WhenBreathBecomesAirPaulKalanithiRandomHousePublishingGroup(2016)

Copyright©2016byCorcovado,Inc.Forewordcopyright©2016byAbrahamVerghese

Allrightsreserved.

PublishedintheUnitedStatesbyRandomHouse,animprintanddivisionofPenguinRandomHouseLLC,NewYork.

RANDOMHOUSEandtheHOUSEcolophonareregisteredtrademarksofPenguinRandomHouseLLC.

LibraryofCongressCataloging-in-PublicationData

Names:Kalanithi,Paul,author.Title:Whenbreathbecomesair/PaulKalanithi;forewordbyAbrahamVerghese.

Description:NewYork:RandomHouse,2016.Identifiers:LCCN2015023815|ISBN9780812988406(hardback)|ISBN9780812988413(ebook)Subjects:LCSH:Kalanithi,Paul—Health.|Lungs—Cancer—Patients—UnitedStates—Biography.|Neurosurgeons—Biography.|Husbandandwife.|BISAC:BIOGRAPHY&AUTOBIOGRAPHY/

PersonalMemoirs.|MEDICAL/General.|SOCIALSCIENCE/Death&Dying.Classification:LCCRC280.L8K352016|DDC616.99/424—dc23LCrecordavailableat

http://lccn.loc.gov/2015023815

eBookISBN 9780812988413

randomhousebooks.com

BookdesignbyLizCosgrove,adaptedforeBook

Coverdesign:RachelAke

v4.1

ep

Contents

CoverTitlePageCopyrightEditor'sNoteEpigraphForewordbyAbrahamVerghese

Prologue

PartI:InPerfectHealthIBegin

PartII:CeaseNottillDeath

EpiloguebyLucyKalanithiDedicationAcknowledgmentsAbouttheAuthor

EVENTSDESCRIBEDAREBASEDonDr.Kalanithi’smemoryofreal-worldsituations.However,thenamesofallpatientsdiscussedinthisbook—ifgivenatall—havebeen changed. In addition, in each of themedical cases described, identifyingdetails—such as patients’ ages, genders, ethnicities, professions, familialrelationships, places of residence, medical histories, and/or diagnoses—havebeen changed. With one exception, the names of Dr. Kalanithi’s colleagues,friends, and treating physicians have also been changed. Any resemblance topersonslivingordeadresultingfromchangestonamesoridentifyingdetailsisentirelycoincidentalandunintentional.

Youthatseekwhatlifeisindeath,Nowfinditairthatoncewasbreath.Newnamesunknown,oldnamesgone:Tilltimeendbodies,butsoulsnone.

Reader!thenmaketime,whileyoube,Butstepstoyoureternity.

—BaronBrookeFulkeGreville,“Caelica83”

FOREWORDAbrahamVerghese

ITOCCURSTOME,as Iwrite this, that theforeword to thisbookmightbebetterthoughtofasanafterword.BecausewhenitcomestoPaulKalanithi,allsenseoftimeisturnedonitshead.Tobeginwith—or,maybe,toendwith—IgottoknowPaulonlyafterhisdeath.(Bearwithme.)Icametoknowhimmostintimatelywhenhe’dceasedtobe.

Imet him onememorable afternoon at Stanford in early February 2014.He’d justpublishedanop-ed titled“HowLongHaveIGotLeft?” inTheNewYorkTimes,anessaythatwouldelicitanoverwhelmingresponse,anoutpouringfrom readers. In the ensuing days, it spread exponentially. (I’m an infectiousdiseases specialist, so please forgive me for not using the word viral as ametaphor.) In theaftermathof that,he’dasked tocomeseeme, tochat, togetadviceaboutliteraryagents,editors,thepublishingprocess—hehadadesiretowriteabook,thisbook,theoneyouarenowholdinginyourhands.Irecallthesunfilteringthroughthemagnoliatreeoutsidemyofficeandlightingthisscene:Paulseatedbeforeme,hisbeautifulhandsexceedinglystill,hisprophet’sbeardfull,thosedarkeyestakingthemeasureofme.Inmymemory,thepicturehasaVermeer-like quality, a camera obscura sharpness. I remember thinking, Youmustrememberthis,becausewhatwasfallingonmyretinawasprecious.Andbecause, in the context of Paul’s diagnosis, I became aware of not just hismortalitybutmyown.

Wetalkedaboutalotofthingsthatafternoon.Hewasaneurosurgicalchiefresident.Wehadprobablycrossedpathsatsomepoint,butwehadn’tsharedapatient that we could recall. He toldme he had been an English and biologymajor as an undergraduate at Stanford, and then stayed on for a master’s inEnglishliterature.Wetalkedabouthislifelongloveofwritingandreading.IwasstruckbyhoweasilyhecouldhavebeenanEnglishprofessor—and,indeed,hehadseemedtobeheadeddownthatpathatonepoint inhis life.But then, justlike his namesake on the road toDamascus, he felt the calling.He became aphysicianinstead,butonewhoalwaysdreamedofcomingbacktoliteratureinsome form.Abook,perhaps.Oneday.He thoughthehad time, andwhynot?Andyetnowtimewastheverythinghehadsolittleof.

Irememberhiswry,gentlesmile,ahintofmischiefthere,eventhoughhisfacewasgauntandhaggard.He’dbeenthroughthewringerwiththiscancerbutanewbiological therapyhadproducedagood response, allowinghim to lookaheadabit.Hesaidduringmedicalschoolhe’dassumedthathewouldbecomeapsychiatrist, only to fall in love with neurosurgery. It wasmuchmore than afallinginlovewiththeintricaciesofthebrain,muchmorethanthesatisfactionof traininghishands toaccomplishamazingfeats—itwasa loveandempathyforthosewhosuffered,forwhattheyenduredandwhathemightbringtobear.Idon’tthinkhetoldmethisasmuchasIhadheardaboutthisqualityofhisfromstudentsofminewhowerehisacolytes:hisfiercebeliefinthemoraldimensionofhisjob.Andthenwetalkedabouthisdying.

After thatmeeting,we kept in touch by email, but never saw each otheragain. It was not just that I disappeared intomy ownworld of deadlines andresponsibilities but also my strong sense that the burden was on me to berespectfulofhistime.ItwasuptoPaulifhewantedtoseeme.Ifeltthatthelastthingheneededwastheobligationtoserviceanewfriendship.Ithoughtabouthimalot,though,andabouthiswife.Iwantedtoaskhimifhewaswriting.Washefindingthetime?Foryears,asabusyphysician,I’dstruggledtofindthetimeto write. I wanted to tell him that a famous writer, commiserating about thiseternalproblem,oncesaidtome,“IfIwereaneurosurgeonandIannouncedthatIhadtoleavemygueststogoinforanemergencycraniotomy,noonewouldsayaword.ButifIsaidIneededtoleavetheguestsinthelivingroomtogoupstairstowrite…”IwonderedifPaulwouldhavefoundthisfunny.Afterall,hecouldactually say hewas going to do a craniotomy! Itwas plausible!And then hecouldgowriteinstead.

WhilePaulwaswritingthisbook,hepublishedashort,remarkableessayinStanfordMedicine, in an issue thatwas devoted to the idea of time. I had anessay in the same issue, my piece juxtaposed to his, though I learned of hiscontributiononlywhenthemagazinewasinmyhands.Inreadinghiswords,Ihadasecond,deeperglimpseofsomethingofwhichtherehadbeenahintintheNewYorkTimesessay:Paul’swritingwassimplystunning.Hecouldhavebeenwritingaboutanything,anditwouldhavebeenjustaspowerful.Buthewasn’twriting about anything—hewaswriting about time andwhat itmeant to himnow,inthecontextofhisillness.Whichmadeitallsoincrediblypoignant.

Buthere’sthethingImustcomebackto:theprosewasunforgettable.Outofhispenhewasspinninggold.

I reread Paul's piece again and again, trying to understand what he hadbroughtabout.First,itwasmusical.IthadechoesofGalwayKinnell,almosta

prosepoem.(“Ifonedayithappens/youfindyourselfwithsomeoneyoulove/inacaféatoneend/ofthePontMirabeau,atthezincbar/wherewinestandsinupwardopeningglasses…” toquoteaKinnell line, fromapoem IonceheardhimreciteinabookstoreinIowaCity,neverlookingdownatthepaper.)Butitalsohadatasteofsomethingelse,somethingfromanantiqueland,fromatimebefore zinc bars. It finally came tome a fewdays laterwhen I picked up hisessay yet again: Paul’swritingwas reminiscent ofThomasBrowne’s.BrownehadwrittenReligioMediciintheproseof1642,withallitsarchaicspellingsandspeech.Asayoungphysician, Iwasobsessedwith thatbook,kept at it likeafarmertryingtodrainabogthathisfatherbeforehimhadfailedtodrain.Itwasa futile task, and yet I was desperate to learn its secrets, tossing it aside infrustration, thenpicking itupagain,unsure that ithadanything formebut, insoundingthewords,sensingthatitdid.IfeltthatIlackedsomecriticalreceptorfor the letters to sing, to impart theirmeaning. It remained opaque, nomatterhowhardItried.

Why,youask?WhydidIpersevere?WhocaresaboutReligioMedici?Well, my heroWilliam Osler cared, that’s who. Osler was the father of

modernmedicine,amanwhodiedin1919.Hehadlovedthebook.Hekeptitonhisnightstand.He’daskedtobeburiedwithacopyofReligioMedici.For thelifeofme, Ididn’tgetwhatOslersawin it.Aftermany tries—andaftersomedecades—thebookfinallyrevealeditself tome.(Ithelpedthatanewereditionhadmodernspellings.)Thetrick,Idiscovered,wastoreaditaloud,whichmadethe cadence inescapable: “We carrywith us thewonders,we seekwithout us:There is allAfrica, andher prodigies in us;we are that bold and adventurouspiece of nature, which he that studies, wisely learns in a compendium, whatotherslabouratinadividedpieceandendlessvolume.”WhenyoucometothelastparagraphofPaul’sbook,readitaloudandyouwillhearthatsamelongline,thecadenceyouthinkyoucantapyourfeetto…butaswithBrowne,youwillbejustoff.Paul,itoccurredtome,wasBrowneredux.(Orgiventhatforwardtimeis our illusion, perhaps it’s that Browne was Kalanithi redux. Yes, it’s head-spinningstuff.)

And then Paul died. I attended his memorial in the Stanford church, agorgeousspacewhereIoftengowhenitisemptytositandadmirethelight,thesilence,andwhereIalwaysfindrenewal.Itwaspackedfortheservice.Isatofftooneside,listeningtoaseriesofmovingandsometimesraucousstoriesfromhisclosestfriends,hispastor,andhisbrother.Yes,Paulwasgone,butstrangely,IfeltIwascomingtoknowhim,beyondthatvisitinmyoffice,beyondthefewessayshe’dwritten.HewastakingforminthosetalesbeingtoldintheStanford

Memorial Church, its soaring cathedral dome a fitting space in which torememberthismanwhosebodywasnowintheearthbutwhoneverthelesswasso palpably alive. He took form in the shape of his lovely wife and babydaughter,hisgrievingparentsandsiblings,inthefacesofthelegionsoffriends,colleagues, and former patients who filled that space; he was there at thereceptionlater,outdoorsinasettingwheresomanycametogether.Isawfaceslookingcalm,smiling,asiftheyhadwitnessedsomethingprofoundlybeautifulinthechurch.Perhapsmyfacewaslikethat,too:wehadfoundmeaningintheritual of a service, in the ritual of eulogizing, in the shared tears. There wasfurthermeaning residing in this receptionwherewe slaked our thirst, fed ourbodies, and talked with complete strangers to whom we were intimatelyconnectedthroughPaul.

ButitwasonlywhenIreceivedthepagesthatyounowholdinyourhands,twomonthsafterPauldied,thatIfeltIhadfinallycometoknowhim,toknowhimbetterthanifIhadbeenblessedtocallhimafriend.Afterreadingthebookyouareabouttoread,IconfessIfeltinadequate:therewasanhonesty,atruthinthewritingthattookmybreathaway.

Beready.Beseated.Seewhatcouragesoundslike.Seehowbraveitistoreveal yourself in this way. But above all, see what it is to still live, toprofoundlyinfluencethelivesofothersafteryouaregone,byyourwords.Inaworld of asynchronous communication, where we are so often buried in ourscreens, our gaze rooted to the rectangular objects buzzing in our hands, ourattention consumed by ephemera, stop and experience this dialogue with myyoungdepartedcolleague,nowagelessandextantinmemory.ListentoPaul.Inthesilencesbetweenhiswords,listentowhatyouhavetosayback.Thereinlieshismessage.Igotit.Ihopeyouexperienceit,too.Itisagift.LetmenotstandbetweenyouandPaul.

PROLOGUE

WebsterwasmuchpossessedbydeathAndsawtheskullbeneaththeskin;AndbreastlesscreaturesundergroundLeanedbackwardwithaliplessgrin.

—T.S.Eliot,“WhispersofImmortality”

I FLIPPEDTHROUGHTHECTscan images, thediagnosis obvious: the lungswerematted with innumerable tumors, the spine deformed, a full lobe of the liverobliterated.Cancer,widelydisseminated.Iwasaneurosurgicalresidententeringmy finalyearof training.Over the last sixyears, I’dexamined scoresof suchscans,ontheoffchancethatsomeproceduremightbenefitthepatient.Butthisscanwasdifferent:itwasmyown.

Iwasn’t in the radiology suite,wearingmy scrubs andwhite coat. Iwasdressedinapatient’sgown,tetheredtoanIVpole,usingthecomputerthenursehadleftinmyhospitalroom,withmywife,Lucy,aninternist,atmyside.Iwentthrough each sequence again: the lung window, the bone window, the liverwindow,scrollingfromtoptobottom,thenlefttoright,thenfronttoback,justasIhadbeentrainedtodo,asifImightfindsomethingthatwouldchangethediagnosis.

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

possibilitythatit’ssomethingelse?”“No,”Isaid.Weheld eachother tightly, like young lovers. In the past yearwe’dboth

suspected, but refused to believe, or even discuss, that a cancer was growinginsideme.

Aboutsixmonthsbefore,Ihadstartedlosingweightandhavingferociousback pain. When I dressed in the morning, my belt cinched one, then twonotches tighter. I went to seemy primary care doctor, an old classmate fromStanford.Hersisterhaddiedsuddenlyasaneurosurgeryintern,aftercontractingavirulentinfection,andsoshe’dtakenamaternalwatchonmyhealth.WhenIarrived,however,Ifoundadifferentdoctorinheroffice—myclassmatewasonmaternityleave.

Dressed in a thin blue gown on a cold examining table, I described thesymptoms to her. “Of course,” I said, “if thiswere a boards examquestion—

thirty-five-year-oldwithunexplainedweightlossandnew-onsetbackpain—theobviousanswerwouldbe (C)cancer.Butmaybe it’s just that I’mworking toohard.Idon’tknow.I’dliketogetanMRItobesure.”

“I think we should get X-rays first,” she said. MRIs for back pain areexpensive,andunnecessaryimaginghadlatelybecomeamajornationalpointofcost-saving emphasis. But the value of a scan also depends on what you arelookingfor:X-raysarelargelyuselessforcancer.Still,formanydocs,orderinganMRIat this early stage is apostasy.Shecontinued: “X-raysaren’tperfectlysensitive,butitmakessensetostartthere.”

“How about we get flexion-extension X-rays, then—maybe the morerealisticdiagnosishereisisthmicspondylolisthesis?”

Fromthereflectioninthewallmirror,Icouldseehergooglingit.“It’s a pars fracture affecting up to five percent of people and a frequent

causeofbackpainintheyoung.”“Okay,I’llorderthem,then.”“Thanks,”Isaid.Whywas I so authoritative in a surgeon’s coatbut someek in apatient's

gown?The truthwas, I knewmore aboutbackpain than shedid—halfofmytraining as a neurosurgeon had involved disorders of the spine. But maybe aspondywasmorelikely.Itdidaffectasignificantpercentofyoungadults—andcancerinthespineinyourthirties?Theoddsofthatcouldn’tbemorethanoneintenthousand.Evenifitwereonehundredtimesmorecommonthanthat,it’dstillbelesscommonthanaspondy.MaybeIwasjustfreakingmyselfout.

TheX-rayslookedfine.Wechalkedthesymptomsuptohardworkandanagingbody, scheduled a follow-up appointment, and Iwent back to finishmylastcaseoftheday.Theweightlossslowed,andthebackpainbecametolerable.Ahealthydoseofibuprofengotmethroughtheday,andafterall,thereweren’tthatmanyof thesegrueling, fourteen-hourdays left.Myjourneyfrommedicalstudent to professor of neurosurgery was almost complete: after ten years ofrelentless training, I was determined to persevere for the next fifteenmonths,until residencyended. Ihadearned the respectofmy seniors,wonprestigiousnationalawards,andwasfieldingjoboffersfromseveralmajoruniversities.MyprogramdirectoratStanfordhadrecentlysatmedownandsaid,“Paul,I thinkyou’llbe thenumberonecandidate forany jobyouapply for. JustasanFYI:we’ll be starting a faculty search for someone like you here.No promises, ofcourse,butit’ssomethingyoushouldconsider.”

Atagethirty-six,Ihadreachedthemountaintop;IcouldseethePromisedLand, from Gilead to Jericho to the Mediterranean Sea. I could see a nice

catamaranonthatseathatLucy,ourhypotheticalchildren,andIwouldtakeouton weekends. I could see the tension in my back unwinding as my workschedule eased and life became more manageable. I could see myself finallybecomingthehusbandI’dpromisedtobe.

Then,afewweekslater,Ibeganhavingboutsofseverechestpain.HadIbumped into something at work? Cracked a rib somehow? Some nights, I’dwake up on soaked sheets, dripping sweat.Myweight began dropping again,morerapidlynow,from175to145pounds.Idevelopedapersistentcough.Littledoubt remained.OneSaturday afternoon,Lucy and Iwere lying in the sun inDolores Park in San Francisco, waiting to meet her sister. She glimpsed myphone screen, which displayedmedical database search results: “frequency ofcancersinthirty-toforty-year-olds.”

“What?”shesaid.“Ididn’trealizeyouwereactuallyworriedaboutthis.”Ididn’trespond.Ididn’tknowwhattosay.“Doyouwanttotellmeaboutit?”sheasked.Shewasupsetbecauseshehadbeenworriedabout it, too.Shewasupset

becauseIwasn’ttalkingtoheraboutit.ShewasupsetbecauseI’dpromisedheronelife,andgivenheranother.

“Canyoupleasetellmewhyyouaren’tconfidinginme?”sheasked.Iturnedoffmyphone.“Let’sgetsomeicecream,”Isaid.

—

WewerescheduledforavacationthefollowingweektovisitsomeoldcollegefriendsinNewYork.Maybeagoodnight’ssleepandafewcocktailswouldhelpusreconnectabitanddecompressthepressurecookerofourmarriage.

ButLucyhadanotherplan.“I’mnotcomingtoNewYorkwithyou,”sheannouncedafewdaysbeforethetrip.Shewasgoingtomoveoutforaweek;shewanted time to consider the state of our marriage. She spoke in even tones,whichonlyheightenedthevertigoIfelt.

“What?”Isaid.“No.”“Iloveyousomuch,whichiswhythisissoconfusing,”shesaid.“ButI’m

worried we want different things from our relationship. I feel like we’reconnectedhalfway.Idon’twanttolearnaboutyourworriesbyaccident.WhenItalktoyouaboutfeelingisolated,youdon'tseemtothinkit’saproblem.Ineedtodosomethingdifferent.”

“Thingsaregoingtobeokay,”Isaid.“It’sjustresidency.”Werethingsreallysobad?Neurosurgicaltraining,amongthemostrigorous

and demanding of all medical specialties, had surely put a strain on ourmarriage.ThereweresomanynightswhenIcamehomelatefromwork,afterLucyhadgonetobed,andcollapsedonthelivingroomfloor,exhausted,andsomanymorningswhenIleftforworkintheearlydark,beforeshe’dawoken.Butour careers were peaking now—most universities wanted both of us: me inneurosurgery,Lucyininternalmedicine.We’dsurvivedthemostdifficultpartofourjourney.Hadn’twediscussedthisadozentimes?Didn’tsherealizethiswastheworstpossibletimeforhertoblowthingsup?Didn’tsheseethatIhadonlyone year left in residency, that I loved her, that we were so close to the lifetogetherwe’dalwayswanted?

“Ifitwerejustresidency,Icouldmakeit,”shesaid.“We’vemadeitthisfar.Buttheproblemis,whatifit’snotjustresidency?Doyoureallythinkthingswillbebetterwhenyou’reanacademicneurosurgeryattending?”

Iofferedtoskipthetrip,tobemoreopen,toseethecouplestherapistLucyhadsuggestedafewmonthsago,butsheinsistedthatsheneededtime—alone.Atthatpoint,thefuzzinessoftheconfusiondissipated,leavingonlyahardedge.Fine, I said. If shedecided to leave, then Iwouldassume the relationshipwasover.IfitturnedoutthatIhadcancer,Iwouldn’ttellher—she’dbefreetolivewhateverlifeshechose.

BeforeleavingforNewYork,Isnuckinafewmedicalappointmentstoruleout some common cancers in the young. (Testicular? No. Melanoma? No.Leukemia?No.)Theneurosurgicalservicewasbusy,asalways.ThursdaynightslippedintoFridaymorningasIwascaughtintheoperatingroomforthirty-sixhours straight, in a series of deeply complex cases: giant aneurysms,intracerebral arterialbypasses, arteriovenousmalformations. Ibreatheda silentthankswhentheattendingcamein,allowingmeafewminutestoeasemybackagainst a wall. The only time to get a chest X-ray was as I was leaving thehospital,on thewayhomebeforeheading to theairport. I figuredeither Ihadcancer, inwhich case thismight be the last time Iwould seemy friends, or Ididn’t,inwhichcasetherewasnoreasontocancelthetrip.

Irushedhometograbmybags.Lucydrovemetotheairportandtoldmeshehadscheduledusintocouplestherapy.

Fromthegate,Isentheratextmessage:“Iwishyouwerehere.”A fewminutes later, the response cameback: “I love you. Iwill be here

whenyougetback.”Myback stiffened terriblyduring the flight, andby the time Imade it to

GrandCentraltocatchatraintomyfriends’placeupstate,mybodywasripplingwithpain.Over thepast fewmonths, I’dhadbackspasmsofvarying ferocity,

from simple ignorable pain, to pain thatmademe forsake speech to grindmyteeth,topainsosevereIcurleduponthefloor,screaming.Thispainwastowardthemoresevereendofthespectrum.Ilaydownonahardbenchinthewaitingarea, feeling my back muscles contort, breathing to control the pain—theibuprofenwasn’ttouchingthis—andnamingeachmuscleasitspasmedtostaveofftears:erectorspinae,rhomboid,latissimus,piriformis…

Asecurityguardapproached.“Sir,youcan’tliedownhere.”“I’msorry,”Isaid,gaspingoutthewords.“Bad…back…spasms.”“Youstillcan’tliedownhere.”I’msorry,butI’mdyingfromcancer.Thewords lingeredonmytongue—butwhat if Iwasn’t?Maybe thiswas

just what people with back pain live with. I knew a lot about back pain—itsanatomy, its physiology, thedifferentwordspatientsused todescribedifferentkinds of pain—but I didn’t knowwhat it felt like.Maybe that’s all this was.Maybe.Ormaybe I didn’twant the jinx.Maybe I just didn’twant to say thewordcanceroutloud.

Ipulledmyselfupandhobbledtotheplatform.ItwaslateafternoonwhenIreachedthehouseinColdSpring,fiftymiles

north ofManhattan on theHudsonRiver, andwas greeted by a dozen ofmyclosest friends from years past, their cheers of welcome mixed with thecacophony of young, happy children. Hugs ensued, and an ice-cold dark andstormymadeitswaytomyhand.

“NoLucy?”“Suddenworkthing,”Isaid.“Verylast-minute.”“Oh,whatabummer!”“Say,doyoumindifIputmybagsdownandrestabit?”I had hoped a few days out of the OR, with adequate sleep, rest, and

relaxation—inshort,a tasteofanormal life—wouldbringmysymptomsbackintothenormalspectrumforbackpainandfatigue.Butafteradayortwo,itwascleartherewouldbenoreprieve.

IsleptthroughbreakfastsandshambledtothelunchtabletostareatampleplatesofcassouletandcrablegsthatIcouldn’tbringmyselftoeat.Bydinner,Iwas exhausted, ready for bed again. Sometimes I read to the kids, butmostlytheyplayedonandaroundme, leapingandyelling. (“Kids, I thinkUnclePaulneeds a rest.Why don’t you play over there?”) I remembered a day off as asummer camp counselor, fifteen years prior, sitting on the shore of a lake inNorthernCalifornia,withabunchof joyouskidsusingmeasanobstacle ina

convoluted game of Capture the Flag, while I read a book calledDeath andPhilosophy. Iusedtolaughat theincongruitiesofthatmoment:atwenty-year-oldamidthesplendoroftrees,lake,mountains,thechirpingofbirdsmixedwiththesquealofhappyfour-year-olds,hisnoseburiedinasmallblackbookaboutdeath.Onlynow, in thismoment, I felt theparallels: insteadofLakeTahoe, itwastheHudsonRiver;thechildrenwerenotstrangers’,butmyfriends’;insteadofabookondeathseparatingmefromthelifearoundme,itwasmyownbody,dying.

Onthethirdnight,IspoketoMike,ourhost,totellhimIwasgoingtocutthetripshortandheadhomethenextday.

“Youdon’tlooksogreat,”hesaid.“Everythingokay?”“Whydon’twegrabsomescotchandhaveaseat?”Isaid.In frontofhis fireplace, I said,“Mike, I think Ihavecancer.Andnot the

goodkind,either.”ItwasthefirsttimeI’dsaiditoutloud.“Okay,”hesaid.“Itakeitthisisnotsomeelaboratepracticaljoke?”“No.”Hepaused.“Idon’tknowexactlywhattoask.”“Well,Isuppose,first,IshouldsaythatIdon’tknowforafactthatIhave

cancer. I’m just pretty sure of it—a lot of the symptoms point that way. I’mgoingtogohometomorrowandsortitout.Hopefully,I’mwrong.”

