverthecourseofthedayIbegantodeteriorate,

mydiarrhearapidlyworsening.Iwasbeingrehydrated,butnotquicklyenough.My

kidneysbegantofail.MymouthbecamesodryIcouldnotspeakorswallow.Atthe

nextlabcheck,myserumsodiumhadreachedanear-fatallevel.Iwastransferredto

theICU.Partofmysoftpalateandpharynxdiedfromdehydrationandpeeledoutof

mymouth.Iwasinpain,floatingthroughvaryinglevelsofconsciousness,whilea

pantheon of specialists was brought together to help: medical intensivists,

nephrologists, gastroenterologists, endocrinologists, infectious disease specialists,

neurosurgeons,generaloncologists,thoraciconcologists,otolaryngologists.Lucy,

thirty-eightweekspregnant,stayedwithmebydayandsecretlymovedintomyold

callroom,stepsfromtheICU,soshecouldcheckonmeatnight.Sheandmyfather

alsolenttheirvoices.

During lucid moments, I was acutely aware that with this many voices,

cacophonyresults.In medicine,thisisknown as theWICOSproblem: Who Is the

Captain Of the Ship? The nephrologists disagreed with the ICU doctors, who

disagreed with the endocrinologists, who disagreed with the oncologists, who

disagreed with thegastroenterologists. Ifeltthe responsibilityof my care: during

boutsofconsciousness,Itypedoutthesequentialdetailsofmycurrentillnessand,

withLucy’shelp,triedtocorralallthedoctorstokeepthefactsandinterpretations

straight.Later,whilehalfasleep,IcoulddimlyhearmyfatherandLucydiscussing

myconditionwitheachteamofdoctors.Wesuspectedthatthemainplanshouldjust

betotreatmewithfluidsuntiltheeffectsofthechemotherapy woreoff.Buteach

groupofspecialistshadtoallowformoreesotericpossibilitiesandadvocatetests

and treatments for them, some of which seemed unnecessary and ill-advised.

Samples were taken, scans were ordered, medications were given; I began losing

track of events and time. I requested that these plans be explained to me, but

sentenceswouldbecomeslippery,voices would dampenand muffle,and darkness

would descend in the midst of doctors’ speeches as I wobbled in and out of

coherence.IdesperatelywishedEmmawerethere,incharge.

Suddenly,sheappeared.

“You’rebackalready?”Isaid.

“You’vebeenintheICUforoveraweek,”shesaid.“Butdon’tworry.You’re

getting better. Most of your labs have normalized. You’ll be out of here soon.”

She’dbeenintouchwithmydoctorsoveremail,Ilearned.

“You know how you offered to just be the doctor and I could just be the

patient?”I asked.“I thinkthat’s maybe agoodidea.I’vebeenreadingscienceand

literaturetryingtofindtherightperspective,butIhaven’tfoundit.”

“I’mnotsurethat’ssomethingyoucanfindbyreadingaboutit,”shereplied.

Emmawasnowthecaptainoftheship,lendingasenseofcalmtothechaosof

thishospitalization.T.S.Eliotsprangtomind:

Damyata:Theboatresponded

Gaily,tothehandexpertwithsailandoar

Theseawascalm,yourheartwouldhaveresponded

Gaily,wheninvited,beatingobedient

Tocontrollinghands

I leaned back in my hospital bed and closed my eyes. As the darkness of

deliriumdescendedagain,Ifinallyrelaxed.

—

Lucy’s due date came and went without labor, and I was finally scheduled to be

dischargedfrom the hospital. Ihad lost over forty pounds since being diagnosed,

fifteeninthelastweek.IweighedasmuchasIhadineighthgrade,thoughmyhair

had considerably thinned since those days, mostly in the past month. I was awake

again, alert to the world, but withered. I could see my bones against my skin, a

living X-ray. At home, simply holding my head up was tiring. Lifting a glass of

waterrequiredbothhands.Readingwasoutofthequestion.

Bothsetsofparentswereintowntohelp.Twodaysafterdischarge,Lucyhad

herfirstcontractions.Shestayedhomewhilemymotherdrovemetomyfollow-up

appointmentwithEmma.

“Frustrated?”Emmaasked.

“No.”

“Youshouldbe.It’sgoingtobealongrecovery.”

“Well,yes,okay.Iamfrustratedonthebigpicture.Butontheday-by-day,I’m

readytogetbacktophysicaltherapyandstartrecovering.Ididitonce,soitshould

beoldhat,right?”

“Didyouseeyourlastscan?”sheasked.

“No,I’vekindofstoppedlooking.”

“It looks good,” she said. “The disease looks stable, maybe even slightly

shrinking.”

We talkedthrough someof the coming logistics;chemotherapywould beon

holduntilIwasstronger.Experimentaltrialswouldn’tacceptmeinmycurrentstate,

either.Treatmentwasn’tanoption—notuntilIregainedsomestrength.Ileanedmy

headagainstthewalltosupporttheflaggingmusclesofmyneck.Mythoughtswere

clouded. I needed that oracle to scry again, to gather secrets from birds or star

charts,frommutantgenesorKaplan-Meiergraphs.

“Emma,”Isaid,“what’sthenextstep?”

“Getstronger.That’sit.”

“Butwhenthecancerrecurs…Imean,theprobabilities…”Ipaused.First-line

therapy (Tarceva) had failed. Second-line therapy (chemo) had nearly killed me.

