Arabella: Hi averstance community! This is Arabella. Welcome to averstance Take.
Margo: Margo here! How are you guys? Hope you are doing well. You look nice today!
Arabella: We will discuss the book When Breath Becomes Air by Paul Kalanithi.
Arabella: He spent his entire life studying what makes life meaningful, looking for answers in literature and philosophy, only to find himself confronting the question head-on, not as a philosopher, but as a neurosurgeon and then, ultimately, as a patient.
Margot: It's a profound story. However, the idea of finding the “meaning of life” can sound a bit lofty and abstract. He starts with books, right? Deep in literature.
Arabella: Exactly. He grew up in Kingman, Arizona, and his mother was determined to provide him and his brothers with more than what a rural education could offer. She gave them a college reading list, and he just devoured it. He became captivated by literature, studying it at Stanford because he wanted to find the language that gave depth to human experiences.
Margot: I get that. I remember reading certain books in college and feeling like my whole world cracked open. For me, it was Virginia Woolf. The way she wrote about consciousness felt more real than reality. But how do you go from that to wanting to cut into people's brains? It feels like a massive jump.
Arabella: He made the jump because he felt words were not enough. Alongside literature, he also studied biology and neuroscience because he was fascinated with how the brain, this physical organ, was involved in creating meaning. He had this experience during his senior year when his class visited a facility for people with traumatic brain injuries. He was horrified that families had stopped visiting. His professor, someone he respected, told him that sometimes it is better if patients in that state do not survive.
Margot: Wow. That's a cold dose of reality.
Arabella: It was. He was angry at first, but it sparked a question in him: when the brain fails and our ability to connect and make meaning is lost, is that life still worth living? He realized that to find the answers he was looking for truly, he could not just study them; he had to be on the front lines, in a relationship with people who were facing life and death. That's why he chose neurosurgery. He saw neurosurgeons as treating not just the brain but the spirit and identity of the person.
Margot: Okay, I can see the logic there, moving from the theoretical to the practical. But the reality of being a doctor, especially a surgeon, is grueling. I had a friend in med school, and the person who went in was not the same person who came out. The empathy gets beaten out of you.
Arabella: Paul talks about that exact process. He describes how, in anatomy class, the pendulum swings between seeing the cadaver as a former human and seeing it as a mere specimen you carve up. He says the humanity is eventually drained from you until you are a hardened professional. He even tells this story that makes me cringe every time.
Margot: Go on.
Arabella: A motorcycle trauma patient came into the ER while he was eating an ice cream sandwich. He stashed it and went to work on the patient, who sadly did not survive. After they pronounced him dead, Paul remembered his snack and snuck back into the trauma room to retrieve the ice cream sandwich before it melted right there in front of the body. He had this moment of reckoning, questioning if his professional expertise had completely eroded his morality.
Margot: That is uncomfortably human. It reminds me of a time years ago when my dad was in the hospital. I was so wrapped up in the logistics—talking to doctors, calling family, figuring out insurance—that I went down to the cafeteria. I remember getting angry that they were out of the soup I wanted. And it hit me like a ton of bricks: my dad is upstairs, possibly dying, and I am obsessing over soup. It's a weird, protective numbness, I think.
Arabella: I think you are right. Paul calls it adapting your baseline of normalcy to the environment. But he had a turning point. A friend from medical school died, and he realized he had been processing her death like he would any other patient. He felt this crushing guilt for every time he had failed to see his patients as suffering individuals and just moved through their pain like a worker on a factory line.
Margot: So what did he do? How do you change that in a system that demands efficiency over empathy?
Arabella: He decided to embrace what he calls the “pastoral role” of a physician. It meant he was no longer just a brilliant surgeon. He became a companion, guiding patients and their families through their grief. He stopped spewing statistics and learned to deliver hard news a spoonful at a time, allowing their emotional states to guide his words. He believed human relationality was paramount. Before he would even decide to operate, he needed to understand the patient's mind, what they lived for, what they valued, and what they could or could not live without.
Margot: That sounds like the doctor everyone wishes they had. But it also sounds emotionally exhausting. Did he ever burn out?
Arabella: He describes it as emotionally taxing, admitting he'd sometimes just start crying on the drive home. But he said he never questioned its value. And then, the ultimate irony happens. Just as he is at the peak of his career, about to graduate, with prestigious job offers lined up, he gets his diagnosis.
Margot: The doctor becomes the patient.
Arabella: Precisely. He looked at his own CT scan and knew what it was. He says that at that moment, everything he had worked for, the entire future he had planned with his wife, Lucy, just vanished. He, the expert guide, was now wholly lost. Death was no longer an associate he worked with; it was an adversary sitting right across from him, and he no longer knew how to negotiate with it.
Margot: That must have been terrifying, after spending your life thinking about this from one perspective, to have it flipped entirely. I had a minor health scare last year, nothing like his, but for a few weeks, the world just looked different. The future felt like a locked door. The way he describes his identity just slipping away. I get that. My work and plans have a profound impact on my identity. If that gets taken away, what's left?
Arabella: That became his central question. His oncologist, Dr. Emma Hayward, was terrific. She kept focusing the conversation on his values and his ability to get back to work, trying to preserve his identity. He started a new treatment, a pill called Tarceva, and it worked. His cancer stabilized. And he did it. He went back to work. He returned to the operating room.
Margot: That's incredible. But how could life be the same?
Arabella: It wasn't. He said that fortitude replaced the joy he used to feel. He was constantly managing the side effects of his illness. And then, seven months after he returned, a scan showed a new, sizable tumor in his lung. His career as a neurosurgeon was over for good.
Margot: Devastating. After fighting so hard to get back.
Arabella: It was. But what strikes me about his final months is how he tried to find a new way to live. He and Lucy decided to have a child, reasoning that if human relationality is the foundation of a meaningful life, a child could only enhance that. Their daughter, Cady, was born. Paul writes that holding her gave him a sense of peaceful calm in his dying days that he had never known.
Margot: He found his meaning right there, in that relationship.
Arabella: He did. Lucy, who wrote the epilogue, says Paul died in the hospital on March 9, 2015. In his final hours, he decided to move to comfort care. He held Cady in his arms, told Lucy he loved her, and said, “I'm ready.” He wanted this book published to help guide others. He couldn't be a doctor anymore, but he could still be a guide. His wife writes that he wanted to face his mortality with grace and help others do the same. He didn't fight reality; he mourned the life he lost and did his best to create something new in its place.
Margo: And that is our take on When Breath Becomes Air by Paul Kalanithi. Hope you enjoyed the podcast.
Arabella: See you next time for another averstance Take. Which topic do you want us to tackle next? Magnify the Unheard Voice and Assert Your Stand