Mikeofferedtotakemyluggageandsendithomebymail,soIwouldn’thavetocarryitwithme.Hedrovemetotheairportearlythenextmorning,andsix hours later I landed inSanFrancisco.Myphone rang as I stepped off theplane. Itwasmy primary care doctor, callingwith the chestX-ray result:mylungs, insteadofbeingclear, lookedblurry,as if thecameraaperturehadbeenleftopentoolong.Thedoctorsaidshewasn’tsurewhatthatmeant.

Shelikelyknewwhatitmeant.Iknew.Lucypickedmeupfromtheairport,butIwaiteduntilwewerehometotell

her.Wesatonthecouch,andwhenItoldher,sheknew.Sheleanedherheadonmyshoulder,andthedistancebetweenusvanished.

“Ineedyou,”Iwhispered.“Iwillneverleaveyou,”shesaid.Wecalledaclosefriend,oneoftheattendingneurosurgeonsatthehospital,

andaskedhimtoadmitme.Ireceivedtheplasticarmbraceletallpatientswear,putonthefamiliarlight

bluehospitalgown,walkedpastthenursesIknewbyname,andwascheckedintoaroom—thesameroomwhereIhadseenhundredsofpatientsovertheyears.In this room, I had sat with patients and explained terminal diagnoses andcomplexoperations;inthisroom,Ihadcongratulatedpatientsonbeingcuredofadiseaseandseentheirhappinessatbeingreturnedtotheirlives;inthisroom,Ihadpronouncedpatientsdead. Ihadsat in thechairs,washedmyhands in thesink, scrawled instructions on the marker board, changed the calendar. I hadeven,inmomentsofutterexhaustion,longedtoliedowninthisbedandsleep.NowIlaythere,wideawake.

Ayoungnurse,oneIhadn’tmet,pokedherheadin.“Thedoctorwillbeinsoon.”Andwiththat,thefutureIhadimagined,theonejustabouttoberealized,

theculminationofdecadesofstriving,evaporated.

PARTI

InPerfectHealthIBegin

ThehandoftheLORDwasuponme,andcarriedmeoutinthespiritoftheLORD,andsetmedowninthemidstofthevalleywhichwasfullofbones,Andcausedmetopassbythemroundabout:and,behold,therewereverymanyintheopenvalley;and,lo,theywereverydry.Andhesaiduntome,Sonofman,cantheseboneslive?

—Ezekiel37:1–3,KingJamestranslation

IKNEWWITHCERTAINTYthatIwouldneverbeadoctor.Istretchedoutinthesun,relaxing on a desert plateau just above our house.Myuncle, a doctor, like somanyofmyrelatives,hadaskedmeearlierthatdaywhatIplannedondoingfora career, now that I was heading off to college, and the question barelyregistered.Ifyouhadforcedmetoanswer,IsupposeIwouldhavesaidawriter,butfrankly,thoughtsofanycareeratthispointseemedabsurd.IwasleavingthissmallArizona town in a fewweeks, and I felt less like someone preparing toclimbacareer ladder thanabuzzingelectronabout toachieveescapevelocity,flingingoutintoastrangeandsparklinguniverse.

Ilaythereinthedirt,awashinsunlightandmemory,feelingtheshrinkingsize of this townof fifteen thousand, six hundredmiles frommynew collegedormitoryatStanfordandallitspromise.

Iknewmedicineonlybyitsabsence—specifically,theabsenceofafathergrowingup,onewhowent toworkbeforedawnand returned in thedark toaplateofreheateddinner.WhenIwasten,myfatherhadmovedus—threeboys,ages fourteen, ten,andeight—fromBronxville,NewYork,acompact,affluentsuburbjustnorthofManhattan,toKingman,Arizona,inadesertvalleyringedbytwomountainranges,knownprimarilytotheoutsideworldasaplacetogetgasenroutetosomewhereelse.Hewasdrawnbythesun,bythecostofliving—howelsewouldhepayforhissonstoattendthecollegesheaspiredto?—andby the opportunity to establish a regional cardiology practice of his own.Hisunyieldingdedicationtohispatientssoonmadehimarespectedmemberofthecommunity. When we did see him, late at night or on weekends, he was anamalgam of sweet affections and austere diktats, hugs and kisses mixed withstony pronouncements: “It’s very easy to be number one: find the guywho isnumber one, and score one point higher than he does.”He had reached somecompromise inhismind that fatherhoodcouldbedistilled; short, concentrated

(but sincere) bursts of high intensity could equal…whatever it was that otherfathersdid.AllIknewwas,ifthatwasthepriceofmedicine,itwassimplytoohigh.

Frommydesertplateau,Icouldseeourhouse,justbeyondthecitylimits,at the base of the Cerbat Mountains, amid red-rock desert speckled withmesquite, tumbleweeds,andpaddle-shapedcacti.Outhere,dustdevils swirledup from nothing, blurring your vision, then disappeared. Spaces stretched on,thenfellawayintothedistance.Ourtwodogs,MaxandNip,nevergrewtiredofthe freedom.Everyday, they’dventure forthandbringhomesomenewdeserttreasure: the leg of a deer, unfinished bits of jackrabbit to eat later, the sun-bleachedskullofahorse,thejawboneofacoyote.

My friends and I loved the freedom, too, and we spent our afternoonsexploring,walking, scavenging forbones and raredesert creeks.Having spentmypreviousyearsinalightlyforestedsuburbintheNortheast,withatree-linedmainstreetandacandystore,Ifoundthewild,windydesertalienandalluring.Onmyfirst trekalone,asa ten-year-old,Idiscoveredanold irrigationgrate. Iprieditopenwithmyfingers,lifteditup,andthere,afewinchesfrommyface,werethreewhitesilkenwebs,andineach,marchingalongonspindledlegs,wasa glistening black bulbous body, bearing in its shine the dreaded blood-redhourglass.Neartoeachspiderapale,pulsatingsacbreathedwiththeimminentbirthofcountlessmoreblackwidows.Horrorletthegratecrashshut.Istumbledback.Thehorrorcameinamixof“countryfacts”(Nothingismoredeadlythanthebiteoftheblackwidowspider)andtheinhumanpostureandtheblackshineandtheredhourglass.Ihadnightmaresforyears.

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,withthesecreatures.Forfun,whenmyfriendsandIdiscoveredawolfspider’snest,we’d drop an ant onto its outer limits andwatch as its entangled escapeattemptssentquiversdownthesilkstrands, into thespider’sdarkcentralhole,anticipatingthatfatalmomentwhenthespiderwouldburstfromitshollowsandseizethedoomedantinitsmandibles.“Countryfacts”becamemytermfortheruralcousinof theurban legend.AsI first learned them,countryfactsgrantedfairypowerstodesertcreatures,making,say,theGilamonsternolessanactualmonsterthantheGorgon.Onlyafterlivingoutinthedesertforawhiledidwerealize that some country facts, like the existence of the jackalope, had beendeliberately created to confuse city folk andamuse the locals. I once spent anhourconvincingagroupofexchangestudentsfromBerlinthat,yes,therewasa

particular species of coyote that lived inside cacti and could leap ten yards toattack its prey (like,well, unsuspectingGermans).Yet no one precisely knewwhere the truth layamid thewhirlingsand; foreverycountryfact thatseemedpreposterous,therewasonethatfeltsolidandtrue.Alwayscheckyourshoesforscorpions,forexample,seemedplaingoodsense.

WhenIwassixteen,Iwassupposedtodrivemyyoungerbrother,Jeevan,toschool.Onemorning,asusual, Iwasrunning late,andasJeevanwasstandingimpatiently in the foyer, yelling that he didn’t want to get detention againbecauseofmy tardiness, socould Ipleasehurry thehellup, I raceddown thestairs, threw open the front door…and nearly stepped on a snoozing six-footrattlesnake. Itwasanothercountry fact that ifyoukilleda rattlesnakeonyourdoorstep,itsmateandoffspringwouldcomeandmakeapermanentnestthere,likeGrendel’smother seeking her revenge. So Jeevan and I drew straws: theluckyonegrabbedashovel,theunluckyoneapairofthickgardeningglovesandapillowcase,andthroughaseriocomicdance,wemanagedtogetthesnakeintothepillowcase.Then,likeanOlympichammerthrower,Ihurledthewholeoutintothedesert,withplanstoretrievethepillowcaselaterthatafternoon,soasnottogetintroublewithourmother.

—

Of ourmany childhoodmysteries, chief among themwas notwhy our fatherdecidedtobringhisfamilyto thedesert townofKingman,Arizona,whichwegrewtocherish,buthowheeverconvincedmymothertojoinhimthere.Theyhadeloped,inlove,acrosstheworld,fromsouthernIndiatoNewYorkCity(heaChristian,sheaHindu,theirmarriagewascondemnedonbothsides,andledtoyears of familial rifts—my mother’s mother never acknowledged my name,Paul,insteadinsistingIbecalledbymymiddlename,Sudhir)toArizona,wheremymotherwasforcedtoconfrontanintractablemortalfearofsnakes.Eventhesmallest, cutest, most harmless red racer would send her screaming into thehouse,whereshe’dlockthedoorsandarmherselfwiththenearestlarge,sharpimplement—rake,cleaver,ax.

The snakes were a constant source of anxiety, but it was her children’sfuturethatmymotherfearedformostofall.Beforewemoved,myolderbrother,Suman, had nearly completed high school inWestchester County, where elitecollegesweretheexpectation.HewasacceptedtoStanfordshortlyafterarrivinginKingmanand left thehouse soon thereafter.ButKingman,we learned,wasnot Westchester. As my mother surveyed the Mohave County public schoolsystem,shebecamedistraught.TheU.S.censushadrecentlyidentifiedKingman

as the least educated district in America. The high school dropout rate wassomewherenorthof30percent.Fewstudentswentontocollege,andcertainlynone to Harvard, my father’s standard of excellence. Looking for advice, mymother called her friends and relatives from wealthy East Coast suburbs andfound some sympathetic, others gleeful that their children no longer had tocompetewiththesuddenlyeducation-starvedKalanithis.

Atnight,shebrokeintotears,sobbingaloneinherbed.Mymother,afraidthe impoverished school system would hobble her children, acquired, fromsomewhere,a“collegeprepreadinglist.”TrainedinIndiatobeaphysiologist,marriedattwenty-three,andpreoccupiedwithraisingthreekidsinacountrythatwasnotherown,shehadnotreadmanyofthebooksonthelistherself.Butshewouldmake sureherkidswerenotdeprived.Shemademe read1984when Iwastenyearsold;Iwasscandalizedbythesex,butitalsoinstilledinmeadeeploveof,andcarefor,language.

Endlessbooksandauthors followed,asweworkedourwaymethodicallydownthe list:TheCountofMonteCristo,EdgarAllanPoe,RobinsonCrusoe,Ivanhoe, Gogol, The Last of the Mohicans, Dickens, Twain, Austen, BillyBudd…BythetimeIwastwelve,Iwaspickingthemoutmyself,andmybrotherSuman was sending me the books he had read in college: The Prince, DonQuixote,Candide,LeMorteD’Arthur,Beowulf,Thoreau,Sartre,Camus.Someleftmoreof amark thanothers.BraveNewWorld foundedmy nascentmoralphilosophyandbecamethesubjectofmycollegeadmissionsessay, inwhichIarguedthathappinesswasnotthepointoflife.Hamletboremeathousandtimesthrough theusualadolescentcrises.“ToHisCoyMistress”andother romanticpoemsledmeandmyfriendsonvariousjoyfulmisadventuresthroughouthighschool—we often sneaked out at night to, for example, sing “American Pie”beneaththewindowof thecaptainof thecheerleadingteam.(Herfatherwasalocal minister and so, we reasoned, less likely to shoot.) After I was caughtreturning at dawn from one such late-night escapade, my worried motherthoroughly interrogated me regarding every drug teenagers take, neversuspecting that the most intoxicating thing I’d experienced, by far, was thevolumeofromanticpoetryshe’dhandedmethepreviousweek.Booksbecamemyclosestconfidants,finelygroundlensesprovidingnewviewsoftheworld.

Inherquesttoseethatherchildrenwereeducated,mymomdroveusmorethanahundredmilesnorth,tothenearestbigcity,LasVegas,sowecouldtakeourPSATs,SATs,andACTs.Shejoinedtheschoolboard,ralliedteachers,anddemanded thatAPclassesbeadded to thecurriculum.Shewasaphenom:shetook it upon herself to transform the Kingman school system, and she did.

Suddenly therewas a feeling inourhigh school that the twomountain rangesthat bounded the town no longer defined the horizon: itwaswhat lay beyondthem.

Senior year, my close friend Leo, our salutatorian and the poorest kid Iknew, was advised by the school guidance counselor, “You’re smart—youshouldjointhearmy.”

He told me about it afterward. “Fuck that,” he said. “If you’re going toHarvard,orYale,orStanford,thenIam,too.”

Idon’tknowifIwashappierwhenIgotintoStanfordorwhenLeogotintoYale.

Summerpassed,andsinceStanfordbeganclassesamonthlaterthaneveryotherschool,allofmyfriendsscattered,leavingmebehind.Mostafternoons,I’dtrekintothedesertaloneandnapandthinkuntilmygirlfriend,Abigail,gotoffhershiftatKingman’s lonecoffeeshop.Thedesertofferedashortcut, throughthe mountains and down into town, and hiking was more fun than driving.Abigailwasinherearlytwenties,astudentatScrippsCollegewho,wantingtoavoid loans,was takinga semesteroff to stockpile tuitionmoney. Iwas takenwithherworldliness,thesensethatsheknewsecretsoneonlylearnedatcollege—shehadstudiedpsychology!—andwe’doftenmeetasshegotoffwork.Shewasaharbingerofthesubrosa,thenewworldawaitingmeinjustafewweeks.One afternoon, I woke from my nap, looked up, and saw vultures circling,mistakingmeforcarrion.Icheckedmywatch;itwasalmostthree.Iwasgoingto be late. I dusted off my jeans and jogged the rest of the way through thedesert, until sand gave way to pavement, the first buildings appeared, and Irounded the corner to findAbigail, broom in hand, sweeping the coffee shopdeck.

“Ialreadycleanedtheespressomachine,”shesaid,“sonoicedlatteforyoutoday.”

Thefloorsswept,wewent inside.Abigailwalked to thecashregisterandpicked up a paperback she’d stashed there. “Here,” she said, tossing it atme.“Youshouldreadthis.You’realwaysreadingsuchhigh-culturecrap—whydon’tyoutrysomethinglowbrowforonce?”

It was a five-hundred-page novel called Satan: His Psychotherapy andCurebytheUnfortunateDr.Kassler,J.S.P.S.,byJeremyLeven.Itookithomeand read it in a day. It wasn’t high culture. It should have been funny, but itwasn’t. However, it did make the throwaway assumption that the mind wassimplytheoperationofthebrain,anideathatstruckmewithforce;itstartledmynaïve understanding of theworld. Of course, it must be true—what were our

brains doing, otherwise? Though we had free will, we were also biologicalorganisms—the brain was an organ, subject to all the laws of physics, too!Literatureprovideda richaccountofhumanmeaning; thebrain, then,was themachinery that somehow enabled it. It seemed likemagic. That night, in myroom, I opened upmy red Stanford course catalog,which I had read throughdozensoftimes,andgrabbedahighlighter.InadditiontoalltheliteratureclassesIhadmarked,Ibeganlookinginbiologyandneuroscienceaswell.

—

A few years later, I hadn’t thoughtmuchmore about a career but had nearlycompleteddegreesinEnglishliteratureandhumanbiology.Iwasdrivenlessbyachievement than by trying to understand, in earnest:Whatmakes human lifemeaningful? I still felt literature provided the best account of the life of themind, while neuroscience laid down the most elegant rules of the brain.Meaning, while a slippery concept, seemed inextricable from humanrelationships and moral values. T. S. Eliot’s The Waste Land resonatedprofoundly, relatingmeaninglessness and isolation, and thedesperatequest forhuman connection. I found Eliot’s metaphors leaking into my own language.Other authors resonated as well. Nabokov, for his awareness of how oursufferingcanmakeuscalloustotheobvioussufferingofanother.Conrad,forhishypertunedsenseofhowmiscommunicationbetweenpeoplecansoprofoundlyimpact their lives. Literature not only illuminated another’s experience, itprovided, I believed, the richestmaterial formoral reflection.Mybrief foraysinto the formal ethics of analytic philosophy felt dry as a bone, missing themessinessandweightofrealhumanlife.

Throughout college, my monastic, scholarly study of human meaningwouldconflictwithmyurgetoforgeandstrengthenthehumanrelationshipsthatformed that meaning. If the unexamined life was not worth living, was theunlived lifeworth examining?Heading intomy sophomore summer, I appliedfor two jobs: as an intern at the highly scientific Yerkes Primate ResearchCenter,inAtlanta,andasaprepchefatSierraCamp,afamilyvacationspotforStanford alumni on the pristine shores of FallenLeafLake, abutting the starkbeauty of Desolation Wilderness in Eldorado National Forest. The camp’sliterature promised, simply, the best summer of your life. Iwas surprised andflatteredtobeaccepted.YetIhadjustlearnedthatmacaqueshadarudimentaryform of culture, and I was eager to go to Yerkes and see what could be thenaturaloriginofmeaningitself.Inotherwords,IcouldeitherstudymeaningorIcouldexperienceit.

Afterdelayingforaslongaspossible,Ifinallychosethecamp.Afterward,Idroppedbymybiologyadviser’soffice to informhimofmydecision.WhenIwalkedin,hewassittingathisdesk,headinajournal,asusual.Hewasaquiet,amiablemanwithheavy-liddedeyes,butas I toldhimmyplans,hebecameadifferentpersonentirely:hiseyesshotopen,andhisfaceflushedred,flecksofspitspraying.

“What?”he said. “Whenyougrowup,areyougoing tobea scientistora…chef?”

EventuallythetermendedandIwasonthewindymountainroadtocamp,stillslightlyworriedthatI’dmadeawrongturninlife.Mydoubt,however,wasshort-lived. The camp delivered on its promise, concentrating all the idylls ofyouth: beauty manifest in lakes, mountains, people; richness in experience,conversation, friendships. Nights during a full moon, the light flooded thewilderness,soitwaspossibletohikewithoutaheadlamp.Wewouldhitthetrailat twoA.M., summiting thenearest peak,MountTallac, just before sunrise, theclear, starry night reflected in the flat, still lakes spread below us. Snuggledtogetherinsleepingbagsatthepeak,nearlytenthousandfeetup,weweatheredfrigidblastsofwindwithcoffeesomeonehadbeenthoughtfulenoughtobring.Andthenwewouldsitandwatchasthefirsthintofsunlight,alighttingeofdayblue,wouldleakoutoftheeasternhorizon,slowlyerasingthestars.Thedayskywouldspreadwideandhigh,until thefirstrayofthesunmadeanappearance.ThemorningcommutersbegantoanimatethedistantSouthLakeTahoeroads.Butcraningyourheadback,youcouldseetheday’sbluedarkenhalfwayacrossthesky,andtothewest,thenightremainedyetunconquered—pitch-black,starsinfullglimmer,thefullmoonstillpinnedinthesky.Totheeast,thefulllightofdaybeamedtowardyou;tothewest,nightreignedwithnohintofsurrender.Nophilosophercanexplainthesublimebetter thanthis,standingbetweendayandnight. It was as if this were themoment God said, “Let there be light!” Youcould not help but feel your specklike existence against the immensity of themountain, the earth, the universe, and yet still feel your own two feet on thetalus,reaffirmingyourpresenceamidthegrandeur.

This was summer at Sierra Camp, perhaps no different from any othercamp, but every day felt full of life, and of the relationships that give lifemeaning.Other nights found a group of us on the dining room deck, sippingwhiskeywith theassistantdirectorof thecamp,Mo,aStanfordalum takingabreakfromhisEnglishPhD,anddiscussingliteratureandtheweightymattersofpostadolescent life.ThenextyearhereturnedtohisPhD,andlaterhesentmehisfirstpublishedshortstory,summingupourtimetogether:

Suddenly,now,IknowwhatIwant.Iwantthecounselorstobuildapyre…andletmyashesdropandminglewith thesand.Losemybonesamongstthedriftwood,myteethamongstthesand….Idon’tbelieveinthewisdomofchildren,norinthewisdomoftheold.Thereisamoment,acusp,whenthesumofgatheredexperience isworndownby thedetailsof living.Weareneversowiseaswhenweliveinthismoment.

—

Backoncampus,Ididn’tmissthemonkeys.Lifefeltrichandfull,andoverthenexttwoyearsIkeptatit,seekingadeeperunderstandingofalifeofthemind.Istudied literature and philosophy to understand what makes life meaningful,studied neuroscience andworked in an fMRI lab to understand how the braincould give rise to an organism capable of findingmeaning in the world, andenriched my relationships with a circle of dear friends through variousescapades.WeraidedtheschoolcafeteriadressedasMongols;createdafullfakefraternity, completewith fake rush-week events, in our co-op house; posed infrontof thegatesatBuckinghamPalace inagorilla suit;broke intoMemorialChurchatmidnighttolieonourbacksandlistentoourvoicesechointheapse;andsoon.(ThenIlearnedthatVirginiaWoolfonceboardedabattleshipdressedasAbyssinian royalty, and, duly chastened, stopped boasting about our trivialpranks.)

Senior year, in one ofmy last neuroscience classes, on neuroscience andethics,wevisitedahomeforpeoplewhohadsufferedseverebraininjuries.Wewalkedintothemainreceptionareaandweregreetedbyadisconsolatewailing.Ourguide,afriendlythirty-somethingwoman, introducedherself tothegroup,butmyeyeshuntedforthesourceofthenoise.Behindthereceptioncounterwasa large-screen television showinga soapopera,onmute.Ablue-eyedbrunettewithwell-coiffedhair,herheadshakingslightlywithemotion,filledthescreenas shepleadedwith someoneoffcamera;zoomout, and therewasher strong-jawed, undoubtedly gravel-voiced lover; they embraced passionately. Thewailingrose inpitch.Isteppedcloser topeerover thecounter,andthere,onabluemat in front of the television, in a plain flower-print dress,was a youngwoman,maybetwenty,herhandsballedintofistspressedintohereyes,violentlyrockingbackandforth,wailingandwailing.Assherocked,Icaughtglimpsesofthebackofherhead,whereherhairhadwornaway,leavingalarge,palepatchofskin.

I stepped back to join the group, which was leaving to tour the facility.Talkingwiththeguide,Ilearnedthatmanyoftheresidentshadnearlydrowned

asyoungchildren.Lookingaround,Inoticedtherewerenoothervisitorsbesidesus.Wasthatcommon?Iasked.

At first, the guide explained, a familywill visit constantly, daily or eventwiceaday.Thenmaybeeveryotherday.Thenjustweekends.Aftermonthsoryears,thevisitstaperoff,untilit’sjust,say,birthdaysandChristmas.Eventually,mostfamiliesmoveaway,asfarastheycanget.

“Idon’tblamethem,”shesaid.“It’shardcaringforthesekids.”Afurychurnedinme.Hard?Ofcourseitwashard,buthowcouldparents

abandonthesekids?Inoneroom,thepatientslayoncots,mostlystill,arrangedinneatrowslikesoldiers inabarracks.IwalkeddownarowuntilImadeeyecontactwithoneof them.Shewas inher late teens,withdark, tangledhair. Ipaused and tried smiling at her, showing her I cared. I picked up one of herhands;itwaslimp.Butshegurgledand,lookingrightatme,smiled.

“Ithinkshe’ssmiling,”Isaidtotheattendant.“Couldbe,”shesaid.“Itcanbehardtotellsometimes.”ButIwassureofit.Shewassmiling.Whenwegotbacktocampus,Iwasthelastoneleftintheroomwiththe

professor.“So,what’dyouthink?”heasked.I ventedopenly about how I couldn’t believe that parents had abandoned

thesepoorkids,andhowoneofthemhadevensmiledatme.The professor was a mentor, someone who thought deeply about how

scienceandmoralityintersected.Iexpectedhimtoagreewithme.“Yeah,”hesaid.“Good.Goodforyou.Butsometimes,youknow,I think

it’sbetteriftheydie.”Igrabbedmybagandleft.Shehadbeensmiling,hadn’tshe?Only laterwouldI realize thatour triphadaddedanewdimension tomy

understandingofthefactthatbrainsgiverisetoourabilitytoformrelationshipsandmakelifemeaningful.Sometimes,theybreak.

—

Asgraduation loomed, Ihadanagging sense that therewas still far toomuchunresolved for me, that I wasn’t done studying. I applied for a master’s inEnglishliteratureatStanfordandwasacceptedintotheprogram.Ihadcometoseelanguageasanalmostsupernaturalforce,existingbetweenpeople,bringingourbrains,shielded incentimeter-thickskulls, intocommunion.Awordmeant

somethingonlybetweenpeople,andlife’smeaning,itsvirtue,hadsomethingtodowith thedepthof the relationshipswe form. Itwas the relational aspect ofhumans—i.e.,“humanrelationality”—thatundergirdedmeaning.Yetsomehow,this process existed in brains and bodies, subject to their own physiologicimperatives,pronetobreakingandfailing.Theremustbeaway,Ithought,thatthelanguageoflifeasexperienced—ofpassion,ofhunger,oflove—boresomerelationship, however convoluted, to the language of neurons, digestive tracts,andheartbeats.

AtStanford, I had thegood fortune to studywithRichardRorty, perhapsthegreatestlivingphilosopherofhisday,andunderhistutelageIbegantoseealldisciplinesascreatingavocabulary,asetof tools forunderstandinghumanlife in a particularway.Great literaryworks provided their own sets of tools,compellingthereadertousethatvocabulary.Formythesis,IstudiedtheworkofWalt Whitman, a poet who, a century before, was possessed by the samequestionsthathauntedme,whowantedtofindawaytounderstandanddescribewhathetermed“thePhysiological-SpiritualMan.”

As I finishedmy thesis, I could only conclude thatWhitmanhad had nobetter luck than the rest of us at building a coherent “physiological-spiritual”vocabulary,butat least theways inwhichhe’dfailedwere illuminating. Iwasalso increasingly certain that I had little desire to continue in literary studies,whosemainpreoccupationshadbeguntostrikemeasoverlypoliticalandaverseto science. One ofmy thesis advisers remarked that finding a community formyself in the literary world would be difficult, because most English PhDsreactedtoscience,asheputit,“likeapestofire,withsheerterror.”Iwasn’tsurewhere my life was headed. My thesis—“Whitman and the Medicalization ofPersonality”—was well-received, but it was unorthodox, including as muchhistoryofpsychiatryandneuroscienceasliterarycriticism.Itdidn’tquitefitinanEnglishdepartment.Ididn’tquitefitinanEnglishdepartment.