Third-line therapy, if Icouldeven getthere, made fewpromises.Beyondthat,the

vastunknownofexperimentaltreatments.Phrasesofdoubtfellfrommymouth.“I

mean,gettingbacktotheOR,ortowalking,oreven—”

“Youhavefivegoodyearsleft,”shesaid.

Shepronouncedit,butwithouttheauthoritativetoneofanoracle,withoutthe

confidenceofatruebeliever.Shesaidit,instead,likeaplea.Likethatpatientwho

couldspeakonlyinnumbers.Likeshewasnotsomuchspeakingtomeaspleading,

amerehuman,withwhateverforcesandfatestrulycontrolthesethings.Therewe

were,doctorandpatient,inarelationshipthatsometimescarriesamagisterialair

and other times, like now, was no more, and no less, than two people huddled

together,asonefacestheabyss.

Doctors,itturnsout,needhope,too.

—

OnthewayhomefromtheappointmentwithEmma,Lucy’smomcalledtosaythey

were headed to the hospital. Lucy was in labor. (“Make sure you ask about the

epidural early,” I told her. She had suffered enough.) I returned to the hospital,

pushedbymyfatherinawheelchair.Ilaydownonacotinthedeliveryroom,heat

packs and blankets keeping my skeletal body from shivering. For the next two

hours,IwatchedLucyandthenursegothroughtheritualoflabor.Asacontraction

builtup,thenursecountedoffthepushing:“Andaonetwothreefourfivesixseven

eightnineandaten!”

Lucyturnedtome,smiling.“ItfeelslikeI’mplayingasport!”shesaid.

I lay onthe cot andsmiled back, watchingher belly rise. There would be so

manyabsencesinLucy’sandmydaughter ’slife—ifthiswasaspresentasIcould

be,thensobeit.

Sometimeaftermidnight,thenursenudgedmeawake.“It’salmost time,”she

whispered. She gathered the blankets and helped me to a chair, next to Lucy. The

obstetrician was already in theroom, no older than I. Shelooked up at me as the

baby was crowning. “I can tell you one thing: yourdaughter has hair exactly like

yours,” she said. “And a lot of it.” I nodded, holding Lucy’s hand during the last

momentsofherlabor.Andthen,withonefinalpush,onJuly4,at2:11A.M.,there

shewas.ElizabethAcadia—Cady;wehadpickedthenamemonthsbefore.

“Canweputheronyourskin,Papa?”thenurseaskedme.

“No,I’mtooc-c-cold,”Isaid,myteethchattering.“ButIwouldlove to hold

her.”

Theywrappedherinblanketsandhandedhertome.Feelingherweightinone

arm, and gripping Lucy’s hand with the other, the possibilities of life emanated

beforeus.Thecancercellsinmybodywouldstillbedying,orthey’dstartgrowing

again. Looking out over the expanse ahead I saw not an empty wasteland but

somethingsimpler:ablankpageonwhichIwouldgoon.

—

Yetthereisdynamisminourhouse.

Day to day, week to week, Cadyblossoms: a first grasp, a first smile, a first

laugh. Her pediatrician regularly records her growth on charts, tick marks

indicatingherprogressovertime.Abrighteningnewnesssurroundsher.Asshesits

in my lap smiling, enthralled by my tuneless singing, an incandescence lights the

room.

Timeformeisnowdouble-edged:everydaybringsmefurtherfromthelow

ofmylastrelapsebutclosertothenextrecurrence—and,eventually,death.Perhaps

later than I think, but certainly sooner than I desire. There are, I imagine, two

responses to that realization. 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

tortoiselikeapproach.Iplod,Iponder.Somedays,Isimplypersist.

Iftimedilateswhenonemovesathighspeeds,doesitcontractwhenonemoves

barelyatall?Itmust:thedayshaveshortenedconsiderably.

Withlittletodistinguishonedayfromthenext,timehasbeguntofeelstatic.In

English,weusethewordtimeindifferentways:“Thetimeistwoforty-five”versus

“I’mgoingthroughatoughtime.”Thesedays,timefeelslesslikethetickingclock

andmorelikeastateofbeing.Languorsettlesin.There’safeelingofopenness.As

a surgeon, focused on a patientin theOR,I might have foundthe position of the

clock’shandsarbitrary,butIneverthoughtthemmeaningless.Nowthetimeofday

meansnothing,thedayoftheweekscarcelymore.Medicaltrainingisrelentlessly

future-oriented, allaboutdelayedgratification;you’re always thinkingaboutwhat

you’llbedoingfiveyearsdowntheline.ButnowIdon’tknowwhatI’llbedoing

five yearsdown the line. I may bedead. Imaynot be. Imaybe healthy. I maybe

writing.Idon’tknow.Andsoit’snotallthatusefultospendtimethinkingaboutthe

future—thatis,beyondlunch.

Verb conjugation has become muddled, as well. Which is correct: “I am a

neurosurgeon,”“Iwasaneurosurgeon,”or“Ihadbeenaneurosurgeonbeforeand

willbeagain”?GrahamGreeneoncesaidthatlifewaslivedinthefirsttwentyyears

and the remainder was just reflection. So what tense am I living in now? Have I

proceededbeyondthepresenttenseandintothepastperfect?Thefuturetenseseems

vacant and, on others’ lips, jarring. A few months ago, I celebrated my fifteenth

collegereunionatStanfordandstoodoutonthequad,drinkingawhiskeyasapink

sun dipped below the horizon; when old friends called out parting promises

—“We’ll see you at the twenty-fifth!”—it seemed rude to respond with “Well…

probablynot.”

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.

Yetonethingcannotberobbedofherfuturity:ourdaughter,Cady.IhopeI’ll

livelongenoughthatshehassomememoryofme.WordshavealongevityIdonot.

IhadthoughtIcouldleaveheraseriesofletters—butwhatwouldtheysay?Idon’t

knowwhatthisgirlwillbelikewhensheisfifteen;Idon’tevenknowifshe’lltake

to the nickname we’ve given her. 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.

EPILOGUE

LucyKalanithi

Youleftme,sweet,twolegacies,—

Alegacyoflove

AHeavenlyFatherwouldcontent,

Hadhetheofferof;

Youleftmeboundariesofpain

Capaciousasthesea,

Betweeneternityandtime,

Yourconsciousnessandme.

—EmilyDickinson

PAULDIEDONMONDAY,March9,2015,surroundedbyhisfamily,inahospitalbed

roughlytwohundredyardsfromthelaboranddeliverywardwhereourdaughter,

Cady,hadenteredtheworldeightmonthsbefore.BetweenCady’sbirthandPaul’s

death,ifyou’dseenussuckingonribsatourlocalbarbecuerestaurantandsmiling

overasharedbeer,adark-hairedbabywithlongeyelashesnappinginherstroller

besideus,you’dneverhaveguessedthatPaullikelyhadlessthanayeartolive,nor

thatweunderstoodthat.

ItwasaroundCady’sfirstChristmas,whenshewasfivemonthsold,thatPaul’s

cancer began to resist the third-line drugs recommended after Tarceva and then

chemotherapy had stopped working. Cady tried her first solid food during that

holiday season, snug in candy-cane-striped pajamas, gumming mashed yams as

family gathered at Paul’s childhood home in Kingman, Arizona, the house aglow

with candles and chatter. His strength waned over the following months, but we

continuedtoexperiencejoyfulmoments,eveninthemidstofoursorrow.Wehosted

cozydinnerparties,heldeachotheratnight,anddelightedinourdaughter’sbright

eyes and calm nature. And, of course, Paul wrote, reclining in his armchair,

wrappedinawarmfleeceblanket.Inhisfinalmonths,hewassingularlyfocusedon

finishingthisbook.

As winter turned to spring, the saucer magnolias in our neighborhood

bloomedlargeandpink,butPaul’shealthwasdecliningrapidly.BylateFebruary,

heneededsupplementaloxygentokeephisbreathingcomfortable.Iwasaddinghis

untouchedlunchtothetrashcanatophisuntouchedbreakfast,andafewhourslater

I’daddanuntoucheddinnertothepile.Heusedtolovemybreakfastsandwiches—

egg,sausage,and cheeseonaroll—butwith hiswaningappetitewe’dchangedto

eggsandtoast,thenjusteggs,untileventhosebecameintolerable.Evenhisfavorite

smoothies,theglassesIfilledwithasteadystreamofcalories,wereunappetizing.

Bedtime crept earlier, Paul’s voice slurred intermittently, and his nausea

became unremitting. A CT scan and brain MRI confirmed worsening cancer in

Paul’slungsandnewtumorsthathadlandedinhisbrain,includingleptomeningeal

carcinomatosis,arareandlethalinfiltrationthatbroughtwithitaprognosisofonly

severalmonthsandtheloomingshadowofswiftneurologicdecline.Thenewshit

Paulhard.Hesaidlittle,butasaneurosurgeon,heknewwhatlayahead.Although

Paulacceptedhislimitedlifeexpectancy,neurologicdeclinewasanewdevastation,

the prospect of losing meaning and agency agonizing. We strategized with Paul’s

oncologistabouthistoppriority:preservingmentalacuityaslongaspossible.We

arranged entry into a clinical trial, consultation with a neuro-oncology specialist,

andavisitwithhispalliative-careteamtodiscusshospiceoptions,allinserviceof

maximizing the quality of his remaining time. My heart swelled even as I steeled

myself, anticipating his suffering, worrying that he had only weeks left—if that. I

envisionedhis funeral as we held hands. I didn’tknowthat Paul would die within

days.

WespentPaul’slastSaturdaywithfamilyinthenestofourlivingroom,Paul

holdingCadyinhisarmchair;hisfatheronmynursingglider;hismotherandIon

sofas nearby. Paul sang to Cady and bounced her gently in his lap. She grinned

widely,oblivioustothetubingthatdeliveredoxygentohisnose.Hisworldbecame

smaller;Ideflectednonfamilyvisitors,Paultellingme,“Iwanteveryonetoknow

thatevenifIdon’tseethem,Ilovethem.Icherishtheirfriendship,andonemore

glass of Ardbeg won’t change that.” He didn’t write anything that day. The

manuscriptforthisbookwasonlypartiallyfinished,andPaulnowknewthathewas

unlikelytocompleteit—unlikelytohavethestamina,theclarity,thetime.

To prepare for the clinical trial, Paul had stopped taking the daily targeted-

therapypillthathadbeeninsufficientlycontrollinghiscancer.Therewasariskthat

the cancer might grow rapidly, or “flare,” after he stopped the medication.