SomeofmyclosestfriendsfromcollegewereheadedtoNewYorkCitytopursuealifeinthearts—someincomedy,othersinjournalismandtelevision—andIbrieflyconsideredjoiningthemandstartinganew.ButIcouldn’tquiteletgo of the question: Where did biology, morality, literature, and philosophyintersect?Walkinghomefromafootballgameoneafternoon,theautumnbreezeblowing, I letmymindwander.Augustine’s voice in the garden commanded,“Takeupandread,”but thevoiceIheardcommandedtheopposite:“Setasidethebooksandpracticemedicine.”Suddenly,itallseemedobvious.Although—orperhapsbecause—myfather,myuncle,andmyelderbrotherwerealldoctors,medicinehadneveroccurredtomeasaseriouspossibility.Buthadn’tWhitman

himself written that only the physician could truly understand “thePhysiological-SpiritualMan”?

The next day, I consulted a premed adviser to figure out the logistics.Gettingreadyformedicalschoolwouldtakeaboutayearofintensecoursework,plustheapplicationtime,whichaddeduptoanothereighteenmonths.Itwouldmean letting my friends go to New York, to continue deepening thoserelationships,withoutme. Itwouldmean setting aside literature.But itwouldallowmeachancetofindanswersthatarenotinbooks,tofindadifferentsortofsublime, to forgerelationshipswith thesuffering,and tokeepfollowing thequestionofwhatmakes human lifemeaningful, even in the face of death anddecay.

Ibeganworking through thenecessarypremedicalcourses, loadinguponchemistry and physics. Reluctant to take a part-time job—it would slow mystudies—but unable to afford Palo Alto rent, I found an open window in anempty dormitory and climbed in. After a few weeks of squatting, I wasdiscoveredbythecaretaker—whohappenedtobeafriend.Sheprovidedakeyto the room and some useful warnings, like when the high school girls’cheerleading camps would be coming through. Thinking it wise to avoidbecomingaregisteredsexoffender,I’dpackatent,somebooksandgranola,andheaduptoTahoeuntilitwassafetoreturn.

Because themed school application cycle takes eighteenmonths, I had afreeyearoncemyclasseswereover.SeveralprofessorshadsuggestedIpursueadegreeinthehistoryandphilosophyofscienceandmedicinebeforedecidingtoleave academia for good. So I applied for, and was accepted into, the HPSprogram at Cambridge. I spent the next year in classrooms in the Englishcountryside, where I found myself increasingly often arguing that directexperience of life-and-death questions was essential to generating substantialmoralopinionsaboutthem.Wordsbegantofeelasweightlessasthebreaththatcarried them. Stepping back, I realized that I was merely confirming what Ialreadyknew:Iwantedthatdirectexperience.ItwasonlyinpracticingmedicinethatIcouldpursueaseriousbiologicalphilosophy.Moralspeculationwaspunycomparedtomoralaction.IfinishedmydegreeandheadedbacktotheStates.IwasgoingtoYaleformedicalschool.

—

Youwould think that the first timeyoucutupadeadperson,you’d feel abitfunny about it. Strangely, though, everything feels normal. The bright lights,stainlesssteeltables,andbow-tiedprofessorslendanairofpropriety.Evenso,

thatfirstcut,runningfromthenapeoftheneckdowntothesmalloftheback,isunforgettable.Thescalpelissosharpitdoesn’tsomuchcuttheskinasunzipit,revealingthehiddenandforbiddensinewbeneath,anddespiteyourpreparation,youarecaughtunawares,ashamedandexcited.Cadaverdissectionisamedicalriteofpassageandatrespassonthesacrosanct,engenderingalegionoffeelings:fromrevulsion,exhilaration,nausea,frustration,andaweto,astimepasses,themere tedium of academic exercise. Everything teeters between pathos andbathos: here you are, violating society’s most fundamental taboos, and yetformaldehyde is a powerful appetite stimulant, so you also crave a burrito.Eventually,asyoucompleteyourassignmentsbydissecting themediannerve,sawingthepelvisinhalf,andslicingopentheheart,thebathossupersedes:thesacredviolationtakesonthecharacterofyouraveragecollegeclass,repletewithpedants,classclowns,andtherest.Cadaverdissectionepitomizes,formany,thetransformationofthesomber,respectfulstudentintothecallous,arrogantdoctor.

Theenormityofthemoralmissionofmedicinelentmyearlydaysofmedschoolaseveregravity.Thefirstday,beforewegot to thecadavers,wasCPRtraining, my second time doing it. The first time, back in college, had beenfarcical, unserious, everyone laughing: the terribly acted videos and limblessplastic mannequins couldn’t have been more artificial. But now the lurkingpossibility that we would have to employ these skills someday animatedeverything.As I repeatedly slammedmy palm into the chest of a tiny plasticchild, I couldn’t help but hear, alongwithmy fellow students’ jokes, real ribscracking.

Cadavers reverse the polarity. The mannequins you pretend are real; thecadaversyoupretendarefake.Butthatfirstday,youjustcan’t.WhenIfacedmycadaver,slightlyblueandbloated,histotaldeadnessandtotalhumannesswereundeniable.TheknowledgethatinfourmonthsIwouldbebisectingthisman’sheadwithahacksawseemedunconscionable.

Yetthereareanatomyprofessors.Andtheadvicetheygaveuswastotakeonegoodlookatourcadaver’sfaceandthenleaveitcovered;itmakestheworkeasier.Justasweprepared,withdeepbreathsandearnestlooks,tounwrapourcadaver’s head, a surgeon stopped by to chat, leaningwith his elbows on thecorpse’s face. Pointing out various marks and scars on the naked torso, hereconstructedthepatient’shistory.Thisscarisfromaninguinalherniaoperation,thisoneacarotidendarterectomy;thesemarkshereindicatescratching,possiblyjaundice,highbilirubin;heprobablydiedofpancreaticcancer, thoughno scarfor that—killed him too quick. Meanwhile, I could not help but stare at theshiftingelbowsthat,witheachmedicalhypothesisandvocabularylesson,rolled

over this covered head. I thought: Prosopagnosia is a neurological disorderwhereinonelosestheabilitytoseefaces.PrettysoonIwouldhaveit,hacksawinhand.

Because after a few weeks, the drama dissipated. In conversations withnon–medical students, telling cadaver stories, I foundmyself highlighting thegrotesque,macabre,andabsurd,as if toreassure themthat Iwasnormal,eventhoughIwasspendingsixhoursaweekcarvingupacorpse.SometimesItoldofthemomentwhenIturnedaroundandsawaclassmate,thesortofwomanwhohad a mug decorated with puffy paint, tiptoeing on a stool, cheerfullyhammeringachiselintoawoman’sbackbone,splintersflyingthroughtheair.Itold thisstoryas if todistancemyself fromit,butmykinshipwasundeniable.Afterall,hadn’t I justaseagerlydisassembledaman’s ribcagewithapairofboltcutters?Evenworkingonthedead,withtheirfacescovered,theirnamesamystery,youfindthattheirhumanitypopsupatyou—inopeningmycadaver’sstomach, I found two undigestedmorphine pills,meaning that he had died inpain,perhapsaloneandfumblingwiththecapofapillbottle.

Ofcourse,thecadavers,inlife,donatedthemselvesfreelytothisfate,andthe languagesurrounding thebodies infrontofussoonchangedtoreflect thatfact.Wewere instructed to no longer call them “cadavers”; “donors”was thepreferred term.And yes, the transgressive element of dissection had certainlydecreased from the bad old days. (Students no longer had to bring their ownbodies, forstarters,as theydid in thenineteenthcentury.Andmedical schoolshad discontinued their support of the practice of robbing graves to procurecadavers—that looting itself a vast improvement over murder, a means oncecommonenoughtowarrantitsownverb:burke,whichtheOEDdefinesas“tokill secretly by suffocation or strangulation, or for the purpose of selling thevictim’sbody fordissection.”)Yet thebest-informedpeople—doctors—almostnever donated their bodies. How informed were the donors, then? As oneanatomyprofessorputittome,“Youwouldn’ttellapatientthegorydetailsofasurgeryifthatwouldmakethemnotconsent.”

Even if donors were informed enough—and they might well have been,notwithstanding one anatomy professor’s hedging—it wasn’t so much thethoughtofbeingdissected thatgalled. Itwas the thoughtofyourmother,yourfather, your grandparents being hacked to pieces bywisecracking twenty-two-year-old medical students. Every time I read the pre-lab and saw a term like“bonesaw,”IwonderedifthiswouldbethesessioninwhichIfinallyvomited.Yet I was rarely troubled in lab, even when I found that the “bone saw” inquestionwasnothingmorethanacommon,rustywoodsaw.TheclosestIever

cametovomitingwasnowherenearthelabbutonavisittomygrandmother’sgrave inNewYork, on the twentieth anniversaryof her death. I foundmyselfdoubled over, almost crying, and apologizing—not to my cadaver but to mycadaver’s grandchildren. In the midst of our lab, in fact, a son requested hismother’shalf-dissectedbodyback.Yes,shehadconsented,buthecouldn’tlivewiththat.IknewI’ddothesame.(Theremainswerereturned.)

Inanatomylab,weobjectifiedthedead,literallyreducingthemtoorgans,tissues, nerves, muscles. On that first day, you simply could not deny thehumanityofthecorpse.Butbythetimeyou’dskinnedthelimbs,slicedthroughinconvenientmuscles,pulledout the lungs, cutopen theheart, and removedalobeoftheliver,itwashardtorecognizethispileoftissueashuman.Anatomylab,intheend,becomeslessaviolationofthesacredandmoresomethingthatinterfereswithhappyhour,andthatrealizationdiscomfits.Inourrarereflectivemoments, we were all silently apologizing to our cadavers, not because wesensedthetransgressionbutbecausewedidnot.

It was not a simple evil, however. All of medicine, not just cadaverdissection,trespassesintosacredspheres.Doctorsinvadethebodyineverywayimaginable. They see people at theirmost vulnerable, theirmost scared, theirmost private. They escort them into theworld, and then back out. Seeing thebody as matter and mechanism is the flip side to easing the most profoundhuman suffering. By the same token, the most profound human sufferingbecomesamerepedagogicaltool.Anatomyprofessorsareperhapstheextremeendofthisrelationship,yettheirkinshiptothecadaversremains.Earlyon,whenImadealong,quickcutthroughmydonor’sdiaphragminordertoeasefindingthe splenic artery, our proctorwas both livid andhorrified.Not because I haddestroyed an important structure or misunderstood a key concept or ruined afuturedissectionbutbecauseIhadseemedsocavalieraboutit.Thelookonhisface,his inability tovocalizehissadness, taughtmemoreaboutmedicinethanany lecture I would ever attend. When I explained that another anatomyprofessorhadtoldmetomakethecut,ourproctor’ssadnessturnedtorage,andsuddenlyred-facedprofessorswerebeingdraggedintothehallway.

Other times, the kinship wasmuch simpler. Once, while showing us theruins of our donor’s pancreatic cancer, the professor asked, “How old is thisfellow?”

“Seventy-four,”wereplied.“That’smyage,”hesaid,setdowntheprobe,andwalkedaway.

—

Medical school sharpened my understanding of the relationship betweenmeaning,life,anddeath.IsawthehumanrelationalityIhadwrittenaboutasanundergraduate realized in the doctor-patient relationship. Asmedical students,wewere confrontedbydeath, suffering, and thework entailed in patient care,whilebeingsimultaneouslyshieldedfromtherealbruntofresponsibility,thoughwecouldspotitsspecter.Medstudentsspendthefirsttwoyearsinclassrooms,socializing, studying, and reading; it was easy to treat the work as a mereextensionofundergraduatestudies.Butmygirlfriend,Lucy,whomImetinthefirstyearofmedicalschool(andwhowouldlaterbecomemywife),understoodthesubtextoftheacademics.Hercapacitytolovewasbarelyfinite,andalessontome.Onenightonthesofainmyapartment,whilestudyingthereamsofwavylines that make up EKGs, she puzzled over, then correctly identified, a fatalarrhythmia.All atonce, itdawnedonherand shebegan tocry:wherever this“practiceEKG”hadcomefrom,thepatienthadnotsurvived.Thesquigglylineson that page were more than just lines; they were ventricular fibrillationdeterioratingtoasystole,andtheycouldbringyoutotears.

LucyandIattended theYaleSchoolofMedicinewhenShepNulandstilllectured there, but I knewhimonly inmycapacity as a reader.Nulandwas arenowned surgeon-philosopher whose seminal book about mortality,How WeDie,hadcomeoutwhenIwasinhighschoolbutmadeitintomyhandsonlyinmedical school. Few books I had read so directly and wholly addressed thatfundamentalfactofexistence:allorganisms,whethergoldfishorgrandchild,die.Iporedoveritinmyroomatnight,andrememberinparticularhisdescriptionofhisgrandmother’sillness,andhowthatonepassagesoperfectlyilluminatedtheways in which the personal, medical, and spiritual all intermingled. Nulandrecalled how, as a child, hewould play a game inwhich, using his finger, heindentedhisgrandmother’sskintoseehowlongittooktoresumeitsshape—apart of the aging process that, along with her newfound shortness of breath,showedher“gradualslideintocongestiveheartfailure…thesignificantdeclineintheamountofoxygenthatagedbloodiscapableoftakingupfromtheagedtissuesoftheagedlung.”But“whatwasmostevident,”hecontinued,“wastheslowdrawing away from life….By the timeBubbeh stopped praying, she hadstopped virtually everything else as well.” With her fatal stroke, NulandrememberedSirThomasBrowne’sReligioMedici:“Withwhatstrifeandpainswecomeintotheworldweknownot,but’tiscommonlynoeasymattertogetoutofit.”

IhadspentsomuchtimestudyingliteratureatStanfordandthehistoryofmedicineatCambridge,inanattempttobetterunderstandtheparticularitiesof

death, only to come away feeling like they were still unknowable to me.DescriptionslikeNuland’sconvincedmethatsuchthingscouldbeknownonlyface-to-face.Iwaspursuingmedicinetobearwitnesstothetwinnedmysteriesofdeath,itsexperientialandbiologicalmanifestations:atoncedeeplypersonalandutterlyimpersonal.

IrememberNuland,intheopeningchaptersofHowWeDie,writingaboutbeingayoungmedicalstudentaloneintheORwithapatientwhosehearthadstopped. In an act of desperation, he cut open the patient’s chest and tried topumphis heartmanually, tried to literally squeeze the life back into him.Thepatient died, and Nuland was found by his supervisor, covered in blood andfailure.

MedicalschoolhadchangedbythetimeIgotthere,tothepointwheresuchascenewassimplyunthinkable:asmedicalstudents,wewerebarelyallowedtotouchpatients, letaloneopen theirchests.Whathadnotchanged, though,wastheheroicspiritofresponsibilityamidbloodandfailure.Thisstruckmeasthetrueimageofadoctor.

—

ThefirstbirthIwitnessedwasalsothefirstdeath.IhadrecentlytakenStep1ofmymedicalboards,wrappinguptwoyearsof

intensive studyburied in books, deep in libraries, poring over lecture notes incoffeeshops,reviewinghand-madeflashcardswhilelyinginbed.Thenexttwoyears, then, I would spend in the hospital and clinic, finally putting thattheoretical knowledge to use to relieve concrete suffering, with patients, notabstractions, asmy primary focus. I started in ob-gyn,working the graveyardshiftinthelaboranddeliveryward.

Walkingintothebuildingasthesundescended,Itriedtorecallthestagesoflabor, thecorrespondingdilationof thecervix, thenamesof the“stations” thatindicatedthebaby’sdescent—anythingthatmightprovehelpfulwhenthetimecame. As a medical student, my task was to learn by observation and avoidgetting in theway.Residents,whohad finishedmedical school andwerenowcompletingtraininginachosenspecialty,andnurses,withtheiryearsofclinicalexperience,wouldserveasmyprimary instructors.But the fear still lurked—Icouldfeelitsfluttering—thatthroughaccidentorexpectation,I’dbecalledontodeliverachildbymyself,andfail.

Imademywaytothedoctors’ loungewhereIwastomeet theresident.Iwalked 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. Iintroducedmyself.

“Oh,hi,”shesaid.“I’mMelissa. I’llbe inhereor in thecall roomifyouneedme.ProbablythebestthingforyoutodoiskeepaneyeonpatientGarcia.She’satwenty-two-year-old,herewithpretermlaborandtwins.Everyoneelseisprettystandard.”

Betweenbites,Melissabriefedme,abarrageoffactsandinformation:Thetwinswere only twenty-three and a halfweeks old; the hopewas to keep thepregnancygoinguntil theyweremoredeveloped,however long thatmightbe;twenty-four weeks was considered the cusp of viability, and every extra daymade a difference; the patient was getting various drugs to control hercontractions.Melissa’spagerwentoff.

“Okay,”shesaid,swingingherlegsoffthecouch.“Igottago.Youcanhangouthere,ifyoulike.Wehavegoodcablechannels.Oryoucancomewithme.”

IfollowedMelissatothenurses’station.Onewallwaslinedwithmonitors,displayingwavytelemetrylines.

“What’sthat?”Iasked.“That’stheoutputofthetocometersandthefetalheartrates.Letmeshow

youthepatient.Shedoesn’tspeakEnglish.DoyouspeakSpanish?”Ishookmyhead.Melissabroughtmetotheroom.Itwasdark.Themother

layinabed,resting,quiet,monitorbandswrappedaroundherbelly,trackinghercontractionsandthetwins’heartratesandsendingthesignaltothescreensI’dseen at the nurses’ station. The father stood at the bedside holding his wife’shand, worry etched on his brow. Melissa whispered something to them inSpanish,thenescortedmeout.

Forthenextseveralhours,thingsprogressedsmoothly.Melissasleptinthelounge. I tried decoding the indecipherable scribbles in Garcia’s chart, whichwaslikereadinghieroglyphics,andcameawaywiththeknowledgethatherfirstnamewasElena, thiswasher secondpregnancy, shehad receivednoprenatalcare, and shehadno insurance. Iwrotedown thenamesof thedrugs shewasgetting andmade a note to look themup later. I read a little about prematurelabor in a textbook I found in the doctors’ lounge. Preemies, if they survived,apparently incurred high rates of brain hemorrhages and cerebral palsy. Thenagain,myolderbrother,Suman,hadbeenbornalmost eightweekspremature,threedecadesearlier,andhewasnowapracticingneurologist.Iwalkedovertothe nurse and asked her to teachme how to read those little squiggles on themonitor,whichwere no clearer tome than the doctors’ handwriting but couldapparently foretell calmordisaster.Shenoddedandbegan talkingme through

readingacontractionandthefetalhearts’reactiontoit, theway, ifyoulookedclosely,youcouldsee—

Shestopped.Worryflashedacrossherface.Withoutaword,shegotupandran into Elena’s room, then burst back out, grabbed the phone, and pagedMelissa.Aminutelater,Melissaarrived,bleary-eyed,glancedatthestrips,andrushed into the patient’s room,withme trailing behind. She flipped open hercellphone and called the attending, rapidly talking in a jargon I only partiallyunderstood.Thetwinswereindistress,Igathered,andtheironlyshotatsurvivalwasanemergencyC-section.

Iwascarriedalongwiththecommotionintotheoperatingroom.TheygotElena supine on the table, drugs running into her veins. A nurse franticallypainted the woman’s swollen abdomen with an antiseptic solution, while theattending, the resident, and I splashed alcohol cleanser on our hands andforearms.Imimickedtheirurgentstrokes,standingsilentlyastheycursedundertheirbreath.Theanesthesiologistsintubatedthepatientwhiletheseniorsurgeon,theattending,fidgeted.

“C’mon,”hesaid.“Wedon’thavealotoftime.Weneedtomovefaster!”Iwas standingnext to theattendingashe slicedopen thewoman’sbelly,

makingasinglelongcurvilinearincisionbeneathherbellybutton,justbelowtheapexofherprotuberantwomb.Itriedtofolloweverymovement,digginginmybrainfortextbookanatomicalsketches.Theskinslidapartatthescalpel’stouch.Heslicedconfidentlythroughthetoughwhiterectusfasciacoveringthemuscle,thensplitthefasciaandtheunderlyingmusclewithhishands,revealingthefirstglimpseof themelon-likeuterus.Heslicedthatopenaswell,andasmallfaceappeared, then disappeared amid the blood. In plunged the doctor’s hands,pullingoutone,thentwopurplebabies,barelymoving,eyesfusedshut,liketinybirds fallen too soon fromanest.With their bonesvisible through translucentskin, they lookedmore like the preparatory sketches of children than childrenthemselves.Toosmalltocradle,notmuchbiggerthanthesurgeon’shands,theywererapidlypassedtothewaitingneonatalintensivists,whorushedthemtotheneonatalICU.

With the immediate danger averted, the pace of the operation slowed,frenzyturningtosomethingresemblingcalm.Theodorofburntfleshwaftedupas the cautery arrested little spurts of blood. The uterus was sutured backtogether,thestitcheslikearowofteeth,bitingclosedtheopenwound.

“Professor, do you want the peritoneum closed?”Melissa asked. “I readrecentlythatitdoesn’tneedtobe.”

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

least,nomore than temporarily. I like to leave things theway I found them—let’ssewitbackup.”

The peritoneum is a membrane that surrounds the abdominal cavity.SomehowIhadcompletelymisseditsopening,andIcouldn’tseeitatallnow.Tome,thewoundlookedlikeamassofdisorganizedtissue,yettothesurgeonsithadanappreciableorder,likeablockofmarbletoasculptor.

Melissacalledfortheperitonealstitch,reachedherforcepsintothewound,andpulledupa transparent layerof tissuebetween themuscle and theuterus.Suddenly the peritoneum, and the gaping hole in it, was clear. She sewed itclosedandmovedontothemuscleandfascia,puttingthembacktogetherwithalargeneedle anda fewbig looping stitches.Theattending left, and finally theskinwas sutured together.Melissa askedme if Iwanted to place the last twostitches.

MyhandsshookasIpassedtheneedlethroughthesubcutaneoustissue.AsItighteneddownthesuture,Isawthattheneedlewasslightlybent.Theskinhadcometogetherlopsided,agloboffatpokingthrough.

Melissa sighed. “That’s uneven,” she said. “You have to just catch thedermallayer—youseethisthinwhitestripe?”

Idid.Notonlywouldmymindhavetobetrained,myeyeswould,too.“Scissors!”Melissacutoutmyamateurknots,resuturedthewound,applied

thedressing,andthepatientwastakentorecovery.AsMelissahadtoldmeearlier,twenty-fourweeksinuterowasconsidered

the edge of viability. The twins had lasted twenty-three weeks and six days.Their organswere present, but perhaps not yet ready for the responsibility ofsustaining life. They were owed nearly four more months of protecteddevelopmentinthewomb,whereoxygenatedbloodandnutrientscametothemthroughtheumbilicalcord.Nowoxygenwouldhavetocomethroughthelungs,and the lungswerenotcapableof thecomplexexpansionandgas transfer thatwas respiration. Iwent to see them in theNICU,each twinencased inaclearplastic incubator, dwarfed by large, beepingmachines, barely visible amid thetangleofwiresandtubes.Theincubatorhadsmallsideportsthroughwhichtheparents could strain to reach and gently stroke a leg or arm, providing vitalhumancontact.

The sunwas up,my shift over. Iwas sent home, the image of the twinsbeingextractedfromtheuterusinterruptingmysleep.Likeaprematurelung,Ifeltunreadyfortheresponsibilityofsustaininglife.

WhenIreturnedtoworkthatnight,Iwasassignedtoanewmother.Nooneanticipated problemswith this pregnancy. Thingswere as routine as possible;

today was even her actual due date. Along with the nurse, I followed themother’s steady progress, contractions racking her body with increasingregularity.Thenursereportedthedilationof thecervix,fromthreecentimeterstofivetoten.

“Okay,it’stimetopushnow,”thenursesaid.Turningtome,shesaid,“Don’tworry—we’llpageyouwhenthedelivery

isclose.”IfoundMelissainthedoctors’lounge.Aftersometime,theOBteamwas

calledintotheroom:deliverywasnear.Outsidethedoor,Melissahandedmeagown,gloves,andapairoflongbootcovers.

“Itgetsmessy,”shesaid.We entered the room. I stood awkwardly off to the side until Melissa

pushedmetothefront,betweenthepatient’slegs,justinfrontoftheattending.“Push!”thenurseencouraged.“Nowagain:justlikethat,onlywithoutthe

screaming.”Thescreamingdidn’tstop,andwassoonaccompaniedbyagushofblood

and other fluids. The neatness of medical diagrams did nothing to representNature, rednotonly in tooth andclawbut inbirth aswell. (AnAnneGeddesphotothiswasnot.)Itwasbecomingclearthatlearningtobeadoctorinpracticewasgoingtobeaverydifferenteducationfrombeingamedicalstudent intheclassroom. Reading books and answeringmultiple-choice questions bore littleresemblancetotakingaction,withitsconcomitantresponsibility.Knowingyouneed to be judicious when pulling on the head to facilitate delivery of theshoulder is not the same as doing it.What if I pulled too hard? (Irreversiblenerve injury, my brain shouted.) The head appeared with each push and thenretracted with each break, three steps forward, two steps back. I waited. Thehuman brain has rendered the organism’s most basic task, reproduction, atreacherous affair. That same brainmade things like labor and delivery units,cardiotocometers, epidurals, and emergency C-sections both possible andnecessary.

Istoodstill,unsurewhentoactorwhattodo.Theattending’svoiceguidedmyhandstotheemerginghead,andonthenextpush,Igentlyguidedthebaby’sshouldersasshecameout.Shewaslarge,plump,andwet,easilythreetimesthesizeofthebirdlikecreaturesfromthepreviousnight.Melissaclampedthecord,and I cut it. The child’s eyes opened and she began to cry. I held the baby amomentlonger,feelingherweightandsubstance,thenpassedhertothenurse,whobroughthertothemother.

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 tocelebrate, a riot of handshakes and hugs. I was a prophet returning from themountaintopwithnewsofajoyousnewcovenant!Allthemessinessofthebirthdisappeared;hereIhadjustbeenholdingthenewestmemberofthisfamily,thisman’sniece,thisgirl’scousin.