Therefore, Paul’s oncologist had instructed me to videotape him daily, doing the

sametask,totrackanydeficitsinhisspeechorgait.“Aprilisthecruellestmonth,”

PaulreadaloudinthelivingroomthatSaturdayasIfilmed,choosingT.S.Eliot’s

TheWasteLandashisscript.“Mixingmemoryanddesire,stirring/Dullrootswith

springrain.”Thefamilychuckledwhen,thoughitwasnotpartoftheassignment,he

setthebookfacedownonhislapandinsistedonrecitingfrommemory.

“Solikehim!”hismothersaid,smiling.

Thenextday,Sunday,wehopedforacontinuationofthecalmweekend.IfPaul

feltwellenough,wewouldattendchurch,thentakeCadyandhercousintothebaby

swingsattheparkupthehill.We’dcontinuetoabsorbtherecentpainfulnews,share

thesorrow,savorourtimetogether.

Butinstead,timespedup.

EarlySundaymorning,IstrokedPaul’sforeheadandfounditscorchingwith

fever, 104 degrees, though he was relatively comfortable and free of other new

symptoms.Wemadeitinandoutoftheemergencyroomwithinafewhours,Paul’s

father and Suman with us, returning home to the rest of the family after starting

antibioticsincaseofpneumonia(Paul’schestX-raywasdensewithtumors,which

couldobscureaninfection).Butwasthis,instead,thecancerprogressingrapidly?

Paulnappedcomfortablyintheafternoon,buthewasgravelyill.IstartedtocryasI

watchedhimsleep,thencreptouttoourlivingroom,wherehisfather’stearsjoined

mine.Ialreadymissedhim.

Sundayevening,Paul’sconditionworsenedabruptly.Hesatontheedgeofour

bed, struggling to breathe—a startling change. I called an ambulance. When we

reenteredtheemergencyroom,Paulonagurneythistime,hisparentsclosebehind

us,heturnedtowardmeandwhispered,“Thismightbehowitends.”

“I’mherewithyou,”Isaid.

ThehospitalstaffgreetedPaulwarmly,asalways.Buttheymovedquicklyonce

they saw his condition. Afterinitial testing, they placed a mask over his nose and

mouthto help his breathing viaBiPAP, a breathing supportsystem thatsupplied a

strong mechanized flow of air each time he inhaled, doing much of the work of

breathingforhim.Thoughithelpswithrespiratorymechanics,BiPAPcanbehard

work fora patient—noisy and forceful, blowing one’s lips apart witheachbreath

likethoseofadogwithitsheadoutacarwindow.Istoodclose,leaningoverthe

gurney,myhandinPaul’sasthesteadywhoosh,whooshofthemachinebegan.

Paul’sbloodcarbondioxidelevelwascriticallyhigh,indicatingthatthework

ofbreathingwasoverwhelminghim.Bloodtestssuggestedthatsomeoftheexcess

carbondioxidehadbeenaccumulatingoverdaystoweeks,ashislungdiseaseand

debilityhadadvanced.Becausehisbrainhadslowlybecomeacclimatedtohigher-

than-normal levels of carbon dioxide, he remained lucid. He observed. He

understood,asaphysician,theominoustestresults.Iunderstoodthem,too,walking

behindhimashewaswheeledtoanintensive-careroom,onewheresomanyofhis

ownpatientshadstruggledbeforeorafterneurosurgery,theirfamiliesassembledin

vinylchairsbytheirbedsides.“WillIneedtobeintubated?”heaskedmebetween

BiPAPbreathswhenwearrived.“ShouldIbeintubated?”

Through the night, Paul discussed that question in a series of conversations

withhisphysicians,hisfamily,andthenjustme.Aroundmidnight,thecritical-care

attending,alongtimementortoPaul,cameintodiscusstreatmentoptionswiththe

family.BiPAPwasatemporarysolution,hesaid.Theonlyremainingintervention

wouldbeforPaultobeintubated—putonaventilator.Wasthatwhathewanted?

Thekeyquestionquicklycameintoview:Couldthesuddenrespiratoryfailure

bereversed?

Of concern was whether Paul would remain too ill to ever come off the

ventilator—wouldhebelosttodeliriumandthenorganfailure,firstmindandthen

body slipping away? We’d witnessed this agonizing scenario as physicians. Paul

explored the alternative: in lieu of intubation, he could choose “comfort care,”

thoughdeathwouldcomemoresurelyandswiftly.“EvenifImakeitthroughthis,”

hesaid,thinkingofthecancerinhisbrain,“I’mnotsureIseeafuturethatincludes

meaningful time.” His mother chimed in, desperately. “No decisions tonight,

Pubby,”shesaid. “Let’sallgetsomerest.”After ensuringhis“donotresuscitate”

status, Paul agreed. Sympathetic nurses brought him extra blankets. I switched off

thefluorescentlights.

Paul managed to doze until sunrise, his father sitting vigil while I napped

brieflyinanadjacent room,hopingto preservemymental strength,knowingthat

thefollowingdaymightbethehardestofmylife.IcreptbacktoPaul’sroomatsix

A.M., the lights still low, the intensive-care monitors chiming intermittently. Paul

opened his eyes. We talked again about “comfort care”—avoiding aggressive

attemptstoforestallhisdecline—andhewonderedaloudwhetherhecouldgohome.

HewassoillthatIworriedhemightsufferanddieontheway.However,IsaidI

woulddoeverythingpossibletotakehimhomeifthatwasmostimportanttohim,

noddingthatyes,comfortcaremightbethedirectionwewereheaded.Orwasthere

somewaytore-createhomehere?BetweenBiPAPpuffs,heanswered:“Cady.”

Cadyarrivedinshortorder—ourfriendVictoriahadretrievedherfromhome

—and began her own unwitting, cheerful vigil, happily nestled in the crook of

Paul’srightarm,tuggingathertinysocks,battingathishospitalblankets,smiling

andcooing,unbotheredbytheBiPAPmachineasitcontinuedtoblow,keepingPaul

alive.

Themedicalteamcamebyonrounds,discussingPaul’scaseoutsidetheroom,

wherehisfamilyandIjoinedthem.Paul’sacuterespiratoryfailurewaslikelyrapid

cancer progressing. His carbon dioxide level was rising still—a hardening

indication for intubation. The family was torn: Paul’s oncologist had phoned in,

hopefulthattheacuteproblemcouldbeameliorated,butthephysicianspresentwere

lessoptimistic.Ientreatedthemtoweighinwithasmuchconvictionaspossibleon

thechanceofreversinghisabruptdecline.

“He doesn’t want a Hail Mary,” I said. “If he doesn’t have a chance of

meaningfultime,hewantstotakethemaskoffandholdCady.”

IreturnedtoPaul’sbedside.Helookedatme,hisdarkeyesalertabovethenose

bridge of the BiPAP mask, and said clearly, his voice soft but unwavering, “I’m

ready.”

Ready,hemeant,toremovethebreathingsupport,tostartmorphine,todie.

The family gathered together. During the precious minutes after Paul’s

decision,weallexpressedourloveandrespect.TearsglistenedinPaul’seyes.He

expressed gratitude to his parents. He asked us to ensure that his manuscript be

published in some form. He told me a last time that he loved me. The attending

physiciansteppedinwithstrengtheningwords:“Paul,afteryoudie,yourfamilywill

fall apart, butthey’ll pull it back together because of the example of bravery you

set.”Jeevan’seyesweretrainedonPaulasSumansaid,“Goinpeace,mybrother.”

Withmyheartbreaking,Iclimbedintothelastbedwewouldshare.

I thought of other beds we’d shared. Eight years prior, as medical students,

we’dsleptsimilarlyensconcedinatwinbednexttomygrandfatherashelaydying

at home, having cut our honeymoon short to help with caregiving duties. We

awakenedeveryfewhourstogivehimmedications,myloveforPauldeepeningasI

watchedhimleaninandlistencloselytomygrandfather ’swhisperedrequests.We’d

neverhaveimaginedthisscene,Paul’sowndeathbed,sonearinourfuture.Twenty-

twomonthsago,we’dcriedinabedonanotherfloorofthissamehospitalaswe

learned of Paul’s cancer diagnosis. Eight months ago, we’d beentogether here in

my hospital bed the day after Cady was born, both napping, the first good, long

sleepI’dhadsinceher birth,wrappedineachother’sarms.Ithoughtofourcozy

bedemptyathome,rememberedfallinginloveinNewHaventwelveyearsearlier,

surprisedrightawaybyhowwellourbodiesandlimbsfittogether,andthoughtof

howeversince,we’dbothsleptbestwhenentwined.IhopedwithallIhadthathefelt

thatsamerestfulcomfortnow.

An hour later, the mask and monitors were off, and morphine was flowing

through Paul’s IV. He was breathing steadily but shallowly, and he appeared

comfortable. Nonetheless, I asked him whether he needed more morphine, and he

noddedyes,hiseyesclosed.Hismothersatclose;hisfather ’shandrestedatophis

head.Finally,heslippedintounconsciousness.

Formorethannine hours,Paul’s family—his parents,brothers,sister-in-law,

daughter, and I—sat vigil as Paul, unconscious, now drew increasingly halting,

infrequentbreaths,hiseyelidsclosed,hisfaceunburdened.Hislongfingersrested

softly in mine. Paul’s parents cradled Cady and then put her in the bed again to

snuggle,nurse,nap.Theroom,saturatedwithlove,mirroredthemanyholidaysand

weekendswehadallspenttogetherovertheyears.IstrokedPaul’shair,whispering,

“You’reabravePaladin”—mynicknameforhim—andsingingquietlyintohiseara

favorite jingle we’d made up over the previous months, its core message being

“Thankyouforlovingme.”Aclosecousinandunclearrived,andthenourpastor.

The family shared loving anecdotes and inside jokes; then we all took turns

weeping, studying Paul’s face and each other ’s with concern, steeped in the

preciousnessandpainofthistime,ourlasthoursalltogether.

Warm rays of evening light began to slant through the northwest-facing

windowoftheroomasPaul’sbreathsgrewmorequiet.Cadyrubbedhereyeswith

chubby fists as her bedtime approached, and a family friend arrived to take her

home.IheldhercheektoPaul’s,tuftsoftheirmatchingdarkhairsimilarlyaskew,

hisfaceserene,hersquizzicalbutcalm,hisbelovedbabyneversuspectingthatthis

momentwasafarewell.SoftlyIsangCady’sbedtimesong,toher,tobothofthem,

andthenreleasedher.

As the room darkened into night, a low wall lamp glowing warmly, Paul’s

breaths became faltering and irregular. His body continued to appear restful, his

limbsrelaxed.Justbeforenineo’clock,hislipsapartandeyesclosed,Paulinhaled

andthenreleasedonelast,deep,finalbreath.