Returningtotheward,ebullient,IranintoMelissa.“Hey,doyouknowhowlastnight’stwinsaredoing?”Iasked.Shedarkened.BabyAdiedyesterdayafternoon;BabyBmanaged to live

notquitetwenty-fourhours,thenpassedawayaroundthetimeIwasdeliveringthe new baby. In that moment, I could only think of Samuel Beckett, themetaphors that, in those twins, reachedtheir terminal limit:“Onedaywewereborn,onedayweshalldie, thesameday, thesamesecond….Birthastrideofagrave,thelightgleamsaninstant,thenit’snightoncemore.”Ihadstoodnextto“thegravedigger”withhis“forceps.”Whathadtheselivesamountedto?

“You think that’s bad?” she continued. “Mostmotherswith stillborns stillhavetogothroughlaboranddeliver.Canyouimagine?Atleasttheseguyshadachance.”

Amatchflickersbutdoesnotlight.Themother’swailinginroom543,thesearing red rimsof the father’s lower eyelids, tears silently streakinghis face:thisflipsideofjoy,theunbearable,unjust,unexpectedpresenceofdeath…Whatpossiblesensecouldbemade,whatwordswerethereforcomfort?

“Wasittherightchoice,todoanemergencyC-section?”Iasked.“Noquestion,”shesaid.“Itwastheonlyshottheyhad.”“Whathappensifyoudon’t?”“Probably, they die. Abnormal fetal heart tracings show when the fetal

bloodisturningacidemic;thecordiscompromisedsomehow,orsomethingelseseriouslybadishappening.”

“But how do you know when the tracing looks bad enough? Which isworse,beingborntooearlyorwaitingtoolongtodeliver?”

“Judgmentcall.”What a call tomake. Inmy life, had I evermade a decision harder than

choosingbetweenaFrenchdipandaReuben?HowcouldIeverlearntomake,andlivewith,suchjudgmentcalls?Istillhadalotofpracticalmedicinetolearn,but would knowledge alone be enough, with life and death hanging in thebalance?Surely intelligencewasn’t enough;moral claritywasneeded aswell.Somehow,Ihadtobelieve,Iwouldgainnotonlyknowledgebutwisdom,too.After all, when I had walked into the hospital just one day before, birth and

deathhadbeenmerelyabstract concepts.Now Ihad seen thembothupclose.MaybeBeckett’sPozzoisright.Maybelife ismerelyan“instant,” toobrief toconsider. But my focus would have to be on my imminent role, intimatelyinvolvedwiththewhenandhowofdeath—thegravediggerwiththeforceps.

Not long after, my ob-gyn rotation ended, and it was immediately on tosurgical oncology.Mari, a fellowmed student, and Iwould rotate together.Afewweeksin,afterasleeplessnight,shewasassignedtoassistinaWhipple,acomplex operation that involves rearranging most abdominal organs in anattempt to resect pancreatic cancer, an operation in which a medical studenttypically stands still—or, at best, retracts—for up to nine hours straight. It’sconsideredtheplumoperationtobeselectedtohelpwith,becauseofitsextremecomplexity—only chief residents are allowed to actively participate. But it isgrueling,theultimatetestofageneralsurgeon’sskill.Fifteenminutesaftertheoperationstarted,IsawMariinthehallway,crying.ThesurgeonalwaysbeginsaWhipple by inserting a small camera through a tiny incision to look formetastases, as widespread cancer renders the operation useless and causes itscancellation. Standing there, waiting in the OR with a nine-hour surgerystretchingoutbeforeher,Marihadawhisperofathought:I’msotired—pleaseGod,lettherebemets.Therewere.Thepatientwassewnbackup,theprocedurecalledoff.Firstcamerelief,thenagnawing,deepeningshame.MariburstoutoftheOR,where,needingaconfessor,shesawme,andIbecameone.

—

In the fourth year ofmedical school, I watched as, one by one, many ofmyclassmates elected to specialize in less demanding areas (radiology ordermatology, for example) and applied for their residencies.Puzzledby this, Igathereddatafromseveralelitemedicalschoolsandsawthatthetrendswerethesame:bytheendofmedicalschool,moststudentstendedtofocuson“lifestyle”specialties—thosewithmorehumanehours,highersalaries,andlowerpressures—the idealism of their med school application essays tempered or lost. Asgraduation neared and we sat down, in a Yale tradition, to rewrite ourcommencement oath—a melding of the words of Hippocrates, Maimonides,Osler,alongwithafewothergreatmedicalforefathers—severalstudentsarguedfortheremovaloflanguageinsistingthatweplaceourpatients’interestsaboveourown. (Therestofusdidn’tallow thisdiscussion tocontinue for long.Thewordsstayed.Thiskindofegotismstruckmeasantitheticaltomedicineand,itshould be noted, entirely reasonable. Indeed, this is how99 percent of peopleselect their jobs: pay, work environment, hours. But that’s the point. Putting

lifestylefirstishowyoufindajob—notacalling.)Asforme,Iwouldchooseneurosurgeryasmyspecialty.Thechoice,which

Ihadbeencontemplatingforsometime,wascementedonenightinaroomjustoff theOR,whenI listened inquietaweasapediatricneurosurgeonsatdownwiththeparentsofachildwithalargebraintumorwhohadcomeinthatnightcomplainingofheadaches.Henotonlydeliveredtheclinicalfactsbutaddressedthe human facts as well, acknowledging the tragedy of the situation andproviding guidance.As it happened, the child’smotherwas a radiologist.Thetumorlookedmalignant—themotherhadalreadystudiedthescans,andnowshesatinaplasticchair,underfluorescentlight,devastated.

“Now,Claire,”thesurgeonbegan,softly.“Is it as bad as it looks?” the mother interrupted. “Do you think it’s

cancer?”“Idon’tknow.WhatIdoknow—andIknowyouknowthesethings,too—

isthatyourlifeisaboutto—italreadyhaschanged.Thisisgoingtobealonghaul,youunderstand?Youhavegottobethereforeachother,butyoualsohaveto get your rest when you need it. This kind of illness can either bring youtogether,oritcantearyouapart.Nowmorethanever,youhavetobethereforeachother.Idon’twanteitherofyoustayingupallnightatthebedsideorneverleavingthehospital.Okay?”

He went on to describe the planned operation, the likely outcomes andpossibilities,whatdecisionsneededtobemadenow,whatdecisionstheyshouldstartthinkingaboutbutdidn’tneedtodecideonimmediately,andwhatsortsofdecisionstheyshouldnotworryaboutatallyet.Bytheendoftheconversation,thefamilywasnotatease,buttheyseemedabletofacethefuture.Ihadwatchedtheparents’ faces—at firstwan,dull,almostotherworldly—sharpenand focus.And as I sat there, I realized that the questions intersecting life, death, andmeaning,questionsthatallpeoplefaceatsomepoint,usuallyariseinamedicalcontext. In the actual situations where one encounters these questions, itbecomes a necessarily philosophical and biological exercise. Humans areorganisms, subject to physical laws, including, alas, the one that says entropyalwaysincreases.Diseasesaremoleculesmisbehaving;thebasicrequirementoflifeismetabolism,anddeathitscessation.

While all doctors treat diseases, neurosurgeons work in the crucible ofidentity: every operation on the brain is, by necessity, a manipulation of thesubstanceofourselves,andeveryconversationwithapatientundergoingbrainsurgerycannothelpbutconfrontthisfact.Inaddition,tothepatientandfamily,thebrainsurgeryisusuallythemostdramaticeventtheyhaveeverfacedand,as

such, has the impact of any major life event. At those critical junctures, thequestionisnotsimplywhethertoliveordiebutwhatkindoflifeisworthliving.Wouldyoutradeyourability—oryourmother’s—totalkforafewextramonthsof mute life? The expansion of your visual blind spot in exchange foreliminatingthesmallpossibilityofafatalbrainhemorrhage?Yourrighthand’sfunction to stop seizures?Howmuch neurologic sufferingwould you let yourchildendurebeforesayingthatdeathispreferable?Becausethebrainmediatesour experience of the world, any neurosurgical problem forces a patient andfamily,ideallywithadoctorasaguide,toanswerthisquestion:Whatmakeslifemeaningfulenoughtogoonliving?

Iwas compelled by neurosurgery,with its unforgiving call to perfection;liketheancientGreekconceptarete,Ithought,virtuerequiredmoral,emotional,mental, and physical excellence. Neurosurgery seemed to present the mostchallenging and direct confrontation with meaning, identity, and death.Concomitantwiththeenormousresponsibilitiestheyshouldered,neurosurgeonswere also masters of many fields: neurosurgery, ICU medicine, neurology,radiology.Not onlywould I have to trainmymind and hands, I realized; I’dhave to train my eyes, and perhaps other organs as well. The idea wasoverwhelming and intoxicating: perhaps I, too, could join the ranks of thesepolymaths who strode into the densest thicket of emotional, scientific, andspiritualproblemsandfound,orcarved,waysout.

—

Aftermedicalschool,LucyandI,newlymarried,headedtoCaliforniatobeginourresidencies,meatStanford,LucyjustuptheroadatUCSF.Medicalschoolwas officially behind us—now real responsibility lay inwait. In short order, Imadeseveralclosefriendsinthehospital,inparticularVictoria,myco-resident,andJeff,ageneralsurgeryresidentafewyearsseniortous.Overthenextsevenyears of training, wewould grow from bearingwitness tomedical dramas tobecomingleadingactorsinthem.

Asan intern in the first yearof residency,one is littlemore than apaperpusheragainstabackdropoflifeanddeath—though,eventhen,theworkloadisenormous. My first day in the hospital, the chief resident said to me,“Neurosurgeryresidentsaren’tjustthebestsurgeons—we’rethebestdoctorsinthehospital.That’syourgoal.Makeusproud.”Thechairman,passingthroughthe ward: “Always eat with your left hand. You’ve got to learn to beambidextrous.”Oneoftheseniorresidents:“Justaheads-up—thechiefisgoingthroughadivorce,sohe’sreallythrowinghimselfintohisworkrightnow.Don’t

makesmalltalkwithhim.”Theoutgoinginternwhowassupposedtoorientmebutinsteadjusthandedmealistofforty-threepatients:“TheonlythingIhavetotellyouis:theycanalwayshurtyoumore,buttheycan’tstoptheclock.”Andthenhewalkedaway.

I didn’t leave the hospital for the first two days, but before long, theimpossible-seeming, day-killing mounds of paperwork were only an hour’swork.Still,whenyouworkinahospital,thepapersyoufilearen’tjustpapers:theyarefragmentsofnarrativesfilledwithrisksandtriumphs.Aneight-year-oldnamedMatthew,forexample,cameinonedaycomplainingofheadachesonlytolearn that he had a tumor abutting his hypothalamus. The hypothalamusregulatesourbasicdrives:sleep,hunger, thirst,sex.LeavinganytumorbehindwouldsubjectMatthewtoalifeofradiation,furthersurgeries,braincatheters…inshort,itwouldconsumehischildhood.Completeremovalcouldpreventthat,but at the risk of damaging his hypothalamus, rendering him a slave to hisappetites.Thesurgeongottowork,passedasmallendoscopethroughMatthew’snose,anddrilledoffthefloorofhisskull.Onceinside,hesawaclearplaneandremoved the tumor.A fewdays later,Matthewwas bopping around theward,sneakingcandiesfromthenurses,readytogohome.Thatnight,Ihappilyfilledouttheendlesspagesofhisdischargepaperwork.

IlostmyfirstpatientonaTuesday.She was an eighty-two-year-old woman, small and trim, the healthiest

persononthegeneralsurgeryservice,whereIspentamonthasanintern.(Atherautopsy,thepathologistwouldbeshockedtolearnherage:“Shehastheorgansofafifty-year-old!”)Shehadbeenadmittedforconstipationfromamildbowelobstruction.Aftersixdaysofhopingherbowelswoulduntanglethemselves,wedidaminoroperationtohelpsortthingsout.AroundeightP.M.Mondaynight,Istoppedbytocheckonher,andshewasalert,doingfine.Aswetalked,Ipulledfrommypocketmylistoftheday’sworkandcrossedoffthelastitem(post-opcheck,Mrs.Harvey).Itwastimetogohomeandgetsomerest.

Sometimeaftermidnight, thephone rang.Thepatientwascrashing.Withthecomplacencyofbureaucraticworksuddenly tornaway, Isatup inbedandspatoutorders:“OneliterbolusofLR,EKG,chestX-ray,stat—I’monmywayin.”Icalledmychief,andshetoldmetoaddlabsandtocallherbackwhenIhad a better sense of things. I sped to the hospital and found Mrs. Harveystruggling for air, her heart racing, her blood pressure collapsing. She wasn’tgettingbetternomatterwhatIdid;andasIwastheonlygeneralsurgeryinternon 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). Iwas drowning, out ofmy depth, pulled in a thousanddirections,andMrs.Harveywasstillnotimproving.IarrangedatransfertotheICU,whereweblastedherwithdrugsandfluidstokeepherfromdying,andIspentthenextfewhoursrunningbetweenmypatientthreateningtodieintheERandmypatientactivelydyingintheICU.By5:45A.M.,thepatientintheERwason his way to the OR, and Mrs. Harvey was relatively stable. She’d neededtwelvelitersoffluid,twounitsofblood,aventilator,andthreedifferentpressorstostayalive.

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.Harveyhadcoded,andtheICUteamwasattemptingCPR.Iracedbacktothehospital,andonceagain,shepulledthrough.Barely.Thistime,insteadofgoinghome,Igrabbeddinnernearthehospital,justincase.

AteightP.M.,myphonerang:Mrs.Harveyhaddied.Iwenthometosleep.I was somewhere between angry and sad. For whatever reason, Mrs.

Harvey had burst through the layers of paperwork to becomemypatient. Thenext day, I attended her autopsy, watched the pathologists open her up andremoveherorgans.I inspectedthemmyself,ranmyhandsoverthem,checkedtheknotsIhadtied inher intestines.Fromthatpointon,I resolvedto treatallmypaperworkaspatients,andnotviceversa.

In that first year, Iwouldglimpsemy share of death. I sometimes saw itwhile peeking around corners, other times while feeling embarrassed to becaughtinthesameroom.HerewereafewofthepeopleIsawdie:

1.Analcoholic,hisbloodnolongerabletoclot,whobledtodeathintohisjointsandunderhisskin.Everyday,thebruiseswouldspread.Beforehebecamedelirious,helookedupatmeandsaid,“It’snotfair—I’vebeendilutingmydrinkswithwater.”

2.Apathologist,dyingofpneumonia,wheezingherdeathrattlebeforeheadingdowntobeautopsied—herfinaltriptothepathologylab,whereshehadspentsomanyyearsofherlife.

3.Amanwho’dhadaminorneurosurgicalproceduretotreatlightningboltsofpainthatwereshootingthroughhisface:atinydropofliquidcementhadbeenplacedonthesuspectednervetokeepaveinfrompressingonit.Aweeklater,hedevelopedmassiveheadaches.Nearlyeverytestwasrun,butnodiagnosiswaseveridentified.

4.Dozensofcasesofheadtrauma:suicides,gunshots,barfights,motorcycleaccidents,carcrashes.Amooseattack.

At moments, the weight of it all became palpable. It was in the air, thestress andmisery.Normally, you breathed it in,without noticing it. But somedays,likeahumidmuggyday,ithadasuffocatingweightofitsown.Somedays,this is how it felt when I was in the hospital: trapped in an endless junglesummer,wetwith sweat, the rainof tearsof the familiesof thedyingpouringdown.

—

Inthesecondyearoftraining,you’rethefirsttoarriveinanemergency.Somepatientsyoucan’tsave.Othersyoucan:thefirsttimeIrushedacomatosepatientfromtheERtotheOR,drainedthebloodfromhisskull,andthenwatchedhimwakeup,starttalkingtohisfamily,andcomplainabouttheincisiononhishead,Igotlostinaeuphoricdaze,promenadingaroundthehospitalattwoA.M.untilIhadnosenseofwhereIwas.Ittookmeforty-fiveminutestofindmywaybackout.

The schedule took a toll.As residents,wewereworking asmuch as onehundredhoursaweek;thoughregulationsofficiallycappedourhoursateighty-eight, there was always more work to be done. My eyes watered, my headthrobbed,IdownedenergydrinksattwoA.M.Atwork,Icouldkeepittogether,but as soon as I walked out of the hospital, the exhaustion would hit me. Istaggered through the parking lot, often napping inmy car before driving thefifteenminuteshometobed.

Notallresidentscouldstandthepressure.Onewassimplyunabletoacceptblameorresponsibility.Hewasatalentedsurgeon,buthecouldnotadmitwhenhe’dmadeamistake.Isatwithhimonedayintheloungeashebeggedmetohelphimsavehiscareer.

“All you have to do,” I said, “is lookme in the eye and say, ‘I’m sorry.Whathappenedwasmyfault,andIwon’tletithappenagain.’ ”

“Butitwasthenursewho—”“No.Youhavetobeabletosayitandmeanit.Tryagain.”“But—”“No.Sayit.”ThiswentonforanhourbeforeIknewhewasdoomed.The stress drove another resident out of the field entirely; she elected to

leaveforalesstaxingjobinconsulting.Otherswouldpayevenhigherprices.As my skills increased, so too did my responsibility. Learning to judge

whoselivescouldbesaved,whosecouldn’tbe,andwhoseshouldn’tberequiresanunattainableprognosticability.Imademistakes.RushingapatienttotheORto saveonly enoughbrain that his heart beats but he cannever speak, he eatsthrough a tube, andhe is condemned to an existencehewouldneverwant…Icametoseethisasamoreegregiousfailurethanthepatientdying.Thetwilightexistenceofunconsciousmetabolismbecomesanunbearableburden,usuallylefttoaninstitution,wherethefamily,unabletoattainclosure,visitswithincreasingrarity,untiltheinevitablefatalbedsoreorpneumoniasetsin.Someinsistonthislifeandembraceitspossibility,eyesopen.Butmanydonot,orcannot,andtheneurosurgeonmustlearntoadjudicate.

Ihadstartedinthiscareer,inpart, topursuedeath:tograspit,uncloakit,and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for itsintertwiningofbrainandconsciousnessasforitsintertwiningoflifeanddeath.Ihad thought thata lifespent in thespacebetween the twowouldgrantmenotmerely a stage for compassionate action but an elevation of my own being:getting as far away from pettymaterialism, from self-important trivia, gettingright there, to the heart of the matter, to truly life-and-death decisions andstruggles…surelyakindoftranscendencewouldbefoundthere?

But in residency, somethingelsewasgraduallyunfolding. In themidstofthisendlessbarrageofheadinjuries,Ibegantosuspectthatbeingsoclosetothefierylightofsuchmomentsonlyblindedmetotheirnature,liketryingtolearnastronomy by staring directly at the sun. I was not yetwith patients in theirpivotalmoments, Iwasmerelyat those pivotalmoments. I observed a lot ofsuffering;worse, I became inured to it.Drowning, even in blood, one adapts,learnstofloat,toswim,eventoenjoylife,bondingwiththenurses,doctors,andotherswhoareclingingtothesameraft,caughtinthesametide.

MyfellowresidentJeffandIworkedtraumastogether.Whenhecalledmedowntothetraumabaybecauseofaconcurrentheadinjury,wewerealwaysinsync. He’d assess the abdomen, then ask for my prognosis on a patient’scognitivefunction.“Well,hecouldstillbeasenator,”Ioncereplied,“butonlyfrom a small state.” Jeff laughed, and from that moment on, state populationbecame our barometer for head-injury severity. “Is he a Wyoming or aCalifornia?” Jeff would ask, trying to determine how intensive his care planshouldbe.OrI’dsay,“Jeff,Iknowhisbloodpressureis labile,butIgottagethim to theORor he’s gonnago fromWashington to Idaho—canyouget him

stabilized?”Inthecafeteriaoneday,asIwasgrabbingmytypicallunch—aDietCoke

andanicecreamsandwich—mypagerannouncedanincomingmajortrauma.Irantothetraumabay,tuckingmyicecreamsandwichbehindacomputerjustasthe paramedics arrived, pushing the gurney, reciting the details: “Twenty-two-year-oldmale,motorcycleaccident,fortymilesperhour,possiblebraincomingouthisnose…”

Iwent straight towork, calling for an intubation tray, assessing his othervitalfunctions.Oncehewassafelyintubated,Isurveyedhisvariousinjuries:thebruisedface,theroadrash,thedilatedpupils.Wepumpedhimfullofmannitoltoreducebrainswellingandrushedhimtothescanner:ashatteredskull,heavydiffusebleeding.Inmymind,Iwasalreadyplanningthescalpincision,howI’ddrill the bone, evacuate the blood. His blood pressure suddenly dropped.Werushed him back to the trauma bay, and just as the rest of the trauma teamarrived, his heart stopped. A whirlwind of activity surrounded him: catheterswere slipped into his femoral arteries, tubes shoveddeep into his chest, drugspushed into his IVs, and all thewhile, fists pounded on his heart to keep thebloodflowing.After thirtyminutes,we lethimfinishdying.With thatkindofheadinjury,weallmurmuredinagreement,deathwastobepreferred.

Islippedoutofthetraumabayjustasthefamilywasbroughtintoviewthebody. Then I remembered: my Diet Coke, my ice cream sandwich…and theswelteringheatofthetraumabay.WithoneoftheERresidentscoveringforme,Islippedbackin,ghostlike,tosavetheicecreamsandwichinfrontofthecorpseofthesonIcouldnot.

Thirty minutes in the freezer resuscitated the sandwich. Pretty tasty, Ithought, picking chocolate chips out of my teeth as the family said its lastgoodbyes.Iwonderedif,inmybrieftimeasaphysician,Ihadmademoremoralslidesthanstrides.

A few days later, I heard that Laurie, a friend frommedical school, hadbeenhitbyacarandthataneurosurgeonhadperformedanoperationtotrytosave her. She’d coded,was revived, and then died the following day. I didn’twant to know more. The days when someone was simply “killed in a caraccident” were long gone. Now those words opened a Pandora’s box, out ofwhichemergedall the images: the roll of thegurney, thebloodon the traumabayfloor, the tubeshoveddownher throat, thepoundingonherchest. Icouldseehands,myhands,shavingLaurie’sscalp,thescalpelcuttingopenherhead,couldhearthefrenzyofthedrillandsmelltheburningbone,itsdustwhirling,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 herfriendsandfamily.Maybetherewerechesttubes,andalegwasintraction…

Ididn’taskfordetails.Ialreadyhadtoomany.In thatmoment,allmyoccasionsoffailedempathycamerushingback to

me:thetimesIhadpusheddischargeoverpatientworries,ignoredpatients’painwhen other demands pressed. The people whose suffering I saw, noted, andneatly packaged into various diagnoses, the significance of which I failed torecognize—theyallreturned,vengeful,angry,andinexorable.

I feared I was on the way to becoming Tolstoy’s stereotype of a doctor,preoccupiedwithempty formalism, focusedon the rote treatmentofdisease—and utterly missing the larger human significance. (“Doctors came to see hersinglyand inconsultation, talkedmuch inFrench,German, andLatin,blamedone another, and prescribed a great variety of medicines for all the diseasesknown to them, but the simple idea never occurred to any of them that theycouldnotknowthediseaseNatashawassufferingfrom.”)Amothercametome,newly diagnosed with brain cancer. She was confused, scared, overcome byuncertainty. I was exhausted, disconnected. I rushed through her questions,assuredherthatsurgerywouldbeasuccess,andassuredmyselfthattherewasn’tenoughtimetoanswerherquestionsfairly.Butwhydidn’t Imake the time?Atruculent vet refused the advice and coaxing of doctors, nurses, and physicaltherapists forweeks; as a result, his backwound broke down, just aswe hadwarnedhimitwould.CalledoutoftheOR,Istitchedthedehiscentwoundasheyelpedinpain,tellingmyselfhe’dhaditcoming.

Nobodyhasitcoming.ItookmeagersolaceinknowingthatWilliamCarlosWilliamsandRichard

Selzer had confessed to doing worse, and I swore to do better. Amid thetragediesandfailures,I fearedIwas losingsightof thesingular importanceofhumanrelationships,notbetweenpatientsandtheirfamiliesbutbetweendoctorand patient. Technical excellence was not enough. As a resident, my highestidealwasnotsavinglives—everyonedieseventually—butguidingapatientorfamilytoanunderstandingofdeathor illness.Whenapatientcomesinwithafatalheadbleed, that firstconversationwithaneurosurgeonmayforevercolorhowthefamilyremembersthedeath,fromapeacefullettinggo(“Maybeitwashis time”) to anopen soreof regret (“Thosedoctorsdidn’t listen!Theydidn’teven try to save him!”).When there’s no place for the scalpel, words are thesurgeon’sonlytool.

For amid that unique suffering invoked by severe brain damage, thesuffering often felt more by families than by patients, it is not merely the

physicianswhodonotseethefullsignificance.Thefamilieswhogatheraroundtheirbeloved—theirbelovedwhoseshearedheadscontainedbatteredbrains—donot usually recognize the full significance, either. They see the past, theaccumulation of memories, the freshly felt love, all represented by the bodybefore them. I see the possible futures, the breathing machines connectedthrough a surgical opening in the neck, the pasty liquid dripping in through ahole in the belly, the possible long, painful, and only partial recovery—or,sometimesmore likely, no return at all of the person they remember. In thesemoments, I acted not, as I most often did, as death’s enemy, but as itsambassador.Ihadtohelpthosefamiliesunderstandthatthepersontheyknew—thefull,vitalindependenthuman—nowlivedonlyinthepastandthatIneededtheirinputtounderstandwhatsortoffutureheorshewouldwant:aneasydeathor to be strung between bags of fluids going in, others coming out, to persistdespitebeingunabletostruggle.

HadIbeenmorereligiousinmyyouth,Imighthavebecomeapastor,foritwasthepastoralroleI’dsought.

—

Withmyrenewedfocus,informedconsent—theritualbywhichapatientsignsapieceofpaper,authorizingsurgery—becamenota juridicalexerciseinnamingall the risks as quickly as possible, like the voiceover in an ad for a newpharmaceutical, but an opportunity to forge a covenant with a sufferingcompatriot:Herewearetogether,andherearethewaysthrough—Ipromisetoguideyou,asbestasIcan,totheotherside.

Bythispointinmyresidency,Iwasmoreefficientandexperienced.Icouldfinallybreathealittle,nolongertryingtohangonformyowndearlife.Iwasnowacceptingfullresponsibilityformypatients’well-being.

My thoughts turned to my father. As medical students, Lucy and I hadattendedhis hospital rounds inKingman,watching as he brought comfort andlevity to his patients. To one woman, who was recovering from a cardiacprocedure:“Areyouhungry?WhatcanIgetyoutoeat?”