—

WhenBreathBecomesAiris,inasense,unfinished,derailedbyPaul’srapiddecline,

butthatisanessentialcomponentofitstruth,oftherealityPaulfaced.Duringthe

last year of his life, Paul wrote relentlessly, fueled by purpose, motivated by a

tickingclock.Hestartedwithmidnightburstswhenhewasstillaneurosurgerychief

resident,softlytappingawayonhislaptopashelaynexttomeinbed;laterhespent

afternoons in his recliner, drafted paragraphs in his oncologist’s waiting room,

tookphonecallsfromhiseditorwhilechemotherapydrippedintohisveins,carried

hissilverlaptopeverywherehewent.Whenhisfingertipsdevelopedpainfulfissures

because of his chemotherapy, wefoundseamless,silver-linedglovesthat allowed

useofatrackpadandkeyboard.Strategiesforretainingthementalfocusneededto

write, despite the punishing fatigue of progressive cancer, were the focus of his

palliative-careappointments.Hewasdeterminedtokeepwriting.

This book carries the urgency of racing against time, of having important

thingstosay.Paulconfronteddeath—examinedit,wrestledwithit,acceptedit—asa

physician and a patient. He wanted to help people understand death and face their

mortality.Dyinginone’sfourthdecadeisunusualnow,butdyingisnot.“Thething

aboutlungcanceristhatit’snotexotic,”Paulwroteinanemailtohisbestfriend,

Robin.“It’sjusttragicenoughandjustimaginableenough.[Thereader]cangetinto

theseshoes,walkabit,andsay,‘Sothat’swhatitlookslikefromhere…sooneror

laterI’llbebackhereinmyownshoes.’That’swhatI’maimingfor,Ithink.Notthe

sensationalismofdying,andnotexhortationstogatherrosebuds,but:Here’swhat

liesupaheadontheroad.”Ofcourse,hedidmorethanjustdescribetheterrain.He

traverseditbravely.

Paul’sdecisionnottoaverthiseyesfromdeathepitomizesafortitudewedon’t

celebrate enough in our death-avoidant culture. His strength was defined by

ambitionandeffort,butalsobysoftness,theoppositeofbitterness.Hespentmuch

ofhislifewrestlingwiththequestionofhowtoliveameaningfullife,andhisbook

explores that essential territory. “Always the seer is a sayer,” Emerson wrote.

“Somehowhis dream is told; somehow he publishes it with solemn joy.” Writing

thisbookwasa chancefor thiscourageousseer tobe asayer,to teachustoface

deathwithintegrity.

Mostofourfamilyandfriendswillhavebeenunaware,untilthepublicationof

this book, of the marital trouble Paul and I weathered toward the end of his

residency. But I am glad Paul wrote about it. It’s part of our truth, another

redefinition,apieceofthestruggleandredemptionandmeaningofPaul’slifeand

mine. His cancer diagnosis was like a nutcracker, getting us back into the soft,

nourishing meat of our marriage. We hung on to each other for his physical

survivalandouremotionalsurvival,ourlovestrippedbare.Weeachjokedtoclose

friends that the secret to saving a relationship is for one person to become

terminallyill.Conversely,weknewthatonetricktomanagingaterminalillnessis

tobedeeplyinlove—tobevulnerable,kind,generous,grateful.Afewmonthsafter

hisdiagnosis,wesangthehymn“TheServantSong”whilestandingsidebysidein

achurchpew,andthewordsvibratedwithmeaningaswefaceduncertaintyandpain

together:“Iwillshareyourjoyandsorrow/Tillwe’veseenthisjourneythrough.”

WhenPaultoldme,immediatelyafterhisdiagnosis,toremarryafterhedied,it

exemplified the way he would, throughout his illness, work hard to secure my

future.Hewasfiercelycommittedtoensuringthebestforme,inourfinances,my

career,whatmotherhoodwouldmean.Atthesametime,Iworkedhardtosecurehis

present, to make his remaining time the best it could be, tracking and managing

everysymptomandaspectofhismedicalcare—themostimportantdoctoringrole

ofmylife—whilesupportinghisambitions,listeningtohiswhisperedfearsaswe

embraced in the safety of our darkened bedroom, witnessing, acknowledging,

accepting,comforting.Wewereasinseparableaswehadbeenasmedicalstudents,

whenwewouldholdhandsduringlectures.Nowweheldhandsinhiscoatpocket

during walksoutsideafterchemotherapy,Paul in awintercoatand hat evenwhen

the weather turned warm. 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.

BothofusdrewstrengthfromPaul’sfamily,whobolsteredusasweweathered

his illness and supported us in bringing our own child into the family. Despite

stunninggriefovertheirson’sillness,hisparentsremainedanunwaveringsource

of comfort and security. Renting an apartment nearby, they visited often, Paul’s

father rubbing his feet, his mothermaking him Indian dosa withcoconut chutney.

Paul,Jeevan,andSumanloungedonoursofas,Paul’slegsproppeduptoalleviate

hisbackpain,discussingthe“syntax”offootballplays.Jeevan’swife,Emily,andI

laughed nearby while Cady and her cousins, Eve and James, napped. On those

afternoons,ourlivingroomfeltlikeasmall,safevillage.Laterinthatsameroom,

PaulwouldholdCadyinhiswritingchair,readingaloudworksbyRobertFrost,T.

S.Eliot,Wittgenstein,asIsnappedphotos.Suchsimplemomentsswelledwithgrace

andbeauty,andevenluck,ifsuchaconceptcanbesaidtoexistatall.Andyetwedid

feellucky,grateful—forfamily,forcommunity,foropportunity,forourdaughter,

for having risen to meet each other at a time when absolute trust and acceptance

were required.Although these lastfewyears have been wrenchingand difficult—

sometimesalmostimpossible—theyhavealsobeenthemostbeautifulandprofound

ofmylife,requiringthedailyactofholdinglifeanddeath,joyandpaininbalance

andexploringnewdepthsofgratitudeandlove.

Relyingonhisownstrengthandthesupportofhisfamilyandcommunity,Paul

faced each stageof his illness withgrace—not withbravado or amisguided faith

thathewould“overcome”or“beat”cancerbutwithanauthenticitythatallowedhim

togrievethelossofthefuturehehadplannedandforgeanewone.Hecriedonthe

dayhewasdiagnosed.Hecriedwhilelookingatadrawingwekeptonthebathroom

mirrorthatsaid,“Iwanttospendalltherestofmydaysherewithyou.”Hecriedon

hislastdayintheoperatingroom.Helethimselfbeopenandvulnerable,lethimself

be comforted. Even while terminally ill, Paul was fully alive; despite physical

collapse,heremainedvigorous,open,fullofhopenotforanunlikelycurebutfor

daysthatwerefullofpurposeandmeaning.

Paul’s voice in When Breath Becomes Air is strong and distinctive, but also

somewhatsolitary.Paralleltothisstoryaretheloveandwarmthandspaciousness

andradicalpermissionthatsurroundedhim.Weallinhabitdifferentselvesinspace

andtime.Hereheisasadoctor,asapatient,andwithinadoctor-patientrelationship.

He wrote with a clear voice, the voice of someone with limited time, a ceaseless

striver,thoughtherewereotherselvesaswell.Notfullycapturedinthesepagesare

Paul’ssense of humor—he waswickedlyfunny—or his sweetness andtenderness,

thevalueheplacedonrelationshipswithfriendsandfamily.Butthisisthebookhe

wrote;thiswashisvoiceduringthistime;thiswashismessageduringthistime;this

was what he wrote when he needed to write it. Indeed, the version of Paul I miss

most,moreeventhantherobust,dazzlingversionwithwhomIfirstfellinlove,is

thebeautiful,focusedmanhewasinhislastyear,thePaulwhowrotethisbook—

frailbutneverweak.

Paulwasproudofthisbook,whichwasaculminationofhisloveforliterature

—he once said that he found poetry more comforting than Scripture—and his

abilitytoforgefromhislifeacogent,powerfultaleoflivingwithdeath.WhenPaul

emailedhisbestfriendinMay2013toinformhimthathehadterminalcancer,he

wrote, “The good news is I’ve already outlived two Brontës, Keats, and Stephen

Crane.ThebadnewsisthatIhaven’twrittenanything.”Hisjourneythereafterwas

oneoftransformation—fromonepassionatevocationtoanother,fromhusbandto

father, and finally, of course, from life to death, the ultimate transformation that

awaits us all. I am proud to have been his partner throughout,including while he

wrotethisbook,anactthatallowedhimtolivewithhope,withthatdelicatealchemy

ofagencyandopportunitythathewritesaboutsoeloquently,untiltheveryend.

—

Paul was buried in a willow casket at the edge of a field in the Santa Cruz

Mountains,overlookingthePacificOceanandacoastlinestuddedwithmemories—

brisk hikes, seafood feasts, birthday cocktails. Two months before, on a warm

weekendinJanuary,we’ddippedCady’schubbyfeetintothebrinywateratabeach

below.Hewasunattachedtothefateofhisbodyafterhedied,andheleftittousto

makedecisionsonhisbehalf.Ibelievewechosewell.Paul’sgravelookswest,over

five miles of green hillcrests, tothe ocean. Aroundhim are hills covered in wild

grass, coniferous trees, and yellow euphorbia. As you sit down, you hear wind,

chirpingbirds,thescufflingofchipmunks.Hemadeithereonhisownterms,and

hisgravesitefeelsappropriatelyfullofruggednessandhonor,aplacehedeserves

to be—a place we all deserve to be. I am reminded of a line from a blessing my

grandfather liked: “We shall rise insensibly, and reach the tops of the everlasting

hills,wherethewindsarecoolandthesightisglorious.”

And yet this is not always an easy place to be. The weather is unpredictable.

BecausePaulisburiedonthewindwardsideofthemountains,Ihavevisitedhimin

blazingsun,shroudingfog,andcold,stingingrain.Itcanbeasuncomfortableasit

ispeaceful,bothcommunalandlonely—likedeath,likegrief—butthereisbeautyin

allofit,andIthinkthisisgoodandright.

I visit his grave often, taking a small bottle of Madeira, the wine of our

honeymoon destination. Each time, I pour some out on the grass for Paul. When

Paul’sparentsandbrothersarewithme,wetalkasIrubthegrassasifitwerePaul’s

hair.Cadyvisitshisgravebeforehernap,lyingonablanket,watchingtheclouds

pass overhead and grabbing at the flowers we’ve laid down. The evening before

Paul’smemorial service, oursiblingsandI gatheredwithtwenty of Paul’s oldest,

closestfriends,andIwonderedbrieflyifwe’dmarthegrassbecausewepouredout

somuchwhiskey.