“Anything,”shesaid.“I’mstarving.”“Well,howaboutlobsterandsteak?”Hepickedupthephoneandcalledthe

nursingstation.“Mypatientneedslobsterandsteak—rightaway!”Turningbacktoher,hesaid,withasmile:“It’sontheway,butitmaylookmorelikeaturkeysandwich.”

Theeasyhumanconnectionsheformed,thetrustheinstilledinhispatients,

wereaninspirationtome.Athirty-five-year-oldsatinherICUbed,asheenofterroronherface.She

had been shopping for her sister’s birthdaywhen she’d had a seizure.A scanshowedthatabenignbraintumorwaspressingonherrightfrontallobe.Intermsofoperativerisk,itwasthebestkindoftumortohave,andthebestplacetohaveit;surgerywouldalmostcertainlyeliminateherseizures.Thealternativewasalifetimeontoxicantiseizuremedications.ButIcouldseethat theideaofbrainsurgeryterrifiedher,morethanmost.Shewaslonesomeandinastrangeplace,havingbeen sweptoutof the familiarhubbubofa shoppingmall and into thealienbeepsandalarmsandantisepticsmellsofanICU.Shewouldlikelyrefusesurgery if I launched into a detached spiel detailing all the risks and possiblecomplications.Icoulddoso,documentherrefusalinthechart,considermydutydischarged, and move on to the next task. Instead, with her permission, Igatheredherfamilywithher,andtogetherwecalmlytalkedthroughtheoptions.Aswetalked,Icouldseetheenormousnessofthechoiceshefaceddwindleintoadifficultbutunderstandabledecision.Ihadmetherinaspacewhereshewasaperson,insteadofaproblemtobesolved.Shechosesurgery.Theoperationwentsmoothly.Shewenthometwodayslater,andneverseizedagain.

Anymajor illness transforms a patient’s—really, an entire family’s—life.Butbraindiseaseshavetheadditionalstrangenessoftheesoteric.Ason’sdeathalreadydefiestheparents’ordereduniverse;howmuchmoreincomprehensibleisitwhenthepatientisbrain-dead,hisbodywarm,hisheartstillbeating?Theroot ofdisastermeans a star coming apart, and no image expresses better thelookinapatient’seyeswhenhearinganeurosurgeon’sdiagnosis.Sometimesthenews so shocks the mind that the brain suffers an electrical short. Thisphenomenon is known as a “psychogenic” syndrome, a severe version of theswoon some experience after hearing bad news. When my mother, alone atcollege,heardthatherfather,whohadchampionedherrighttoaneducationinrural 1960s India, had finally died after a long hospitalization, she had apsychogenic seizure—which continued until she returned home to attend thefuneral. One of my patients, upon being diagnosed with brain cancer, fellsuddenlyintoacoma.Iorderedabatteryoflabs,scans,andEEGs,searchingforacause,withoutresult.Thedefinitivetestwasthesimplest:Iraisedthepatient’sarm above his face and let go. A patient in a psychogenic coma retains justenough volition to avoid hitting himself. The treatment consists in speakingreassuringly,untilyourwordsconnectandthepatientawakens.

Cancerofthebraincomesintwovarieties:primarycancers,whichareborninthebrain,andmetastases,whichemigratefromsomewhereelseinthebody,

mostcommonly from the lungs.Surgerydoesnotcure thedisease,but itdoesprolong life; formostpeople,cancer in thebrainsuggestsdeathwithinayear,maybe two. Mrs. Lee was in her late fifties, with pale green eyes, and hadtransferred to my service two days earlier from a hospital near her home, ahundredmilesaway.Herhusband,hisplaidshirt tuckedintocrispjeans,stoodby her bedside, fidgeting with his wedding ring. I introduced myself and satdown,andshetoldmeherstory:Forthepastfewdays,shehadfeltatinglinginher right hand, and then she’d begun to lose control of it, until she could nolongerbuttonherblouse.She’dgonetoherlocalER,fearingshewashavingastroke.AnMRIwasobtainedthere,andshewassenthere.

“DidanyonetellyouwhattheMRIshowed?”Iasked.“No.” The buck had been passed, as it often was with difficult news.

Oftentimes,we’dhaveaspatwiththeoncologistoverwhosejobitwastobreakthenews.HowmanytimeshadIdonethesame?Well,Ifigured,itcanstophere.

“Okay,”Isaid.“Wehavealottotalkabout.Ifyoudon’tmind,canyoutellmewhat you understand is happening? It’s always helpful for me to hear, tomakesureIdon’tleaveanythingunanswered.”

“Well,IthoughtIwashavingastroke,butIguess…I’mnot?”“That’sright.Youaren’thavingastroke.”Ipaused.Icouldseethevastness

ofthechasmbetweenthelifeshe’dhadlastweekandtheoneshewasabouttoenter.Sheandherhusbanddidn’tseemreadytohearbraincancer—isanyone?—soIbeganacouplestepsback.“TheMRIshowsamassinyourbrain,whichiscausingyoursymptoms.”

Silence.“DoyouwanttoseetheMRI?”“Yes.”I brought up the images on the bedside computer, pointing out her nose,

eyes,andearstoorienther.ThenIscrolleduptothetumor,alumpywhiteringsurroundingablacknecroticcore.

“What’sthat?”sheasked.Couldbeanything.Maybeaninfection.Wewon’tknowtillaftersurgery.My inclination to dodge the question still persisted, to let their obvious

worriesfloatintheirheads,unpinned.“Wecan’tbesureuntilaftersurgery,”Ibegan,“butitlooksverymuchlike

abraintumor.”“Isitcancer?”“Again,wewon’tknowforcertainuntilitisremovedandexaminedbyour

pathologists,but,ifIhadtoguess,Iwouldsayyes.”Based on the scan, there was no doubt in my mind that this was

glioblastoma—anaggressivebraincancer,theworstkind.YetIproceededsoftly,taking my cues from Mrs. Lee and her husband. Having introduced thepossibilityofbraincancer, Idoubted theywould recallmuchelse.A tureenoftragedywas best allotted by the spoonful. Only a few patients demanded thewholeatonce;mostneeded time todigest.Theydidn’taskaboutprognosis—unlikeintrauma,whereyouhaveonlyabouttenminutestoexplainandmakeamajordecision,hereIcouldletthingssettle.Idiscussedindetailwhattoexpectoverthenextcoupleofdays:whatthesurgeryentailed;howwe’dshaveonlyasmall strip of her hair to keep it cosmetically appealing; how her armwouldlikelygetalittleweakerafterwardbutthenstrongeragain;thatifallwentwell,she’dbe out of the hospital in three days; that thiswas just the first step in amarathon;thatgettingrestwasimportant;andthatIdidn’texpectthemtoretainanythingIhadjustsaidandwe’dgoovereverythingagain.

After surgery,we talkedagain, this timediscussingchemo, radiation, andprognosis. By this point, I had learned a couple of basic rules. First, detailedstatistics are for research halls, not hospital rooms. The standard statistic, theKaplan-Meiercurve,measuresthenumberofpatientssurvivingovertime.Itisthemetricbywhichwegaugeprogress,bywhichweunderstandtheferocityofadisease.Forglioblastoma,thecurvedropssharplyuntilonlyabout5percentofpatients are alive at twoyears.Second, it is important to be accurate, but youmustalwaysleavesomeroomforhope.Ratherthansaying,“Mediansurvivaliselevenmonths”or“Youhaveaninety-fivepercentchanceofbeingdeadintwoyears,”I’dsay,“Mostpatientslivemanymonthstoacoupleofyears.”Thiswas,tome,amorehonestdescription.Theproblemisthatyoucan’ttellanindividualpatientwhereshesitsonthecurve:Willshedieinsixmonthsorsixty?Icametobelievethatitisirresponsibletobemoreprecisethanyoucanbeaccurate.Thoseapocryphaldoctorswhogave specificnumbers (“Thedoctor toldme Ihad sixmonthstolive”):Whowerethey,Iwondered,andwhotaughtthemstatistics?

Patients, when hearing the news, mostly remainmute. (One of the earlymeaningsofpatient,afterall,is“onewhoendureshardshipwithoutcomplaint.”)Whether out of dignity or shock, silence usually reigns, and so holding apatient’shandbecomesthemodeofcommunication.Afewimmediatelyharden(usually the spouse, rather than the patient): “We’re gonna fight and beat thisthing,Doc.”Thearmamentvaries,fromprayertowealthtoherbstostemcells.To me, that hardness always seems brittle, unrealistic optimism the onlyalternative to crushing despair. In any case, in the immediacy of surgery, a

warlikeattitudefit.IntheOR,thedarkgrayrottingtumorseemedaninvaderinthe fleshypeachconvolutionsof thebrain, and I felt real anger (Got you, youfucker, Imuttered). Removing the tumorwas satisfying—even though I knewthatmicroscopiccancercellshadalreadyspreadthroughoutthathealthy-lookingbrain. The nearly inevitable recurrence was a problem for another day. Aspoonful at a time. Openness to human relationality does not mean revealinggrand truths from the apse; it means meeting patients where they are, in thenarthexornave,andbringingthemasfarasyoucan.

Yetopennesstohumanrelationalityalsocarriedaprice.Oneeveninginmythirdyear,IranintoJeff,myfriendingeneralsurgery,a

similarly intense and demanding profession. We each noted the other’sdespondency.“Yougofirst,”hesaid.AndIdescribedthedeathofachild,shotin the head for wearing the wrong color shoes, but he had been so close tomakingit…Amidarecentspateoffatal,inoperablebraintumors,myhopeshadbeen pinned on this kid pulling through, and he hadn’t. Jeff paused, and Iawaitedhisstory.Instead,helaughed,punchedmeinthearm,andsaid,“Well,IguessIlearnedonething:ifI’meverfeelingdownaboutmywork,Icanalwaystalktoaneurosurgeontocheermyselfup.”

Drivinghomelater thatnight,aftergentlyexplaining toamother thathernewbornhadbeenbornwithoutabrainandwoulddieshortly,Iswitchedontheradio; NPR was reporting on the continuing drought in California. Suddenly,tearswerestreamingdownmyface.

Beingwithpatientsinthesemomentscertainlyhaditsemotionalcost,butitalsohad its rewards. Idon’t thinkIeverspentaminuteofanydaywonderingwhyIdidthiswork,orwhetheritwasworthit.Thecalltoprotectlife—andnotmerelylifebutanother’sidentity;itisperhapsnottoomuchtosayanother’ssoul—wasobviousinitssacredness.

Beforeoperatingonapatient’sbrain,Irealized,Imustfirstunderstandhismind: his identity, his values, what makes his life worth living, and whatdevastationmakesitreasonabletoletthatlifeend.Thecostofmydedicationtosucceed was high, and the ineluctable failures brought me nearly unbearableguilt. Those burdens arewhatmakemedicine holy andwholly impossible: intakingupanother’scross,onemustsometimesgetcrushedbytheweight.

—

Midway through residency, time is set aside for additional training. Perhapsunique in medicine, the ethos of neurosurgery—of excellence in all things—

maintainsthatexcellenceinneurosurgeryaloneisnotenough.Inordertocarrythe field, neurosurgeons must venture forth and excel in other fields as well.Sometimes this is very public, as in the case of the neurosurgeon-journalistSanjayGupta,butmostoftenthedoctor’sfocusisonarelatedfield.Themostrigorousandprestigiouspathisthatoftheneurosurgeon-neuroscientist.

Inmyfourthyear,IbeganworkinaStanfordlabdedicatedtobasicmotorneuroscience and the development of neural prosthetic technology that wouldallow,say,paralyzedpeopletomentallycontrolacomputercursororrobotarm.The head of the lab, a professor of electrical engineering and neurobiology, afellowsecond-generationIndian,wasaffectionatelycalled“V”byeveryone.VwassevenyearsolderthanI,butwegotonlikebrothers.Hislabhadbecomeaworldleaderinreadingoutbrainsignals,butwithhisblessingIembarkedonaprojecttodothereverse:towritesignalsinto thebrain.Afterall, ifyourrobotarm can’t feel how hard it’s grasping a wineglass, you will break a lot ofwineglasses. The implications of writing signals into the brain, or“neuromodulation,”however,werefarmorewide-reachingthanthat:beingabletocontrolneuralfiringwouldconceivablyallowtreatmentofahostofcurrentlyuntreatable or intractable neurological and psychiatric diseases, from majordepression to Huntington’s to schizophrenia to Tourette’s to OCD…thepossibilitieswerelimitless.Puttingsurgeryasidenow,Isettoworklearningtoapply 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 ourweeklymeetings.Ihadgrowntolovethesechats.VwasnotlikeotherscientistsIknew.Hewassoft-spokenandcareddeeplyaboutpeopleandtheclinicalmission,andheoftenconfessedtomethathewishedhe’dbeenasurgeonhimself.Science,Ihad come to learn, is as political, competitive, and fierce a career as you canfind,fullofthetemptationtofindeasypaths.

One could count on V to always choose the honest (and, often, self-effacing)way forward.Whilemost scientists connived to publish in themostprestigious journals and get their names out there,Vmaintained that our onlyobligation was to be authentic to the scientific story and to tell ituncompromisingly. I’d never met someone so successful who was also socommittedtogoodness.Vwasanactualparagon.

Instead of smiling as I sat down across from him, he looked pained.Hesighedandsaid,“Ineedyoutowearyourdoctorhatrightnow.”

“Okay.”“TheytellmeIhavepancreaticcancer.”

“V…okay.Tellmethestory.”He laid out his gradual weight loss, indigestion, and his recent

“precautionary”CT scan—a truly nonstandard procedure at this point—whichshowedapancreaticmass.Wediscussedthewayforward,thedreadedWhippleoperationinhisnearfuture(“Youaregoingtofeellikeatruckhityou,”Itoldhim),whothebestsurgeonswere,theimpacttheillnesswouldhaveonhiswifeandchildren, andhow to run the labduringhisprolongedabsence.Pancreaticcancerhasadismalprognosis,butofcoursetherewasnowaytoknowwhatthatmeantforV.

Hepaused.“Paul,”hesaid,“doyouthinkmylifehasmeaning?DidImaketherightchoices?”

It was stunning: even someone I considered amoral exemplar had thesequestionsinthefaceofmortality.

V’s surgery, chemotherapy, and radiation treatments were trying, but asuccess.Hewasbackatworkayearlater,justasIwasreturningtomyclinicalduties in thehospital.Hishairhad thinnedandwhitened, and the spark inhiseyeshaddulled.Duringourfinalweeklychat,he turned tomeandsaid,“Youknow,todayisthefirstdayitallseemsworthit.Imean,obviously,Iwould’vegonethroughanythingformykids,buttodayisthefirstdaythatallthesufferingseemsworthit.”

Howlittledodoctorsunderstandthehellsthroughwhichweputpatients.

—

Inmysixthyear,Ireturnedtothehospitalfull-time,myresearchinV’slabnowrelegated todaysoff and idlemoments, suchas theywere.Mostpeople, evenyour closest colleagues, don’t quite understand the black hole that isneurosurgical residency.Oneofmy favorite nurses, after sticking arounduntiltenP.M.onenighttohelpusfinishalonganddifficultcase,saidtome,“ThankGodIhavetomorrowoff.Doyou,too?”

“Um,no.”“But at least you can come in later or something, right? When do you

usuallygetin?”“SixA.M.”“No.Really?”“Yep.”“Everyday?”“Everyday.”

“Weekends,too?”“Don’task.”Inresidency,there’sasaying:Thedaysarelong,buttheyearsareshort.In

neurosurgical residency, the day usually began at sixA.M. and lasted until theoperatingwasdone,whichdepended,inpart,onhowquickyouwereintheOR.

A resident’s surgical skill is judged by his technique and his speed. Youcan’tbesloppy,andyoucan’tbeslow.Fromyourfirstwoundclosureonward,spendtoomuchtimebeingpreciseandthescrubtechwillannounce,“Lookslikewe’vegotaplasticsurgeononourhands!”Or:“Igetyourstrategy:bythetimeyoufinishsewingthetophalfofthewound,thebottomwillhavehealedonitsown!Halfthework—verysmart!”Achiefresidentwilladviseajunior,“Learntobefastnow.Youcanlearntobegoodlater.”IntheOR,everyone’seyesarealways on the clock. For the patient’s sake: How long has he been underanesthesia?Duringlongprocedures,nervescangetdamaged,musclescanbreakdown,kidneyscanfail.Foreveryoneelse’ssake:Whattimearewegettingoutofheretonight?

Icouldseethatthereweretwostrategiestocuttingthetimeshort,perhapsbestexemplifiedbythetortoiseandthehare.Theharemovesasfastaspossible,handsablur,instrumentsclattering,fallingtothefloor;theskinslipsopenlikeacurtain,theskullflapisonthetraybeforethebonedustsettles.Asaresult,theopeningmightneed tobeexpandedacentimeterhereor therebecause it’snotoptimallyplaced.Thetortoise,ontheotherhand,proceedsdeliberately,withnowasted movements, measuring twice, cutting once. No step of the operationneeds revisiting; everything moves in a precise, orderly fashion. If the haremakestoomanyminormisstepsandhastokeepadjusting,thetortoisewins.Ifthetortoisespendstoomuchtimeplanningeachstep,theharewins.

The funny thing about time in the OR, whether you race frenetically orproceed steadily, is that you have no sense of it passing. If boredom is, asHeidegger argued, the awareness of time passing, then surgery felt like theopposite: the intensefocusmade thearmsof theclockseemarbitrarilyplaced.Two hours could feel like aminute. Once the final stitchwas placed and thewoundwasdressed,normal timesuddenlyrestarted.Youcouldalmosthearanaudiblewhoosh.Thenyoustartedwondering:Howlonguntilthepatientwakesup?How longuntil thenext case is rolled in?Andwhat timewill Igethometonight?

Itwasn’tuntilthelastcasefinishedthatIfeltthelengthoftheday,thedraginmystep.Thoselastfewadministrativetasksbeforeleavingthehospitalwerelikeanvils.

Coulditwaituntiltomorrow?No.Asigh,andEarthcontinuedtorotatebacktowardthesun.

—

As a chief resident, nearly all responsibility fell on my shoulders, and theopportunities to succeed—or fail—were greater than ever. The pain of failurehad led me to understand that technical excellence was amoral requirement.Good intentionswere not enough, not when somuch depended onmy skills,when the difference between tragedy and triumphwas defined by one or twomillimeters.

Oneday,Matthew,thelittleboywiththebraintumorwhohadcharmedtheward a few years back, was readmitted. His hypothalamus had, in fact, beenslightlydamagedduringtheoperationtoremovehistumor;theadorableeight-year-oldwasnowatwelve-year-oldmonster.Heneverstoppedeating;hethrewviolent fits.Hismother’s armswere scarredwith purple scratches. EventuallyMatthew was institutionalized: he had become a demon, summoned by onemillimeterofdamage.Foreverysurgery,afamilyandasurgeondecidetogetherthat the benefits outweigh the risks, but this was still heartbreaking. No onewanted to think aboutwhatMatthewwould be like as a three-hundred-poundtwenty-year-old.

Anotherday,Iplacedanelectrodeninecentimetersdeepinapatient’sbrainto treat a Parkinson’s tremor. The target was the subthalamic nucleus, a tinyalmond-shapedstructuredeepinthebrain.Differentpartsofitsubservedifferentfunctions:movement,cognition,emotion. In theoperating room,we turnedonthecurrenttoassessthetremor.Withalloureyesonthepatient’slefthand,weagreedthetremorlookedbetter.

Thenthepatient’svoice,confused,roseaboveouraffirmativemurmurs:“Ifeel…overwhelminglysad.”

“Currentoff!”Isaid.“Oh,nowthefeelingisgoingaway,”thepatientsaid.“Let’srecheckthecurrentandimpedance,okay?Okay.Currenton…”“No,everything…itjustfeels…sosad.Justdarkand,and…sad.”“Electrodeout!”Wepulled theelectrodeoutand reinserted it, this time twomillimeters to

theright.Thetremorwentaway.Thepatientfelt,thankfully,fine.Once,Iwasdoingalate-nightcasewithoneoftheneurosurgeryattendings,

asuboccipitalcraniectomyforabrain-stemmalformation. It’soneof themostelegant surgeries, in perhaps the most difficult part of the body—just gettingthereistricky,nomatterhowexperiencedyouare.Butthatnight,Ifeltfluid:theinstruments were like extensions of my fingers; the skin, muscle, and boneseemed to unzip themselves; and there I was, staring at a yellow, glisteningbulge,amassdeepinthebrainstem.Suddenly,theattendingstoppedme.

“Paul, what happens if you cut two millimeters deeper right here?” Hepointed.

Neuroanatomyslideswhirredthroughmyhead.“Doublevision?”“No,” he said. “Locked-in syndrome.” Another two millimeters, and the

patientwouldbecompletelyparalyzed, save for theability toblink.Hedidn’tlookupfromthemicroscope.“AndIknowthisbecausethethirdtimeIdidthisoperation,that’sexactlywhathappened.”

Neurosurgery requires a commitment to one’s own excellence and acommitment to another’s identity. The decision to operate at all involves anappraisalofone’sownabilities,aswellasadeepsenseofwhothepatientisandwhatsheholdsdear.Certainbrainareasareconsiderednear-inviolable,liketheprimary motor cortex, damage to which results in paralysis of affected bodyparts. But the most sacrosanct regions of the cortex are those that controllanguage. Usually located on the left side, they are called Wernicke’s andBroca’sareas;oneisforunderstandinglanguageandtheotherforproducingit.Damage to Broca’s area results in an inability to speak or write, though thepatientcaneasilyunderstandlanguage.DamagetoWernicke’sarearesultsinaninabilitytounderstandlanguage;thoughthepatientcanstillspeak,thelanguagesheproducesisastreamofunconnectedwords,phrases,andimages,agrammarwithout semantics. If both areas are damaged, the patient becomes an isolate,somethingcentraltoherhumanitystolenforever.Aftersomeonesuffersaheadtrauma or a stroke, the destruction of these areas often restrains the surgeon’simpulsetosavealife:Whatkindoflifeexistswithoutlanguage?

WhenIwasamedstudent,thefirstpatientImetwiththissortofproblemwasasixty-two-year-oldmanwithabraintumor.Westrolledintohisroomonmorningrounds,andtheresidentaskedhim,“Mr.Michaels,howareyoufeelingtoday?”

“Foursixoneeightnineteen!”hereplied,somewhataffably.The tumorhad interruptedhis speechcircuitry, sohecould speakonly in

streamsofnumbers,buthestillhadprosody,hecouldstillemote:smile,scowl,sigh.He recited another series of numbers, this timewith urgency.Therewas

somethinghewantedtotellus,butthedigitscouldcommunicatenothingotherthanhisfearandfury.Theteampreparedtoleavetheroom;forsomereason,Ilingered.

“Fourteenonetwoeight,”hepleadedwithme,holdingmyhand.“Fourteenonetwoeight.”

“I’msorry.”“Fourteenonetwoeight,”hesaidmournfully,staringintomyeyes.AndthenIlefttocatchuptotheteam.Hediedafewmonthslater,buried

withwhatevermessagehehadfortheworld.Whentumorsormalformationsabuttheselanguageareas,thesurgeontakes

numerous precautions, ordering a host of different scans, a detailedneuropsychological examination. Critically, however, the surgery is performedwith the patient awake and talking.Once the brain is exposed, but before thetumor excision, the surgeon uses a hand-held ball-tip electrode to deliverelectrical current to stun a small area of the cortexwhile the patient performsvariousverbaltasks:namingobjects,recitingthealphabet,andsoon.Whentheelectrode sends current into a critical piece of cortex, it disrupts the patient’sspeech:“ABCDEguhguhguhrrrr…FGHI…”Thebrainandthetumorarethusmapped to determinewhat can be resected safely, and the patient is keptawakethroughout,occupiedwithacombinationofformalverbaltasksandsmalltalk.

One evening, as I was prepping for one of these cases, I reviewed thepatient’sMRIandnotedthatthetumorcompletelycoveredthelanguageareas.Notagoodsign.Reviewingthenotes,Isawthatthehospital’stumorboard—anexpert panel of surgeons, oncologists, radiologists, and pathologists—haddeemedthecasetoodangerousforsurgery.Howcouldthesurgeonhaveoptedtoproceed?Ibecamealittleindignant:atacertainpoint,itwasourjobtosayno.Thepatientwaswheeledintotheroom.Hefixedhiseyesonmeandpointedtohishead.“Iwantthisthingoutofmyfuckingbrain.Gotit?”

Theattendingstrolledinandsawtheexpressiononmyface.“Iknow,”hesaid.“Itriedtalkinghimoutofthisforabouttwohours.Don’tbother.Readytogo?”

Insteadoftheusualalphabetrecitalorcountingexercise,weweretreated,throughoutthesurgery,toalitanyofprofanityandexhortation.

“Isthatfuckingthingoutofmyheadyet?Whyareyouslowingdown?Gofaster!Iwantitout.Icanstayhereallfuckingday,Idon’tcare,justgetitout!”

I slowly removed the enormous tumor, attentive to the slightest hint of

speechdifficulty.Withthepatient’smonologueunceasing,thetumornowsatonapetridish,hiscleanbraingleaming.

“Why’dyoustop?Yousomekindaasshole?ItoldyouIwantthefuckingthinggone!”

“It’sdone,”Isaid.“It’sout.”How was he still talking? Given the size and location of the tumor, it

seemedimpossible.Profanitysupposedlyranonaslightlydifferentcircuitfromthe rest of language. Perhaps the tumor had caused his brain to rewiresomehow…

But the skull wasn’t going to close itself. There would be time forspeculationtomorrow.

—

Ihadreachedthepinnacleofresidency.Ihadmasteredthecoreoperations.Myresearchhadgarneredthehighestawards.Jobinterestwastricklinginfromalloverthecountry.Stanfordlaunchedasearchforapositionthatfitmyinterestsexactly, for a neurosurgeon-neuroscientist focused on techniques of neuralmodulation.Oneofmy junior residents cameup tomeand said, “I justheardfromthebosses—iftheyhireyou,you’regoingtobemyfacultymentor!”

“Shhhh,”Isaid.“Don’tjinxit.”Itfelttomeasiftheindividualstrandsofbiology,morality,life,anddeath

werefinallybeginningtoweavethemselvesinto,ifnotaperfectmoralsystem,acoherentworldview and a sense ofmy place in it. Doctors in highly chargedfieldsmetpatientsatinflectedmoments,themostauthenticmoments,wherelifeand identity were under threat; their duty included learning what made thatparticularpatient’slifeworthliving,andplanningtosavethosethingsifpossible—ortoallowthepeaceofdeathifnot.Suchpowerrequireddeepresponsibility,sharinginguiltandrecrimination.