OftenIreturntothegraveafterleavingflowers—tulips,lilies,carnations—to

findtheheadseatenbydeer.It’sjustasgoodausefortheflowersasany,andone

Paulwouldhaveliked.Theearthisquicklyturnedoverbyworms,theprocessesof

naturemarchingon,remindingmeofwhatPaulsawandwhatInowcarrydeepin

mybones,too:theinextricabilityoflifeanddeath,andtheabilitytocope, tofind

meaningdespitethis,becauseofthis.WhathappenedtoPaulwastragic,buthewas

notatragedy.

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.Paulisgone,andImiss

himacutelynearlyeverymoment,butIsomehowfeelI’mstilltakingpartinthelife

we created together. “Bereavement is not the truncation of married love,” C. S.

Lewiswrote,“butoneofitsregularphases—likethehoneymoon.Whatwewantis

to live our marriage well and faithfully through that phase too.” Caring for our

daughter, nurturing relationships with family, publishing this book, pursuing

meaningfulwork,visitingPaul’sgrave,grievingandhonoringhim,persisting…my

lovegoeson—liveson—inawayI’dneverexpected.

WhenIseethehospitalwherePaullivedanddiedasaphysicianandapatient,I

understand that had he lived, he would have made great contributions as a

neurosurgeonandneuroscientist.Hewouldhavehelpedcountlesspatientsandtheir

familiesthroughsomeofthemostchallengingmomentsoftheirlives,thetaskthat

drewhimtoneurosurgeryinthefirstplace.Hewas,andwouldhavecontinuedto

be,agoodpersonandadeepthinker.Instead,thisbookisanewwayforhimtohelp

others, a contributiononly he could make. This doesn’t make his death, our loss,

anylesspainful.Buthefoundmeaninginthestriving.Onpage115ofthisbook,he

wrote,“Youcan’teverreachperfection,butyoucanbelieveinanasymptotetoward

which you are ceaselessly striving.” It was arduous, bruising work, and he never

faltered.Thiswasthelifehewasgiven,andthisiswhathemadeofit.WhenBreath

BecomesAiriscomplete,justasitis.

Two days after Paul died, I wrote a journal entry addressed to Cady: “When

someone dies, people tend to say greatthings about him. Please knowthat all the

wonderfulthingspeoplearesayingnowaboutyourdadaretrue.Hereallywasthat

good and that brave.” Reflecting on his purpose, I often think of lyrics from the

hymnderivedfromThePilgrim’sProgress:“Whowouldtruevaloursee,/Lethim

comehither…/Thenfanciesflyaway,/He’llfearnotwhatmensay,/He’lllabour

night and day / To be a pilgrim.” Paul’s decision to look death in the eye was a

testamentnotjusttowhohewasinthefinalhoursofhislifebutwhohehadalways

been.Formuchofhislife,Paulwonderedaboutdeath—andwhetherhecouldfaceit

withintegrity.Intheend,theanswerwasyes.

Iwashiswifeandawitness.

ForCady

ACKNOWLEDGMENTS

Thank youto Dorian Karchmar, Paul’s agent at William MorrisEndeavor, whose

fierce support and nurturing gave Paul the confidence that he could write an

important book. And to Andy Ward, Paul’s editor at Random House, whose

determination,wisdom,andeditorialtalentmadePauleagertoworkwithhim,and

whosehumorandcompassionmadePaulwanttobefriendhim.WhenPaulaskedhis

family—literally his dying wish—to shepherd this book to publication

posthumously, I was able to promise him that we would, because of our shared

confidenceinDorianandAndy.Atthattime,themanuscriptwasjustanopenfileon

hiscomputer,butthankstotheirtalentanddedication,IbelievePauldiedknowing

thatthese wordswouldmaketheirwayintotheworld andthat,throughthem,our

daughter would come to know him. Thank you to Abraham Verghese for a

foreword that would have thrilled Paul (my only objection being that what Dr.

Verghese judged to be a “prophet’s beard” was really an “I-don’t-have-time-to-

shave”beard!).IamgratefultoEmilyRappforherwillingnesstomeetmeinmy

griefandcoachmethroughtheepilogue,teachingme,asPauldid,whatawriteris

andwhywriterswrite.Thankyoutoallwhohavesupportedourfamily,including

thereadersofthisbook.Finally,thankyoutotheadvocates,clinicians,andscientists

working tirelesslyto advance lung cancer awarenessand research, aiming to turn

evenadvancedlungcancerintoasurvivabledisease.

LucyKalanithi

PAULKALANITHIwasaneurosurgeonandwriter.HegrewupinKingman,Arizona,andgraduatedfrom

Stanford University with a BA and MA in English literature and a BA in human biology. He earned an

MPhilinhistoryandphilosophyofscienceandmedicinefromtheUniversityofCambridgeandgraduated

cumlaudefromtheYaleSchoolofMedicine,wherehewasinductedintotheAlphaOmegaAlphanational

medicalhonorsociety.HereturnedtoStanfordtocompletehisresidencytraininginneurologicalsurgery

and a postdoctoral fellowship in neuroscience, during which he received the American Academy of

NeurologicalSurgery’s highestawardfor research.Hedied in March2015.Heis survivedby hislarge,

lovingfamily,includinghiswife,Lucy,andtheirdaughter,ElizabethAcadia.

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