IwasataconferenceinSanDiegowhenmyphonerang.Myco-resident,Victoria.

“Paul?”Somethingwaswrong.Mystomachtightened.“What’sup?”Isaid.Silence.“Vic?”“It’sJeff.Hekilledhimself.”

“What?”JeffwasfinishinghissurgicalfellowshipintheMidwest,andwewereboth

sopunishinglybusy…we’dlosttouch.Itriedtorecallourlastconversationandcouldn’t.

“He,uh—heapparentlyhadadifficult complication,andhispatientdied.Lastnightheclimbedontotheroofofabuildingandjumpedoff.Idon’treallyknowanythingelse.”

Isearchedforaquestiontobringunderstanding.Nonewasforthcoming.Icouldonlyimaginetheoverwhelmingguilt,likeatidalwave,thathadliftedhimupandoffthatbuilding.

Iwished,desperately,thatIcould’vebeenwalkingwithhimoutthedoorofthehospital thatevening. Iwishedwecould’vecommiseratedasweused to. IwishedIcouldhavetoldJeffwhatIhadcometounderstandaboutlife,andourchosenwayoflife,ifonlytohearhiswise,clevercounsel.Deathcomesforallof us. For us, for our patients: it is our fate as living, breathing,metabolizingorganisms.Mostlivesarelivedwithpassivitytowarddeath—it’ssomethingthathappens to you and those around you.But Jeff and I had trained for years toactivelyengagewithdeath,tograpplewithit,likeJacobwiththeangel,and,insodoing, toconfront themeaningofa life.Wehadassumedanonerousyoke,that ofmortal responsibility. Our patients’ lives and identities may be in ourhands,yetdeathalwayswins.Evenifyouareperfect,theworldisn’t.Thesecretis to know that the deck is stacked, that you will lose, that your hands orjudgmentwillslip,andyetstillstruggletowinforyourpatients.Youcan’teverreach perfection, but you can believe in an asymptote toward which you areceaselesslystriving.

PARTII

CeaseNottillDeath

IfIwereawriterofbooks,Iwouldcompilearegister,withacomment,ofthevariousdeathsofmen:hewhoshouldteachmentodiewouldatthesametimeteachthemtolive.

—MicheldeMontaigne,“ThattoStudyPhilosophyIstoLearntoDie”

LYINGNEXTTOLUCYinthehospitalbed,bothofuscrying,theCTscanimagesstillglowingonthecomputerscreen,thatidentityasaphysician—myidentity—nolongermattered.Withthecancerhavinginvadedmultipleorgansystems,thediagnosiswasclear.Theroomwasquiet.Lucytoldmeshelovedme.“Idon’twanttodie,”Isaid.Itoldhertoremarry,thatIcouldn’tbearthethoughtofherbeingalone.Itoldherweshouldrefinancethemortgageimmediately.Westartedcalling family members. At some point, Victoria came by the room, and wediscussed the scan and the likely future treatments.When she brought up thelogisticsofreturningtoresidency,Istoppedher.

“Victoria,” I said, “I’m never coming back to this hospital as a doctor.Don’tyouthink?”

Onechapterofmylifeseemedtohaveended;perhapsthewholebookwasclosing. Instead of being the pastoral figure aiding a life transition, I foundmyself the sheep, lost and confused. Severe illnesswasn’t life-altering, itwaslife-shattering. It felt less like an epiphany—a piercing burst of light,illuminatingWhatReallyMatters—andmorelikesomeonehadjustfirebombedthepathforward.NowIwouldhavetoworkaroundit.

My brother Jeevan had arrived at my bedside. “You’ve accomplished somuch,”hesaid.“Youknowthat,don’tyou?”

I sighed. He meant well, but the words rang hollow. My life had beenbuildingpotential,potential thatwouldnowgounrealized.Ihadplannedtodosomuch, and I had come so close. Iwas physically debilitated,my imaginedfuture and my personal identity collapsed, and I faced the same existentialquandaries my patients faced. The lung cancer diagnosis was confirmed. Mycarefullyplannedandhard-won futureno longerexisted.Death, so familiar tomeinmywork,wasnowpayingapersonalvisit.Herewewere,finallyface-to-face, andyetnothingabout it seemed recognizable.Standingat thecrossroadswhereIshouldhavebeenabletoseeandfollowthefootprintsofthecountlesspatientsIhadtreatedovertheyears,Isawinsteadonlyablank,aharsh,vacant,

gleamingwhitedesert,asifasandstormhaderasedalltraceoffamiliarity.Thesunwassetting.Iwouldbedischargedthenextmorning.Anoncology

appointmentwassetforlaterintheweek,butthenursetoldmemyoncologistwasgoing todropby thatnight,before leaving topickupherkids.HernamewasEmmaHayward,andshewantedtosayhellobeforetheinitialofficevisit.Iknew Emma a little—I had treated some of her patients before—but we hadnever spokenbeyondpassingprofessional courtesies.Myparents andbrotherswere scattered about the room, not saying much, while Lucy sat by the bed,holdingmyhand.Thedooropenedandinshewalked,herwhitecoatshowingthewearofalongdaybuthersmilefresh.Trailingbehindherwereherfellowandaresident.EmmawasonlyafewyearsolderthanI,herhairlonganddark,but as is common to all thosewho spend timewithdeath, streakedwithgray.Shepulledupachair.

“Hi,mynameisEmma,”shesaid.“I’msorrytohavetobesobrieftoday,butIwantedtocomebyandintroducemyself.”

Weshookhands,myarmentangledintheIVline.“Thanksforstoppingby,”Isaid.“Iknowyouhavekidstopickup.Thisis

myfamily.”ShenoddedhelloatLucy,atmybrothersandparents.“I’msorrythisishappeningtoyou,”shesaid.“Toallofyou.Therewillbe

alotoftimetotalkinacoupledays.Iwentaheadandhadthelabstartrunningsometestsonyourtumorsample,whichwillhelpguidetherapy.Treatmentmaybechemotherapyornot,dependingonthetests.”

Eighteenmonthsearlier,I’dbeeninthehospitalwithappendicitis.ThenI’dbeentreatednotasapatientbutasacolleague,almostlikeaconsultantonmyowncase.Iexpectedthesamehere.“Iknownow’snotthetime,”Iproceeded,“butIwillwanttotalkabouttheKaplan-Meiersurvivalcurves.”

“No,”shesaid.“Absolutelynot.”Abriefsilence.Howdareshe?Ithought.Thisishowdoctors—doctorslike

me—understandprognostication.Ihavearighttoknow.“Wecantalkabouttherapieslater,”shesaid.“Wecantalkaboutyourgoing

backtowork,too,ifthat’swhatyou’dliketodo.Thetraditionalchemotherapycombination—cisplatin,pemetrexed,possiblywithAvastin,too—hasahighrateofperipheralneuropathy,sowe’dprobablyswitchthecisplatinforcarboplatin,whichwillprotectyournervesbetter,sinceyou’reasurgeon.”

Goback towork?What is she talkingabout? Is shedelusional?Oram Ideadwrongaboutmyprognosis?Andhowcanwetalkaboutanyofthiswithoutarealisticestimateofsurvival?Theground,havingalreadybuckledandroiled

overthepastfewdays,didsoagain.“Wecandodetailslater,”shecontinued,“asIknowthisisalottoabsorb.

Mostly,IjustwantedtomeetyouallbeforeourappointmentThursday.IsthereanythingIcando,oranswer—besidessurvivalcurves—today?”

“No,” I said,mymind reeling.“Thankssomuch for stoppingby. I reallyappreciateit.”

“Here’smycard,”shesaid,“andthere’stheclinicnumber.Feelfreetocallifanythingcomesupbeforeweseeyouintwodays.”

My family and friends quickly wired through our network of medicalcolleaguestofindoutwhothebestlungcanceroncologistsinthecountrywere.Houston andNewYorkhadmajor cancer centers;was thatwhere I shouldbetreated?The logisticsofmovingor temporarily relocatingorwhathaveyou—thatcouldbesortedout later.Therepliescamebackquickly,andmoreor lessunanimously:Emmanotonlywasoneofthebest—aworld-renownedoncologistwho served as the lung cancer expert on one of the major national canceradvisoryboards—but shewas alsoknown tobe compassionate, someonewhoknewwhentopushandwhentoholdback. Ibrieflywonderedat thestringofeventsthathadsentmeloopingthroughtheworld,myresidencydeterminedbya computerized match process, only to end up assigned here, with a freakdiagnosis,inthehandsofoneofthefinestdoctorstotreatit.

Having spent the better part of the week bedridden, with the cancerprogressing,Ihadgrownnoticeablyweaker.Mybody,andtheidentitytiedtoit,had radically changed. No longer was getting in and out of bed to go to thebathroomanautomatedsubcorticalmotorprogram;it tookeffortandplanning.Thephysicaltherapistsleftalistofitemstoeasemytransitionhome:acane,amodified toilet seat, foamblocks for legsupportwhile resting.Abevyofnewpainmedicationswasprescribed.As Ihobbledoutof thehospital, Iwonderedhow, just six days ago, I had spent nearly thirty-six straight hours in theoperatingroom.HadIgrownthatmuchsickerinaweek?Yes,inpart.ButIhadalso used a number of tricks and help from co-surgeons to get through thosethirty-six hours—and, even so, I had suffered excruciating pain. Had theconfirmationofmyfears—intheCTscan, in the labresults,bothshowingnotmerely cancer but a body overwhelmed, nearing death—releasedme from theduty to serve, from my duty to patients, to neurosurgery, to the pursuit ofgoodness?Yes,Ithought,andthereinwastheparadox:likearunnercrossingthefinish line only to collapse, without that duty to care for the ill pushing meforward,Ibecameaninvalid.

Usually when I had a patient with a strange condition, I consulted the

relevantspecialistandspenttimereadingaboutit.Thisseemednodifferent,butasIstartedreadingaboutchemo,whichincludedawholevarietyofagents,andaraftofmoremodernnoveltreatmentsthattargetedspecificmutations,thesheernumberofquestionsIhadpreventedanyusefuldirectedstudy.(AlexanderPope:“A little learning is a dangerous thing; / Drink deep, or taste not the Pierianspring.”)Withoutappropriatemedicalexperience,Icouldn’tplacemyselfinthisnewworldof information,couldn’t findmyspoton theKaplan-Meiercurve. Iwaited,expectantly,formyclinicvisit.

Butmostly,Irested.Isat,staringataphotoofLucyandmefrommedicalschool,dancingand

laughing; it was so sad, those two, planning a life together, unaware, neversuspecting their own fragility.My friend Laurie had had a fiancéwhen she’ddiedinacaraccident—wasthisanycrueler?

Myfamilyengagedinaflurryofactivitytotransformmylifefromthatofadoctor to that of a patient.We set up an accountwith amail-order pharmacy,ordered a bed rail, and bought an ergonomic mattress to help alleviate thesearingbackpain.Our financialplan,whicha fewdaysbeforehadbankedonmy income increasing sixfold in the next year, now looked precarious, and avariety of new financial instruments seemed necessary to protect Lucy. Myfatherdeclaredthatthesemodificationswerecapitulationstothedisease:Iwasgoing tobeat this thing, Iwould somehowbecured.Howoftenhad Iheardapatient’sfamilymembermakesimilardeclarations?Ineverknewwhattosaytothemthen,andIdidn’tknowwhattosaytomyfathernow.

Whatwasthealternatestory?

—

Twodayslater,LucyandImetEmmaintheclinic.Myparentshoveredinthewaiting room. The medical assistant took my vitals. Emma and her nursepractitionerwereremarkablypunctual,andEmmapulledupachair infrontofme,totalkface-to-face,eye-to-eye.

“Helloagain,”shesaid.“ThisisAlexis,myrighthand.”ShegesturedtotheNP,whosatat thecomputer takingnotes.“Iknowthere’sa lot todiscuss,butfirst:Howareyoudoing?”

“Okay, all things considered,” I said. “Enjoying my ‘vacation,’ I guess.Howareyou?”

“Oh,I’mokay.”Shepaused—patientsdon’ttypicallyaskhowtheirdoctorsare doing, butEmmawas also a colleague. “I’m running the inpatient service

this week, so you know how that is.” She smiled. Lucy and I did know.Outpatientspecialistsrotatedontheinpatientserviceperiodically,addingseveralhoursofworkinanalreadyjam-packedday.

After more pleasantries, we settled into a comfortable discussion on thestate of lung cancer research. There were two paths forward, she said. Thetraditional method was chemotherapy, which generically targeted rapidlydividingcells—primarily cancer cellsbut also cells inyourbonemarrow,hairfollicles,intestines,andsoforth.Emmareviewedthedataandoptions,lecturingasiftoanotherdoctor—butagainwiththeexceptionofanymentionofKaplan-Meiersurvivalcurves.Newertherapieshadbeendeveloped,however,targetingspecificmoleculardefectsinthecanceritself.Ihadheardrumorsofsuchefforts—ithadlongbeenaholygrailincancerwork—andwassurprisedtolearnhowmuchprogresshadbeenmade.Thesetreatments,itseemed,hadledtolong-termsurvivalin“some”patients.

“Mostofyourtestsareback,”Emmasaid.“YouhaveaPI3Kmutation,butnoone’s surewhat thatmeansyet.The test for themost commonmutation inpatientslikeyou,EGFR,isstillpending.I’mbettingthat’swhatyouhave,andifso,there’sapillcalledTarcevathatyoucantakeinsteadofchemotherapy.Thatresultshouldbebacktomorrow,Friday,butyou’resickenoughthatI’vesetyouupforchemostartingMondayincasetheEGFRtestisnegative.”

I immediately felt a kinship. This was exactly how I approachedneurosurgery:haveaplanA,B,andCatalltimes.

“With chemo, our main decision will be carboplatin versus cisplatin. Inisolated studies, head-to-head, carboplatin is better tolerated. Cisplatin haspotentially better results but much worse toxicity, especially for the nerves,thoughall thedata isold,and there’snodirectcomparisonwithinourmodernchemoregimens.Doyouhaveanythoughts?”

“I’mlessworriedaboutprotectingmyhandsforsurgery,”Isaid.“There’salotIcandowithmylife.IfIlosemyhands,Icanfindanotherjob,ornotwork,orsomething.”

Shepaused.“Letmeaskthis:Issurgeryimportanttoyou?Isitsomethingyouwanttodo?”

“Well,yes,I’vespentalmostathirdofmylifepreparingforit.”“Okay, then I’m going to suggest we stick with the carboplatin. I don’t

think itwill change survival, and Ido think it coulddramaticallychangeyourqualityoflife.Doyouhaveanyotherquestions?”

Sheseemedclear that thiswas theway togo,andIwashappy to follow.Maybe,Ibegantoletmyselfbelieve,performingsurgeryagainwasapossibility.

Ifeltmyselfrelaxalittle.“CanIstartsmoking?”Ijoked.Lucylaughed,andEmmarolledhereyes.“No.Anyseriousquestions?”“TheKaplan-Meier—”“We’renotdiscussingthat,”shesaid.I didn’t understand her resistance.After all, Iwas a doctor familiarwith

thesestatistics.Icouldlookthemupmyself…sothat’swhatIwouldhavetodo.“Okay,”Isaid,“thenIthinkeverythingisprettyclear.We’llhearfromyou

tomorrowabouttheEGFRresults.Ifyes,thenwe’llstartapill,Tarceva.Ifno,thenwestartchemotherapyMonday.”

“Right.TheotherthingIwantyoutoknowisthis:Iamyourdoctornow.Anyproblemyouhave,fromprimarycaretowhatever,youcometousfirst.”

Again,Ifeltapangofkinship.“Thanks,”Isaid.“Andgoodluckontheinpatientwards.”Shelefttheroom,onlytopopherheadbackinasecondlater.“Feelfreeto

say no to this, but there are some lung cancer fundraiserswhowould love tomeetyou.Don’tanswernow—thinkaboutit,andletAlexisknowifyoumightbeinterested.Don’tdoanythingyoudon’twantto.”

As we left, Lucy remarked, “She’s great. She’s a good fit for you.Although…”Shesmiled.“Ithinkshelikesyou.”

“And?”“Well, there’s that study that saysdoctorsdo aworse jobprognosticating

forpatientsthey’repersonallyinvestedin.”“Onourlistofthingstoworryabout,”Isaid,withalaugh,“Ithinkthat’sin

thebottomquartile.”Ibegantorealizethatcominginsuchclosecontactwithmyownmortality

had changedbothnothing and everything.Beforemycancerwasdiagnosed, IknewthatsomedayIwoulddie,butIdidn’tknowwhen.Afterthediagnosis,Iknew that someday I would die, but I didn’t knowwhen. But now I knew itacutely. The problem wasn’t really a scientific one. The fact of death isunsettling.Yetthereisnootherwaytolive.

—

Slowlythemedicalfogwasclearing—atleastnowIhadenoughinformationtodive into the literature. While the numbers were fuzzy, having an EGFR

mutationseemedtoaddaroundayearoflifeonaverage,withthepotentialforlong-termsurvival;nothavingitsuggestedan80percentchanceofdeathwithintwoyears.Clarifyingtherestofmylifewasgoingtobeaprocess.

Thenextday,LucyandIwenttothespermbank,topreservegametesandoptions.We had always planned to have kids at the end ofmy residency, butnow…Thecancerdrugswouldhaveanunknowneffectonmysperm,sotokeepa chance of having children, we’d have to freeze sperm before I startedtreatment.Ayoungwomanwalkedus throughavarietyofpaymentplans andoptionsforstorageandlegalformsforownership.Onherdeskwereamultitudeofcolorfulpamphletsaboutvarioussocialoutingsforyoungpeoplewithcancer:improvgroups, a cappella groups, open-mikenights, and soon. I envied theirhappy faces, knowing that, statistically, they all probably had highly treatableformsofcancer,andreasonablelifeexpectancies.Only0.0012percentofthirty-six-year-olds get lung cancer. Yes, all cancer patients are unlucky, but there’scancer,andthenthere’sCANCER,andyouhavetobereallyunluckytohavethelatter.Whensheaskedustospecifywhatwouldhappentothespermifoneofus“weretodie”—whowouldlegallyownthemintheeventofdeath—tearsbeganrollingdownLucy’sface.

The word hope first appeared in English about a thousand years ago,denotingsomecombinationofconfidenceanddesire.ButwhatIdesired—life—wasnotwhatIwasconfidentabout—death.WhenItalkedabouthope,then,didIreallymean“Leavesomeroomforunfoundeddesire?”No.Medicalstatisticsnotonlydescribenumberssuchasmeansurvival,theymeasureourconfidencein our numbers, with tools like confidence levels, confidence intervals, andconfidence bounds. So did I mean “Leave some room for a statisticallyimprobablebut stillplausibleoutcome—asurvival justabove themeasured95percentconfidenceinterval?”Isthatwhathopewas?Couldwedividethecurveinto existential sections, from “defeated” to “pessimistic” to “realistic” to“hopeful” to “delusional”?Weren’t thenumbers just thenumbers?Hadwe alljustgivenintothe“hope”thateverypatientwasaboveaverage?

ItoccurredtomethatmyrelationshipwithstatisticschangedassoonasIbecameone.

During my residency, I had sat with countless patients and families todiscuss grim prognoses; it’s one of the most important jobs you have, as aphysician. It’s easier when the patient is ninety-four, in the last stages ofdementia,withaseverebrainbleed.Butforsomeonelikeme—athirty-six-year-oldgivenadiagnosisofterminalcancer—therearen’treallywords.

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 thebounds of probability—someone expecting to live to 130, say, or someonethinking his benign skin spots are signs of imminent death—doctors areentrusted to bring that person’s expectations into the realm of reasonablepossibility.Whatpatientsseekisnotscientificknowledgethatdoctorshidebutexistential authenticity each personmust find on her own.Getting too deeplyinto statistics is like trying to quench a thirst with salty water. The angst offacingmortalityhasnoremedyinprobability.

Whenwearrivedhomefromthespermbank,IgotaphonecallsayingthatIdid,infact,haveatreatablemutation(EGFR).Chemowasoff,thankfully,andTarceva,alittlewhitepill,becamemytreatment.Isoonbegantofeelstronger.AndeventhoughInolongerreallyknewwhatitwas,Ifeltit:adropofhope.Thefogsurroundingmylife rolledbackanother inch,andasliverofblueskypeekedthrough.Intheweeksthatfollowed,myappetitereturned.Iputonalittleweight. I developed the characteristic severe acne that correlates with a goodresponse.Lucyhadalwayslovedmysmoothskin,butnowitwaspockmarkedand,withmybloodthinners,constantlybleeding.Anypartofmethatidentifiedwithbeinghandsomewasslowlybeingerased—though,infairness,Iwashappytobeuglierandalive.Lucysaidshelovedmyskinjustthesame,acneandall,butwhileIknewthatouridentitiesderivenotjustfromthebrain,Iwaslivingitsembodied nature. The man who loved hiking, camping, and running, whoexpressedhislovethroughgigantichugs,whothrewhisgigglingniecehighintheair—thatwasamanInolongerwas.Atbest,Icouldaimtobehimagain.

Atourfirstofseveralbiweeklyappointments,Emma’sandmydiscussiontended from the medical (“How’s the rash?”) to the more existential. Thetraditional cancernarrative—thatoneought to recede, spend timewith family,andsettleone’stoesinthepeat—wasoneoption.

“Manypeople,oncediagnosed,quitworkentirely,”shesaid.“Othersfocusonitheavily.Eitherwayisokay.”

“Ihadmappedoutthiswholeforty-yearcareerformyself—thefirsttwentyasasurgeon-scientist,thelasttwentyasawriter.ButnowthatIamlikelywellintomylasttwentyyears,Idon’tknowwhichcareerIshouldbepursuing.”

“Well,Ican’ttellyouthat,”shesaid.“Icanonlysaythatyoucangetbacktosurgeryifyouwant,butyouhavetofigureoutwhat’smostimportanttoyou.”

“IfIhadsomesenseofhowmuchtimeIhaveleft, it’dbeeasier.IfIhadtwoyears,I’dwrite.IfIhadten,I’dgetbacktosurgeryandscience.”

“YouknowIcan’tgiveyouanumber.”Yes,Iknew.Itwasuptome,toquoteheroft-repeatedrefrain,tofindmy

values.Partofmefelt thiswasacop-out:okay,fine,Inevergaveoutspecificnumberstopatients,either,butdidn’tIalwayshaveasenseofhowthepatientwould do?How else did Imake life-and-death decisions?Then I recalled thetimes I had been wrong: the time I had counseled a family to withdraw lifesupportfortheirson,onlyfortheparentstoappeartwoyearslater,showingmeaYouTube video of himplaying piano, and delivering cupcakes in thanks forsavinghislife.

My oncology appointments were the most important of many newappointmentswith avarietyof healthcareproviders, but theyweren’t theonlyones.AtLucy’sinsistence,webeganseeingacouplestherapistwhospecializedin cancer patients. Sitting in herwindowless office, in side-by-side armchairs,Lucyand I detailed theways inwhichour lives, present and future, hadbeenfracturedbymydiagnosis,andthepainofknowingandnotknowingthefuture,the difficulty in planning, the necessity of being there for eachother. In truth,cancerhadhelpedsaveourmarriage.

“Well,youtwoarecopingwiththisbetterthananycoupleI’veseen,”thetherapistsaidattheendofourfirstsession.“I’mnotsureIhaveanyadviceforyou.”

I laughedaswewalkedout—at least Iwasexcellingat somethingagain.Theyearsofministeringtoterminallyillpatientshadbornesomefruit!IturnedtoLucy,expectingtoseeasmile;instead,shewasshakingherhead.

“Don’tyougetit?”shesaid,takingmyhandinhers.“Ifwe’rethebestatthis,thatmeansitdoesn’tgetbetterthanthis.”

If theweightofmortalitydoesnotgrow lighter, does it at leastgetmorefamiliar?

Once I had been diagnosed with a terminal illness, I began to view theworld through twoperspectives; Iwasstarting toseedeathasbothdoctorandpatient.Asadoctor,Iknewnottodeclare“CancerisabattleI’mgoingtowin!”or ask “Whyme?” (Answer:Whynotme?) I knew a lot aboutmedical care,complications,and treatmentalgorithms. Iquickly learned frommyoncologistandmyown study that stage IV lung cancer todaywas a diseasewhose storymightbechanging, likeAIDS in the late1980s: still a rapidly fatal illnessbutwithemergingtherapiesthatwere,forthefirsttime,providingyearsoflife.

Whilebeingtrainedasaphysicianandscientisthadhelpedmeprocessthedataandacceptthelimitsofwhatthatdatacouldrevealaboutmyprognosis,itdidn’t helpme as a patient. It didn’t tell Lucy andmewhetherwe should goaheadandhaveachild,orwhatitmeanttonurtureanewlifewhileminefaded.Nordidittellmewhethertofightformycareer,toreclaimtheambitionsIhad

single-mindedly pursued for so long, but without the surety of the time tocompletethem.

Likemy own patients, I had to facemymortality and try to understandwhat made my life worth living—and I needed Emma’s help to do so. Tornbetween being a doctor and being a patient, delving intomedical science andturningbacktoliteratureforanswers,Istruggled,whilefacingmyowndeath,torebuildmyoldlife—orperhapsfindanewone.

—

Thebulkofmyweekwasspentnotincognitivetherapybutinphysicaltherapy.Ihadsentnearlyeveryoneofmypatientstophysicaltherapy.AndnowIfoundmyselfshockedathowdifficultitwas.Asadoctor,youhaveasenseofwhatit’sliketobesick,butuntilyou’vegonethroughityourself,youdon’treallyknow.It’s like falling in love or having a kid. You don’t appreciate the mounds ofpaperwork that come along with it, or the little things.When you get an IVplaced, forexample,youcanactually taste thesaltwhen theystart infusing it.They tell me that this happens to everybody, but even after eleven years inmedicine,Ihadneverknown.

Inphysicaltherapy,Iwasnotevenliftingweightsyet,justliftingmylegs.Thiswasexhaustingandhumiliating.Mybrainwasfine,butIdidnotfeellikemyself.Mybodywasfrailandweak—thepersonwhocouldrunhalfmarathonswas adistantmemory—and that, too, shapesyour identity.Rackingbackpaincanmoldanidentity;fatigueandnauseacan,aswell.Karen,myPT,askedmewhatmygoalswere. Ipicked two: ridingmybikeandgoing for a run. In thefaceofweakness,determinationsetin.DayafterdayIkeptatit,andeverytinyincreaseinstrengthbroadenedthepossibleworlds,thepossibleversionsofme.Istartedaddingreps,weights,andminutestomyworkouts,pushingmyselftothepointofvomiting.Aftertwomonths,Icouldsitforthirtyminuteswithouttiring.Icouldstartgoingtodinnerwithfriendsagain.

Oneafternoon,LucyandIdrovedowntoCañadaRoad,ourfavoritebikingspot. (Usuallywewouldbike there,pride forcesme to add,but thehillswerestill too formidable formy lightweight frame.) Imanagedsixwobblymiles. Itwasa farcry fromthebreezy, thirty-mile ridesof theprevioussummer,butatleastIcouldbalanceontwowheels.

Wasthisavictoryoradefeat?IbegantolookforwardtomymeetingswithEmma.Inheroffice,Ifeltlike

myself, likeaself.Outsideheroffice, Ino longerknewwhoIwas.Because I

wasn’tworking,Ididn’t feel likemyself,aneurosurgeon,ascientist—ayoungman,relativelyspeaking,withabrightfuturespreadbeforehim.Debilitated,athome, I feared I wasn’t much of a husband for Lucy. I had passed from thesubject to thedirect object of every sentenceofmy life. In fourteenth-centuryphilosophy,thewordpatient simplymeant“theobjectofanaction,”andI feltlike one. As a doctor, I was an agent, a cause; as a patient, I was merelysomething towhich thingshappened.But inEmma’soffice,Lucyand I couldjoke,tradedoctorlingo,talkfreelyaboutourhopesanddreams,trytoassemblea plan to move forward. Two months in, Emma remained vague about anyprognostication,andeverystatisticIcitedsherebuffedwitharemindertofocusonmyvalues.ThoughIfeltdissatisfied,atleastIfeltlikesomebody,aperson,rather than a thing exemplifying the second lawof thermodynamics (all ordertendstowardentropy,decay,etc.).

Flushinthefaceofmortality,manydecisionsbecamecompressed,urgentandunreceding.Foremostamongthemforus:ShouldLucyandIhaveachild?Evenifourmarriagehadbeenstrainedtowardtheendofmyresidency,wehadalwaysremainedverymuchinlove.Ourrelationshipwasstilldeepinmeaning,a shared and evolving vocabulary aboutwhatmattered. If human relationalityformed the bedrock of meaning, it seemed to us that rearing children addedanotherdimensiontothatmeaning.Ithadbeensomethingwe’dalwayswanted,andwewerebothimpelledbytheinstinct todoitstill, toaddanotherchair toourfamily’stable.

Bothofusyearningtobeparents,weeachthoughtoftheother.LucyhopedI had years left, but understanding my prognosis, she felt that the choice—whethertospendmyremainingtimeasafather—shouldbemine.

“What are youmost afraidor sad about?” she askedmeonenight aswewerelyinginbed.

“Leavingyou,”Itoldher.Iknewachildwouldbringjoytothewholefamily,andIcouldn’tbearto

pictureLucyhusbandlessandchildlessafterIdied,butIwasadamant that thedecisionultimatelybehers:shewouldlikelyhavetoraisethechildonherown,afterall,andtocareforbothofusasmyillnessprogressed.

“Will having a newborn distract from the time we have together?” sheasked.“Don’tyouthinksayinggoodbyetoyourchildwillmakeyourdeathmorepainful?”

“Wouldn’titbegreatifitdid?”Isaid.LucyandIbothfeltthatlifewasn’taboutavoidingsuffering.

Yearsago,ithadoccurredtomethatDarwinandNietzscheagreedonone

thing: the defining characteristic of the organism is striving. Describing lifeotherwisewaslikepaintingatigerwithoutstripes.Aftersomanyyearsoflivingwithdeath,I’dcometounderstandthattheeasiestdeathwasn’tnecessarilythebest.Wetalkeditover.Ourfamiliesgavetheirblessing.Wedecidedtohaveachild.Wewouldcarryonliving,insteadofdying.

BecauseofthemedicationsIwason,assistedreproductionappearedtobethe only route forward. So we visited a specialist at a reproductiveendocrinology clinic in PaloAlto. Shewas efficient and professional, but herlack of experience dealingwith terminally ill, as opposed to infertile, patientswasobvious.Sheplowedthroughherspiel,eyesonherclipboard:

“Howlonghaveyoubeentrying?”“Well,wehaven’tyet.”“Oh,right.Ofcourse.”Finally she asked, “Given your, uh, situation, I assume you want to get

pregnantfast?”“Yes,”Lucysaid.“We’dliketostartrightaway.”“I’dsuggestyoubeginwithIVF,then,”shesaid.When I mentioned that we’d rather minimize how many embryos were

createdanddestroyed,shelookedslightlyconfused.Mostpeoplewhocamehereprizedexpedienceaboveall.ButIwasdeterminedtoavoidthesituationwhere,afterIdied,Lucyhadresponsibilityforahalfdozenembryos—thelastremnantsof our shared genomes, my last presence on this earth—stuck in a freezersomewhere, too painful to destroy, impossible to bring to full humanity:technologicalartifactsthatnooneknewhowtorelateto.Butafterseveraltrialsofintrauterineinsemination,itwasclearweneededahigherleveloftechnology:we would need to create at least a few embryos in vitro and implant thehealthiest.Theotherswoulddie.Eveninhavingchildreninthisnewlife,deathplayeditspart.

—

Sixweeksafterstartingtreatment,IwasdueformyfirstCTscantomeasuretheefficacyof theTarceva.AsIhoppedoutof thescanner, theCTtech lookedatme. “Well, Doc,” he offered, “I’m not supposed to say this, but there’s acomputerbackthereifyouwanttotakealook.”Iloadeduptheimagesontheviewer,typinginmyownname.

Theacnewasa reassuringsign.Mystrengthhadalso improved, thoughIwas still limited by back pain and fatigue. Sitting there, I remindedmyself of

whatEmmahadsaid:evenasmallamountof tumorgrowth,so longas itwassmall,wouldbeconsideredasuccess.(Myfather,ofcourse,hadpredictedthatall thecancerwouldbegone.“Yourscanwillbeclear,Pubby!”he’ddeclared,usingmy family nickname.) I repeated tomyself that even small growthwasgoodnews, tookabreath,andclicked.The imagesmaterializedon thescreen.My lungs, speckled with innumerable tumors before, were clear except for aone-centimeter nodule in the right upper lobe. I could make out my spinebeginningtoheal.Therehadbeenaclear,dramaticreductionintumorburden.

Reliefwashedoverme.Mycancerwasstable.WhenwemetEmmathenextdayshestillrefusedtotalkprognosis,butshe

said,“You’rewellenoughthatwecanmeeteverysixweeksnow.Nexttimewemeet,wecanstart to talkaboutwhatyour lifemightbe like.” Icould feel thechaos of the past months receding, a sense of a new order settling in. Mycontractedsenseofthefuturebegantorelax.

AlocalmeetingofformerStanfordneurosurgerygraduateswashappeningthatweekend,andIlookedforwardtothechancetoreconnectwithmyformerself.Yetbeingtheremerelyheightenedthesurrealcontrastofwhatmylifewasnow. Iwas surrounded by success and possibility and ambition, by peers andseniorswhose liveswere running along a trajectory thatwas no longermine,whosebodiescouldstilltoleratestandingforagruelingeight-hoursurgery.Ifelttrapped inside a reversed Christmas carol: Victoria was opening the happypresent—grants, joboffers,publications—Ishouldbesharing.Myseniorpeerswerelivingthefuturethatwasnolongermine:earlycareerawards,promotions,newhouses.

Nooneaskedaboutmyplans,whichwasarelief,sinceIhadnone.WhileIcouldnowwalkwithoutacane,aparalyticuncertaintyloomed:WhowouldIbe,going forward, and for how long? Invalid, scientist, teacher? Bioethicist?Neurosurgeon once again, as Emma had implied? Stay-at-home dad?Writer?Whocould,orshould,Ibe?Asadoctor,Ihadhadsomesenseofwhatpatientswith life-changing illnesses faced—and it was exactly these moments I hadwantedtoexplorewiththem.Shouldn’tterminalillness,then,betheperfectgiftto that youngmanwho hadwanted to understand death?What better way tounderstand it than to live it? But I’d had no idea how hard itwould be, howmuch terrain I would have to explore, map, settle. I’d always imagined thedoctor’s work as something like connecting two pieces of railroad track,allowing a smooth journey for the patient. I hadn’t expected the prospect offacingmyownmortalitytobesodisorienting,sodislocating.Ithoughtbackto

myyoungerself,whomight’vewanted to“forge in thesmithyofmysoul theuncreatedconscienceofmyrace”;lookingintomyownsoul,Ifoundthetoolstoobrittle,thefiretooweak,toforgeevenmyownconscience.

Lostinafeaturelesswastelandofmyownmortality,andfindingnotractioninthereamsofscientificstudies,intracellularmolecularpathways,andendlesscurves of survival statistics, I began reading literature again: Solzhenitsyn’sCancerWard,B.S.Johnson’sTheUnfortunates,Tolstoy’s IvanIlyich,Nagel’sMindandCosmos,Woolf,Kafka,Montaigne,Frost,Greville,memoirsofcancerpatients—anything by anyone who had ever written about mortality. I wassearchingforavocabularywithwhichtomakesenseofdeath,tofindawaytobegin defining myself and inching forward again. The privilege of directexperiencehadledmeawayfromliteraryandacademicwork,yetnowIfeltthattounderstandmyowndirectexperiences, Iwouldhave to translate thembackintolanguage.Hemingwaydescribedhisprocessinsimilarterms:acquiringrichexperiences,thenretreatingtocogitateandwriteaboutthem.Ineededwordstogoforward.

Andsoitwasliteraturethatbroughtmebacktolifeduringthistime.Themonolithic uncertainty of my future was deadening; everywhere I turned, theshadowofdeathobscured themeaningofanyaction. I remember themomentwhenmyoverwhelminguneaseyielded,whenthatseeminglyimpassableseaofuncertainty parted. Iwoke up in pain, facing another day—no project beyondbreakfastseemedtenable.Ican’tgoon,Ithought,andimmediately,itsantiphonresponded,completingSamuelBeckett’ssevenwords,wordsIhadlearnedlongagoasanundergraduate: I’ll goon. I got out of bed and took a step forward,repeatingthephraseoverandover:“Ican’tgoon.I’llgoon.”

Thatmorning,Imadeadecision:IwouldpushmyselftoreturntotheOR.Why?BecauseIcould.Becausethat’swhoIwas.BecauseIwouldhavetolearnto live in a different way, seeing death as an imposing itinerant visitor butknowingthatevenifI’mdying,untilIactuallydie,Iamstillliving.

—

Over thenextsixweeks, Ialteredmyphysical therapyprogram,focusingnowon building strength specifically for operating: long hours of standing,micromanipulationofsmallobjects,pronationforplacingpediclescrews.

Another CT scan followed. The tumor had shrunk slightly more. Goingovertheimageswithme,Emmasaid,“Idon’tknowhowlongyou’vegot,butIwill say this: the patient I saw just before you today has been onTarceva for

sevenyearswithoutaproblem.You’vestillgotawaystogobeforewe’rethatcomfortable with your cancer. But, looking at you, thinking about living tenyearsisnotcrazy.Youmightnotmakeit,butit’snotcrazy.”

Here was the prognostication—no, not prognostication: justification.Justificationofmydecisiontoreturntoneurosurgery,toreturntolife.Onepartof me exulted at the prospect of ten years. Another part wished she’d said,“Goingbacktobeinganeurosurgeoniscrazyforyou—picksomethingeasier.”Iwas startled to realize that in spiteof everything, the last fewmonthshadhadone area of lightness: not having to bear the tremendous weight of theresponsibility neurosurgery demanded—and part of me wanted to be excusedfrompickingup theyokeagain.Neurosurgery is reallyhardwork,andnoonewouldhavefaultedmefornotgoingback.(Peopleoftenaskifitisacalling,andmyanswerisalwaysyes.Youcan’tseeitasajob,becauseifit’sajob,it’soneof theworst jobs there is.)Acoupleofmyprofessorsactivelydiscouraged theidea:“Shouldn’tyoubespending timewithyour family?”(“Shouldn’tyou?”Iwondered.Iwasmakingthedecisiontodothisworkbecausethiswork,tome,was a sacred thing.) Lucy and I had just reached the top of the hill, thelandmarks of SiliconValley, buildings bearing the names of every biomedicaland technological transformation of the last generation, unfolding below us.Eventually, though, the itch to hold a surgical drill again had become toocompelling.Moraldutyhasweight,thingsthathaveweighthavegravity,andsotheduty tobearmortal responsibilitypulledmeback into theoperating room.Lucywasfullysupportive.

Icalledup theprogramdirector to tellhimIwasreadytoreturn.Hewasthrilled.VictoriaandItalkedabouthowbesttoreintroducemeandgetmebackuptospeed.Irequestedthatafellowresidentbeavailabletobackmeupatalltimesincasesomethingwentawry.Furthermore,Iwoulddoonlyonecaseperday.Iwouldn’tmanagethepatientsoutsidetheORorbeoncall.We’dproceedconservatively. TheOR schedule came out, and I was assigned to a temporallobectomy, oneofmy favorite operations.Commonly, epilepsy is causedby amisfiringhippocampus,which is locateddeep in the temporal lobe.Removingthehippocampuscancure theepilepsy,but theoperation iscomplex, requiringgentle dissection of the hippocampus off the pia, the delicate transparentcoveringofthebrain,rightnearthebrainstem.

I spent the night prior poring through surgical textbooks, reviewing theanatomy and steps of the operation. I slept restlessly, seeing the angle of thehead, the saw against the skull, theway the light reflects off the pia once thetemporal 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.) Iarrivedatthehospitalandchangedintothefamiliarbluegarbforthefirsttimeineighteenweeks.Ichattedwiththepatienttomakesuretherewerenolast-minutequestions, then began the process of setting up the OR. The patient wasintubated,theattendingandIwerescrubbedandreadytobegin.Ipickedupthescalpelandincisedtheskinjustabovetheear,proceedingslowly,tryingtomakesureIforgotnothingandmadenomistakes.Withtheelectrocautery,Ideepenedtheincisiontothebone,thenelevatedtheskinflapwithhooks.Everythingfeltfamiliar,musclememorykickingin.Itookthedrillandmadethreeholesintheskull.TheattendingsquirtedwatertokeepthedrillcoolasIworked.Switchingtothecraniotome,asideways-cuttingdrillbit,Iconnectedtheholes,freeingupalarge piece of bone. With a crack, I pried it off. There lay the silvery dura.Happily,Ihadn’tdamageditwiththedrill,acommonbeginner’smistake.Iusedasharpknifetoopenthedurawithoutinjuringthebrain.Successagain.Ibegantorelax.Itackedbackthedurawithsmallstitchestokeepitoutofthewayofthemainsurgery.Thebraingentlypulsedandglistened.ThehugeSylvianveinsranacrossthetopofthetemporallobe,pristine.Thefamiliarpeachconvolutionsofthebrainbeckoned.

Suddenly,theedgesofmyvisiondimmed.Iputdownmyinstrumentsandstepped back from the table. The blackness encroached farther as a feeling oflightnessovercameme.

“Sorry,sir,”Itoldtheattending,“I’mfeelingalittlefaint.IthinkIneedtoliedown.Jack,myjuniorresident,willfinishthecase.”

Jackarrivedquickly,andIexcusedmyself. I sippedsomeorange juice inthe lounge, lying on the couch. After twenty minutes, I began to feel better.“Neurocardiogenic syncope,” I whispered to myself. The autonomic nervoussystembrieflyshuttingdowntheheart.Or,asit’smorecommonlyknown,acaseofthenerves.Arookieproblem.ThiswasnothowI’denvisionedmyreturntotheOR.Iwenttothelockerroom,threwmydirtyscrubsinthelaundry,andputon my civilian clothes. On the way out, I grabbed a stack of clean scrubs.Tomorrow,Itoldmyself,wouldbeabetterday.

Itwas.Everyday,eachcasefeltfamiliarbutmovedalittlemoreslowly.Ondaythree,Iwasremovingadegenerateddiscfromapatient’sspine.Istaredatthebulgingdisc,not rememberingmyexactmove.The fellowsupervisingmesuggestedtakingsmallbiteswitharongeur.

“Yeah, I know that’s how it’s usually done,” I mumbled, “but there’sanotherway…”

Inibbledawayfortwentyminutes,mybrainsearchingforthemoreelegant

wayIhad learned todo this.At thenextspinal level, itcameback tome inaflash.

“Cobbinstrument!”Icalledout.“Mallet.Kerrison.”Ihad thewholedisc removed in thirty seconds. “That’show Ido this,” I

said.Over thenext coupleofweeks,my strengthcontinued to improve, asdid

myfluencyandtechnique.Myhandsrelearnedhowtomanipulatesubmillimeterbloodvesselswithoutinjury,myfingersconjuringuptheoldtricksthey’donceknown.Afteramonth,Iwasoperatinganearlyfullload.

Ikeptmyselflimitedtooperating,leavingtheadministration,patientcare,and night and weekend calls to Victoria and the other senior residents. I hadalreadymasteredthoseskills,anyway,andneededtolearnonlythenuancesofcomplex operations to feel complete. I ended my days exhausted beyondmeasure,muscleson fire, slowly improving.But the truthwas, itwas joyless.ThevisceralpleasureI’doncefoundinoperatingwasgone,replacedbyanironfocusonovercomingthenausea,thepain,thefatigue.Cominghomeeachnight,Iwouldscarfdownahandfulofpainpills,thencrawlintobednexttoLucy,whohadreturnedtoafullworkscheduleaswell.Shewasnowinthefirsttrimesterofpregnancy,withthebabydueinJune,whenIwouldcompleteresidency.Wehadaphotoofourchildasablastocyst,takenjustbeforeimplantation.(“Shehasyourcellmembrane,”IremarkedtoLucy.)Still,Iwasdeterminedtorestoremylifetoitspriortrajectory.

Anotherstablescansixmonthsafterdiagnosispassed,andIreopenedmyjob search.With my cancer under control, I might have several years left. ItseemedthecareerIhadworkedforyearstoattain,whichhaddisappearedamiddisease,wasnowbackinreach.Icouldalmostheartrumpetssoundingavictoryfanfare.

—

DuringmynextvisitwithEmma,wetalkedaboutlifeandwhereitwastakingme. I recalled Henry Adams trying to compare the scientific force of thecombustion engine and the existential force of theVirginMary.The scientificquestionsweresettledfornow,allowingtheexistentialonesfullplay,yetbothwere in the doctor’s purview. I had recently learned that the surgeon-scientistposition at Stanford—the job for which I had been heir apparent—had beenfilledwhileIwasoutsick.Iwascrushed,andtoldherso.

“Well,”shesaid,“thisdoctor-professor thingcanbea realgrind.Butyou

knowthatalready.I’msorry.”“Yeah,Iguessthesciencethatexcitedmewasabouttwenty-yearprojects.

Without thatkindof timeframe,I’mnotsureI’mall that interestedinbeingascientist.” I tried to consolemyself. “You can’t getmuch done in a couple ofyears.”

“Right. And just remember, you’re doing great. You’re working again.You’vegotababyontheway.You’refindingyourvalues,andthat’snoteasy.”

Later that dayoneof theyoungerprofessors, a former resident and closefriend,stoppedmeinthehallway.

“Hey,”shesaid.“There’sbeenalotofdiscussioninfacultymeetingsaboutwhattodowithyou.”

“Whattodowithme,how?”“Ithinksomeprofessorsareconcernedaboutyougraduating.”Graduation from residency required two things:meeting a set of national

andlocalrequirements,whichI’dalreadydone,andtheblessingofthefaculty.“What?”Isaid.“Idon’tmeantosoundcocky,butI’magoodsurgeon,just

asgoodas—”“Iknow.Ithinktheyprobablyjustwanttoseeyouperformingthefullload

ofachief.It’sbecausetheylikeyou.Seriously.”Irealizeditwastrue:Forthepastfewmonths,Ihadbeenactingmerelyas

a surgical technician. I had been using cancer as an excuse not to take fullresponsibilityformypatients.Ontheotherhand,itwasagoodexcuse,damnit.But now I started coming in earlier, staying later, fully caring for the patientsagain,addinganotherfourhourstoatwelve-hourday.Itputthepatientsbackinthecenterofmymindatalltimes.ThefirsttwodaysIthoughtIwouldhavetoquit,battlingwavesofnausea,pain,andfatigue,retreatingtoanunusedbedindownmoments 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 themeaning of this work. I took antiemetics and nonsteroidal anti-inflammatorydrugs(NSAIDs)betweencasesandjustbeforerounds.Iwassuffering,butIwasfully back. Instead of finding an unused bed, I started resting on the juniorresidents’couch,supervisingthemonthecareofmypatients,lecturingasIrodeawaveofbackspasms.Themoretorturedmybodybecame,themoreIrelishedhaving done the work. At the end of the first week, I slept for forty hoursstraight.

ButIwascallingtheshots:“Hey,boss,”Isaid,“Iwasjustreviewingcasesfortomorrow,andIknow

the firstcase isbooked interhemispheric,but I think itwillbemuchsaferandeasierifwecomeparietaltranscortical.”

“Really?”theattendingsaid.“Letmelookatthefilms….Youknowwhat?You’reright.Canyouchangethebooking?”

Thenextday:“Hi,sir,it’sPaul.IjustsawMr.FandhisfamilyintheICU—I thinkwe’ll need to take him tomorrow for an ACDF. Okay if I book it?Whenareyoufree?”

AndIwasbacktofullspeedintheOR:“Nurse,canyoupageDr.S?I’mgoingtobedonewiththiscasebeforehe

getshere.”“I’vegothimonthephone.Hesaysyoucan’tpossiblybedoneyet.”Theattendingcamerunningin,outofbreath,scrubbed,andpeeredthrough

themicroscope.“I took a slightly acute angle to avoid the sinus,” I said, “but thewhole

tumor’sout.”“Youavoidedthesinus?”“Yes,sir.”“Yougotitoutinonepiece?”“Yes,sir,it’sonthetablesoyoucanhavealook.”“Looksgood.Reallygood.Whendidyougettobesofast?SorryIwasn’t

hereearlier.”“Notrouble.”The tricky part of illness is that, as you go through it, your values are

constantly changing.You try to figure outwhatmatters to you, and then youkeep figuring it out. It felt like someonehad takenawaymycredit cardand Iwashavingtolearnhowtobudget.Youmaydecideyouwanttospendyourtimeworkingasaneurosurgeon,buttwomonthslater,youmayfeeldifferently.Twomonths after that, you may want to learn to play the saxophone or devoteyourselftothechurch.Deathmaybeaone-timeevent,butlivingwithterminalillnessisaprocess.

It struckme that I had traversed the five stages of grief—the “Denial→Anger→Bargaining→Depression→Acceptance”cliché—butIhaddoneitallbackward.Ondiagnosis,I’dbeenpreparedfordeath.I’devenfeltgoodaboutit.I’dacceptedit. I’dbeenready.ThenIslumpedintoadepression,as itbecameclearthatImightnotbedyingsosoonafterall,whichis,ofcourse,goodnews,butalsoconfusingandstrangelyenervating.Therapidityofthecancerscience,and the nature of the statistics,meant Imight live another twelvemonths, or

another120.Grandillnessesaresupposedtobelife-clarifying.Instead,IknewIwas going to die—but I’d known that before.My state of knowledgewas thesame,butmyabilitytomakelunchplanshadbeenshottohell.Thewayforwardwouldseemobvious,ifonlyIknewhowmanymonthsoryearsIhadleft.Tellmethreemonths,I’dspendtimewithfamily.Tellmeoneyear,I’dwriteabook.Givemetenyears,I’dgetbacktotreatingdiseases.Thetruththatyouliveonedayatatimedidn’thelp:WhatwasIsupposedtodowiththatday?

At some point, then, I began to do a little bargaining—or not exactlybargaining.More like: “God, Ihave read Job, and Idon’tunderstand it,but ifthis is a test of faith, you now realize my faith is fairly weak, and probablyleavingthespicymustardoff thepastramisandwichwouldhavealsotestedit?Youdidn’thavetogonuclearonme,youknow…”Then,after thebargaining,cameflashesofanger:“Iworkmywholelifetogettothispoint,andthenyougivemecancer?”

Andnow,finally,maybeIhadarrivedatdenial.Maybetotaldenial.Maybe,intheabsenceofanycertainty,weshouldjustassumethatwe’regoingtolivealongtime.Maybethat’stheonlywayforward.

—

I was operating until late at night or into the early morning, fixated ongraduation,mydiagnosisninemonthsinthepast.Mybodywastakingabeating.Iwas too tired to eatwhen I got home. I hadbeen slowlyupping thedoseofTylenol and NSAIDs and antiemetics. I had developed a persistent cough,presumablycausedbyscarringfromthedeadtumorinmylungs.Ionlyhadtokeepupthisrelentlesspaceforacouplemoremonths,Itoldmyself,andthenIwouldgraduatefromresidencyandsettleintothecomparativelycalmerroleofaprofessor.

In February, I flew toWisconsin for a job interview. Theywere offeringeverythingIwanted:millionsofdollarstostartaneurosciencelab,headofmyown clinical service, flexibility if I needed it for my health, a tenure-trackprofessorship, appealing job options for Lucy, high salary, beautiful scenery,idyllictown,theperfectboss.“Iunderstandaboutyourhealth,andyouprobablyhave a strong connectionwith your oncologist,” the department chairman toldme.“So ifyouwant tokeepyourcare there,wecanflyyoubackandforth—thoughwedohaveatop-notchcancercenterhere,ifyouwanttoexploreit.IsthereanythingelseIcandotomakethisjobmoreattractive?”

IthoughtaboutwhatEmmahadtoldme.Ihadgonefrombeingunableto

believeIcouldbeasurgeontobeingone,atransformationthatcarriedtheforceof religious conversion.Shehad alwayskept this part ofmy identity inmind,evenwhen I couldn’t. She had donewhat I had challengedmyself to do as adoctoryearsearlier:acceptedmortalresponsibilityformysoulandreturnedmeto a point where I could return to myself. I had attained the heights of theneurosurgical trainee, set to become not only a neurosurgeon but a surgeon-scientist.Everytraineeaspirestothisgoal;almostnonemakeit.

Thatnight,thechairmanwasdrivingmebacktomyhotelafterdinner.Hestoppedthecarandpulledover.“Letmeshowyousomething,”hesaid.Wegotout and stood in front of the hospital, looking over a frozen lake, its far edgeluminouswithspecksoflightleakingfromfacultyhouses.“Insummer,youcanswimorsailtowork.Inwinter,youcanskiorice-skate.”

Itwas likea fantasy.And in thatmoment, ithitme: itwas a fantasy.Wecouldnevermove toWisconsin.What if Ihada serious relapse in twoyears?Lucywouldbe isolated, strippedofher friendsand family, alone, caring for adyinghusbandandnewchild.AsfuriouslyasIhadtried toresist it, I realizedthatcancerhadchangedthecalculus.Forthelastseveralmonths,Ihadstrivenwith every ounce to restoremy life to its precancer trajectory, trying to denycancer any purchase on my life. As desperately as I now wanted to feeltriumphant, instead I felt the clawsof the crabholdingmeback.Thecurseofcancer created a strange and strained existence, challenging me to be neitherblindto,norboundby,death’sapproach.Evenwhenthecancerwasinretreat,itcastlongshadows.

WhenI’dfirstlosttheprofessorshipatStanford,I’dconsoledmyselfwiththeideathatrunningalabmadesenseonlyonatwenty-yeartimescale.NowIsaw that this was, in fact, true. Freud started his career as a successfulneuroscientist.Whenherealizedneurosciencewouldneedat leastacentury tocatch up with his true ambition of understanding the mind, he set aside hismicroscope.IthinkIfeltsomethingsimilar.Transformingneurosurgerythroughmyresearchwasagamblewhoseoddshadbeenmadetoolongbymydiagnosis;thelabwasn’ttheplaceIwantedtoplunktheremainderofmychips.

I could hear Emma’s voice again: You have to figure out what’s mostimportanttoyou.

If Ino longer sought to flyon thehighest trajectoryofneurosurgeonandneuroscientist,whatdidIwant?

Tobeafather?Tobeaneurosurgeon?Toteach?

I didn’t know. But if I did not know what I wanted, I had learnedsomething, something not found in Hippocrates, Maimonides, or Osler: thephysician’sdutyisnottostaveoffdeathorreturnpatientstotheiroldlives,butto take into our arms a patient and familywhose lives have disintegrated andwork until they can stand back up and face, and make sense of, their ownexistence.

Myownhubrisasasurgeonstoodnakedtomenow:asmuchasIfocusedonmyresponsibilityandpoweroverpatients’ lives, itwasatbesta temporaryresponsibility, a fleeting power. Once an acute crisis has been resolved, thepatientawakened,extubated,andthendischarged,thepatientandfamilygoonliving—and thingsareneverquite the same.Aphysician’swordscanease themind,justastheneurosurgeon’sscalpelcaneaseadiseaseofthebrain.Yettheiruncertainties and morbidities, whether emotional or physical, remain to begrappledwith.

Emmahadn’tgivenmebackmyoldidentity.She’dprotectedmyabilitytoforgeanewone.And,finally,IknewIwouldhaveto.

—

OnacrystallinespringmorningonthethirdSundayofLent,LucyandIwenttochurchwithmyparents,whohadflowninfromArizonaforaweekendvisit.Wesattogetherinalongwoodenpew,andmymotherstruckupaconversationwiththe family sitting next to us, first complimenting the mother on her babydaughter’s eyes, then quickly moving on to matters of greater substance, herskillsasa listener,confidante,andconnectorfullyevident.During thepastor’sScripture reading, I suddenly foundmyself chuckling. It featured a frustratedJesus whose metaphorical language receives literal interpretation from hisfollowers:

Jesus answered and said to her, “Everyonewho drinks thiswaterwill bethirstyagain;butwhoeverdrinksthewaterIshallgivewillneverthirst;thewaterIshallgivewillbecomeinhimaspringofwaterwellinguptoeternallife.”Thewomansaidtohim,“Sir,givemethiswater,sothatImaynotbethirstyorhavetokeepcomingheretodrawwater.”

…Meanwhile, the disciples urged him, “Rabbi, eat.” But he said tothem,“Ihavefoodtoeatofwhichyoudonotknow.”Sothedisciplessaidtooneanother,“Couldsomeonehavebroughthimsomethingtoeat?”

It was passages like these, where there is a clear mocking of literalistreadings of Scripture, that had broughtme back around toChristianity after alongstretch,followingcollege,whenmynotionofGodandJesushadgrown,toput it gently, tenuous. During my sojourn in ironclad atheism, the primaryarsenal leveled against Christianity had been its failure on empirical grounds.Surely enlightened reason offered a more coherent cosmos. Surely Occam’srazorcutthefaithfulfreefromblindfaith.ThereisnoproofofGod;therefore,itisunreasonabletobelieveinGod.

AlthoughIhadbeenraisedinadevoutChristianfamily,whereprayerandScripture readingswere a nightly ritual, I, likemost scientific types, came tobelieve in the possibility of a material conception of reality, an ultimatelyscientificworldviewthatwouldgrantacompletemetaphysics,minusoutmodedconceptslikesouls,God,andbeardedwhitemeninrobes.Ispentagoodchunkof my twenties trying to build a frame for such an endeavor. The problem,however,eventuallybecameevident:tomakesciencethearbiterofmetaphysicsis to banish not only God from the world but also love, hate, meaning—toconsideraworldthatisself-evidentlynottheworldwelivein.That’snottosaythatifyoubelieveinmeaning,youmustalsobelieveinGod.Itistosay,though,that ifyoubelieve thatscienceprovidesnobasisforGod, thenyouarealmostobligatedtoconcludethatscienceprovidesnobasisformeaningand,therefore,lifeitselfdoesn’thaveany.Inotherwords,existentialclaimshavenoweight;allknowledgeisscientificknowledge.

Yet the paradox is that scientific methodology is the product of humanhandsandthuscannotreachsomepermanenttruth.Webuildscientifictheoriesto organize andmanipulate the world, to reduce phenomena into manageableunits. Science is based on reproducibility and manufactured objectivity. Asstrongasthatmakesitsabilitytogenerateclaimsaboutmatterandenergy,italsomakes scientific knowledge inapplicable to the existential, visceral nature ofhuman life, which is unique and subjective and unpredictable. Science mayprovide the most useful way to organize empirical, reproducible data, but itspowertodosoispredicatedonitsinabilitytograspthemostcentralaspectsofhuman life: hope, fear, love, hate, beauty, envy, honor, weakness, striving,suffering,virtue.

Between these core passions and scientific theory, therewill always be agap.No systemof thought can contain the fullness of human experience.Therealm ofmetaphysics remains the province of revelation (this, not atheism, iswhat Occam argued, after all). And atheism can be justified only on thesegrounds.Theprototypicalatheist, then, isGrahamGreene’scommandant from

ThePowerandtheGlory,whoseatheismcomesfromarevelationoftheabsenceofGod.Theonlyrealatheismmustbegroundedinaworld-makingvision.Thefavorite quote of many an atheist, from the Nobel Prize–winning FrenchbiologistJacquesMonod,beliesthisrevelatoryaspect:“Theancientcovenantisinpieces;manat lastknowsthathe isalonein theunfeelingimmensityof theuniverse,outofwhichheemergedonlybychance.”

Yet I returned to thecentralvaluesofChristianity—sacrifice, redemption,forgiveness—because I found them so compelling. There is a tension in theBible between justice and mercy, between the Old Testament and the NewTestament. And the New Testament says you can never be good enough:goodness is the thing, and you can never live up to it. Themainmessage ofJesus,Ibelieved,isthatmercytrumpsjusticeeverytime.

Notonlythat,butmaybethebasicmessageoforiginalsinisn’t“Feelguiltyallthetime.”Maybeitismorealongtheselines:“Weallhaveanotionofwhatitmeanstobegood,andwecan’tliveuptoitallthetime.”Maybethat’swhatthemessageof theNewTestament is, after all.Even ifyouhaveanotionaswelldefinedasLeviticus,youcan’tlivethatway.It’snotjustimpossible,it’sinsane.

AboutGodIcouldsaynothingdefinitive,ofcourse,butthebasicrealityofhuman life stands compellingly against blind determinism.Moreover, no one,myself included, credits revelation with any epistemic authority. We are allreasonable people—revelation is not good enough. Even if God spoke to us,we’ddiscountitasdelusional.

Sowhat,Iwonder,istheaspiringmetaphysiciantodo?Giveup?Almost.Struggle toward the capital-T Truth, but recognize that the task is

impossible—or that if a correct answer is possible, verification certainly isimpossible.

Intheend, itcannotbedoubtedthateachofuscanseeonlyapartof thepicture. The doctor sees one, the patient another, the engineer a third, theeconomistafourth,thepearldiverafifth,thealcoholicasixth,thecableguyaseventh,thesheepfarmeraneighth,theIndianbeggaraninth,thepastoratenth.Human knowledge is never contained in one person. It grows from therelationshipswe create between each other and theworld, and still it is nevercomplete.AndTruthcomessomewhereaboveallofthem,where,asattheendofthatSunday’sreading,

the sower and reaper can rejoice together. For here the saying is verifiedthat“Onesowsandanother reaps.” I sentyou to reapwhatyouhavenotworked for; others have done thework, and you are sharing the fruits oftheirwork.

—

Ihoppedoutof theCTscanner, sevenmonthssince Ihad returned to surgery.Thiswouldbemylastscanbeforefinishingresidency,beforebecomingafather,beforemyfuturebecamereal.

“Wannatakealook,Doc?”thetechsaid.“Notrightnow,”Isaid.“I’vegotalotofworktodotoday.”Itwas already six P.M. I had to go see patients, organize tomorrow’sOR

schedule,reviewfilms,dictatemyclinicnotes,checkonmypost-ops,andsoon.Around eight P.M., I sat down in the neurosurgery office, next to a radiologyviewingstation. I turned iton, lookedatmypatients’scansfor thenextday—twosimplespinecases—and,finally, typedinmyownname.Izippedthroughtheimagesasiftheywereakid’sflip-book,comparingthenewscantothelast.Everythinglookedthesame,theoldtumorsremainedexactlythesame…except,wait.

Irolledbacktheimages.Lookedagain.There itwas.Anew tumor, large, fillingmy rightmiddle lobe. It looked,

oddly,likeafullmoonhavingalmostclearedthehorizon.Goingbacktotheoldimages,Icouldmakeoutthefaintesttraceofit,aghostlyharbingernowbroughtfullyintotheworld.

Iwasneitherangrynorscared.Itsimplywas.Itwasafactabouttheworld,likethedistancefromthesuntotheearth.IdrovehomeandtoldLucy.ItwasaThursdaynight,andwewouldn’tseeEmmaagainuntilMonday,butLucyandIsatdown in the living room,withour laptops, andmappedout thenext steps:biopsies,tests,chemotherapy.Thetreatmentsthistimearoundwouldbetougherto endure, the possibility of a long lifemore remote. Eliot again: “But atmybackinacoldblastIhear/therattleofthebones,andchucklespreadfromearto ear.” Neurosurgery would be impossible for a couple of weeks, perhapsmonths, perhaps forever.Butwe decided that all of that couldwait to be realuntil Monday. Today was Thursday, and I’d already made tomorrow’s ORassignments;Iplannedonhavingonelastdayasaresident.

AsIsteppedoutofmycaratthehospitalatfive-twentythenextmorning,I

inhaleddeeply,smellingtheeucalyptusand…wasthatpine?Hadn’tnoticedthatbefore. I met the resident team, assembled for morning rounds.We reviewedovernight events, new admissions, new scans, then went to see our patientsbeforeM&M,ormorbidityandmortalityconference,aregularmeetinginwhichthe neurosurgeons gathered to reviewmistakes that had beenmade and casesthat had gone wrong. Afterward, I spent an extra couple of minutes with apatient,Mr.R.Hehaddevelopeda raresyndrome,calledGerstmann’s,where,afterI’dremovedhisbraintumor,he’dbegunshowingseveralspecificdeficits:aninabilitytowrite,tonamefingers,todoarithmetic,totellleftfromright.I’dseenitonlyoncebefore,asamedicalstudenteightyearsago,ononeofthefirstpatientsI’dfollowedontheneurosurgicalservice.Likehim,Mr.Rwaseuphoric—Iwonderedifthatwaspartofthesyndromethatnoonehaddescribedbefore.Mr.Rwasgettingbetter,though:hisspeechhadreturnedalmosttonormal,andhisarithmeticwasonlyslightlyoff.He’dlikelymakeafullrecovery.

Themorningpassed,andIscrubbedformylastcase.Suddenlythemomentfeltenormous.Mylast timescrubbing?Perhapsthiswasit.Iwatchedthesudsdripoffmyarms,thendownthedrain.IenteredtheOR,gownedup,anddrapedthepatient,makingsurethecornersweresharpandneat.Iwantedthiscasetobeperfect.Iopenedtheskinofhislowerback.Hewasanelderlymanwhosespinehaddegenerated,compressinghisnerverootsandcausingseverepain.IpulledawaythefatuntilthefasciaappearedandIcouldfeelthetipsofhisvertebrae.Iopenedthefasciaandsmoothlydissectedthemuscleaway,untilonlythewide,glistening vertebrae showed up through the wound, clean and bloodless. Theattendingwandered in as I began to remove the lamina, the backwall of thevertebrae, whose bony overgrowths, along with ligaments beneath, werecompressingthenerves.

“Looksgood,”hesaid.“Ifyouwanttogototoday’sconference,Icanhavethefellowcomeinandfinish.”

My back was beginning to ache. Why hadn’t I taken an extra dose ofNSAIDsbeforehand?Thiscaseshouldbequick,though.Iwasalmostthere.

“Naw,”Isaid.“Iwanttofinishthecase.”The attending scrubbed in, and togetherwe completed thebony removal.

He began to pick away at the ligaments, beneath which lay the dura, whichcontainedspinalfluidandthenerveroots.Themostcommonerroratthisstageistearingaholeinthedura.Iworkedontheoppositeside.Outofthecornerofmy eye, I saw near his instrument a flash of blue—the dura starting to peekthrough.

“Watchout!” I said, just as themouthofhis instrumentbit into thedura.

Clearspinalfluidbegantofillthewound.Ihadn’thadaleakinoneofmycasesinmorethanayear.Repairingitwouldtakeanotherhour.

“Getthemicrosetout,”Isaid.“Wehavealeak.”Bythetimewefinishedtherepairandremovedthecompressivesofttissue,

myshouldersburned.Theattendingbrokescrub,offeredhisapologiesandsaidhis thanks, and left me to close. The layers came together nicely. I began tosuture theskin,usingarunningnylonstitch.Mostsurgeonsusedstaples,but Iwasconvincedthatnylonhadlowerinfectionrates,andwewoulddothisone,thisfinalclosure,myway.Theskincametogetherperfectly,withouttension,asiftherehadbeennosurgeryatall.

Good.Onegoodthing.As we uncovered the patient, the scrub nurse, one with whom I hadn’t

workedbefore,said,“Youoncallthisweekend,Doc?”“Nope.”Andpossiblyneveragain.“Gotanymorecasestoday?”“Nope.”Andpossiblyneveragain.“Shit,well,Iguessthatmeansthisisahappyending!Work’sdone.Ilike

happyendings,don’tyou,Doc?”“Yeah.Yeah,Ilikehappyendings.”I sat downby the computer to enterorders as thenurses cleaned and the

anesthesiologists began to wake the patient. I had always jokingly threatenedthatwhenIwasincharge,insteadofthehigh-energypopmusiceveryonelikedtoplayintheOR,we’dlistenexclusivelytobossanova.IputGetz/Gilbertoontheradio,andthesoft,sonoroussoundsofasaxophonefilledtheroom.

IlefttheORshortlyafter,thengatheredmythings,whichhadaccumulatedoversevenyearsofwork—extrasetsofclothesfor thenightsyoudon’t leave,toothbrushes, bars of soap, phone chargers, snacks, my skull model andcollectionofneurosurgerybooks,andsoon.Onsecondthought,Ileftmybooksbehind.They’dbeofmoreusehere.

On my way out to the parking lot, a fellow approached to ask mesomething,buthispagerwentoff.Helookedatit,waved,turned,andranbackin to the hospital—“I’ll catch you later!” he called over his shoulder. TearswelledupasIsatinthecar,turnedthekey,andslowlypulledoutintothestreet.Idrovehome,walkedthroughthefrontdoor,hungupmywhitecoat,andtookoffmyIDbadge.Ipulledthebatteryoutofmypager.Ipeeledoffmyscrubsandtookalongshower.

Laterthatnight,IcalledVictoriaandtoldherIwouldn’tbeinonMonday,

orpossiblyeveragain,andwouldn’tbesettingtheORschedule.“You know, I’ve been having this recurring nightmare that this day was

coming,”shesaid.“Idon’tknowhowyoudidthisforsolong.”

—

Lucy and I met with Emma on Monday. She confirmed the plan we’denvisioned: bronchoscopic biopsy, look for targetable mutations, otherwisechemo.The real reason Iwas there, though,was forherguidance. I toldher Iwastakingleavefromneurosurgery.

“Okay,”shesaid.“That’sfine.Youcanstopneurosurgeryif,say,youwantto focusonsomething thatmattersmore toyou.Butnotbecauseyouaresick.Youaren’tanysickerthanyouwereaweekago.Thisisabumpintheroad,butyoucankeepyourcurrenttrajectory.Neurosurgerywasimportanttoyou.”

Once again, I had traversed the line fromdoctor topatient, fromactor toactedupon, fromsubject todirectobject.My lifeupuntilmy illnesscouldbeunderstood as the linear sum ofmy choices.As inmostmodern narratives, acharacter’s fate depended on human actions, his and others. King Lear’sGloucestermaycomplain abouthuman fate as “flies towantonboys,”but it’sLear’s vanity that sets in motion the dramatic arc of the play. From theEnlightenmentonward,theindividualoccupiedcenterstage.ButnowIlivedinadifferent world, a more ancient one, where human action paled againstsuperhumanforces,aworldthatwasmoreGreektragedythanShakespeare.NoamountofeffortcanhelpOedipusandhisparentsescapetheirfates;theironlyaccesstotheforcescontrollingtheirlivesisthroughtheoraclesandseers,thosegivendivinevision.WhatIhadcomeforwasnotatreatmentplan—Ihadreadenoughtoknowthemedicalwaysforward—butthecomfortoforacularwisdom.

“Thisisnottheend,”shesaid,alineshemusthaveusedathousandtimes—afterall,didInotusesimilarspeechestomyownpatients?—tothoseseekingimpossibleanswers.“Oreven thebeginningof theend.This is just theendofthebeginning.”

AndIfeltbetter.Aweekafter thebiopsy,Alexis, thenursepractitioner,called.Therewere

nonewtargetablemutations, sochemotherapywas theonlyoption,and itwasbeingsetupforMonday.IaskedaboutthespecificagentsandwastoldI’dhavetotalktoEmma.ShewasenroutetoLakeTahoewithherkids,butshe’dgivemeacallovertheweekend.

Thenextday,aSaturday,Emmacalled.Iaskedherwhatshethoughtabout

chemotherapyagents.“Well,”shesaid.“Doyouhavespecificthoughts?”“IguessthemainquestioniswhethertoincludeAvastin,”Isaid.“Iknow

thedataismixedandthatitaddspotentialsideeffects,andsomecancercentersare turning away from it. Inmymind, though, since there are a lot of studiessupportingitsuse,I’dleantowardincludingit.WecandiscontinueitifIhaveabadreactiontoit.Ifthatseemssensibletoyou.”

“Yeah, that sounds about right. Insurance companies alsomake it hard toadditlater,sothat’sanotherreasontouseitupfront.”

“Thanksforcalling.I’llletyougetbacktoenjoyingthelake.”“Okay. But there’s one thing.” She paused. “I’m totally happy for us to

make yourmedical plan together; obviously, you’re a doctor, you knowwhatyou’re talkingabout,and it’syour life.But ifyoueverwantme to justbe thedoctor,I’mhappytodothat,too.”

Ihadn’teverconsideredthatIcouldreleasemyselffromtheresponsibilityofmyownmedical care. I’d just assumed all patients became experts at theirowndiseases.Irememberedhow,asagreenmedicalstudent,knowingnothing,Iwould often endup asking patients to explain their diseases and treatments tome, theirblue toesandpinkpills.Butasadoctor, Ineverexpectedpatients tomakedecisionsalone;Iboreresponsibilityforthepatient.AndIrealizedIwastrying todo the same thingnow,mydoctor-self remaining responsible formypatient-self. Maybe I’d been cursed by a Greek god, but abdicating controlseemedirresponsible,ifnotimpossible.

—

ChemotherapybeganonMonday.Lucy,mymother,andIwent to the infusioncenter together. Ihadan IVplaced,settled intoaneasychair,andwaited.Thedrug cocktail would take four and a half hours to infuse. I passed the timenapping,reading,andsometimesblanklystaring,withLucyandmymothernexttome,interruptingthesilencewithoccasionalsmalltalk.Theotheroccupantsoftheroomwereinvariousstatesofhealth—somebald,somewell-coiffed,somewithered,somesprightly,somedisheveled,somedapper.Alllaystill,silent,withIV tubing dripping poison into outstretched arms. I was to return every threeweeksfortreatment.

I began to feel the effects the next day, a deep fatigue, a profoundbone-weariness setting in. Eating, normally a source of great pleasure, was likedrinking 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.Readingwasexhausting.Ihadagreedtowriteafewchaptersonthetherapeuticpotential ofmy researchwithV for twomajor neurosurgical textbooks. That,too, I set aside. The days passed, television and forced feedings marking thetime. A pattern developed over the weeks: the malaise would slowly ease,normalcyreturningjustintimeforthenexttreatment.

The cycles continued; I shuffled in and out of the hospital with minorcomplications, which were just enough to preclude any return to work. TheneurosurgerydepartmentdeterminedthatIhadmetallnationalandlocalcriteriafor graduation; the ceremonywas scheduled for a Saturday, about twoweeksbeforeLucy’sduedate.

Thedayarrived.As I stood inourbedroom,dressing forgraduation—theculminationofsevenyearsofresidency—apiercingnauseastruckme.Thiswasunlike theusual nauseaof chemotherapy,whichwashedover you like awaveand,likeawave,couldberidden.Ibeganuncontrollablyvomitinggreenbile,itschalkytastedistinctfromstomachacid.Thiswasfromdeepinmygut.

Iwouldnotbegoingtograduation,afterall.I needed IV fluids to avoid dehydration, so Lucy drove me to the

emergency department and rehydration began. The vomiting gave way todiarrhea.Themedicalresident,Brad,andIchattedamicably,andIrelayedmymedical history, covering all my medications, and we ended up discussingadvances in molecular therapies, especially Tarceva, which I was still taking.Themedicalplanwassimple:keepmehydratedwithintravenousfluidsuntilIcoulddrinkenoughbymouth.Thatevening,Iwasadmittedtoahospitalroom.Butwhenthenursereviewedmymedicationlist,InoticedTarcevawasnotonit.Iaskedher tocall the resident tocorrect theoversight.These thingshappen. Iwastakingadozenmedications,afterall.Keepingtrackwasnoteasy.

ItwaswellpastmidnightwhenBradappeared.“Iheardyouhadaquestionaboutyourmedications?”heasked.“Yeah,”Isaid.“Tarcevawasn’tordered.Doyoumindorderingit?”“Idecidedtotakeyouoffit.”“Whyisthat?”“Yourliverenzymesaretoohightotakeit.”Iwasconfused.Myliverenzymeshadbeenhighformonths;ifthiswasan

issue,whyhadn’twediscusseditbefore?Inanycase,thiswasclearlyamistake.“Emma—myoncologist,yourboss—hasseenthesenumbers,andshewants tokeepmeonit.”

Residentsroutinelyhavetomakemedicaldecisionswithouttheattending’sinput.ButnowthathehadEmma’sopinion,surelyhewouldcapitulate.

“ButitmightbecausingyourGIproblems.”Myconfusiondeepened.Usually invoking theattending’sorders ends the

discussion.“I’vebeen taking it forayearwithoutanyproblems,” Isaid.“YouthinkTarcevaiscausingthisallofasudden,andnotthechemotherapy?”

“Maybe,yeah.”Confusionyieldedtoanger.Somekidtwoyearsoutofmedschool,noolder

thanmy junior residents,was really arguingwithme? It’d be one thing if hewere right, but he wasn’t making any sense. “Um, didn’t I mention thisafternoonthatwithoutthatpill,mybonemetastasesbecomeactiveandproduceexcruciating pain? I don’t mean to sound dramatic, but I’ve broken bonesboxing, and this is farmore painful.As in, ten-out-of-ten pain.As in, I-Will-Actually-Soon-Be-Screamingpain.”

“Well,giventhehalf-lifeofthedrug,thatprobablywon’thappenforadayorso.”

IcouldseethatinBrad’seyesIwasnotapatient,Iwasaproblem:aboxtobecheckedoff.

“Look,”hecontinued,“ifyouweren’tyou,wewouldn’tevenbehavingthisconversation.I’djuststopthedrugandmakeyouproveitcausesallthispain.”

Whathadhappenedtoouramicablechatthisafternoon?Ithoughtbacktomedschool,whenapatienthadtoldmethatshealwaysworehermostexpensivesocks to the doctor’s office, so that when she was in a patient’s gown andshoeless, the doctor would see the socks and know she was a person ofsubstance, tobe treatedwith respect. (Ah, there’s theproblem—Iwaswearinghospital-issuesocks,whichIhadbeenstealingforyears!)

“Anyway,Tarcevaisaspecialdrug,anditrequiresafelloworattendingtosignoffonit.Doyoureallywantmetowakesomeoneupforthis?Can’titwaittillmorning?”

Andthereitwas.Meetinghisobligationtomemeantaddingonemorethingtohisto-dolist:

anembarrassingphonecallwithhisboss, revealinghiserror.Hewasworkingthe night shift. Residency education regulations had forcedmost programs toadoptshiftwork.Andalongwithshiftworkcomesakindofshiftiness,asubtleundercuttingofresponsibility.Ifhecouldjustpushitoffforafewmorehours,Iwouldbecomesomebodyelse’sproblem.

“IusuallytakeitatfiveA.M.,”Isaid.“AndyouknowaswellasIdothat

‘waitingtillmorning’meanslettingsomeonedealwithitaftermorningrounds,whichwillbemoreliketheafternoon.Right?”

“Okay,fine,”hesaid,andlefttheroom.Whenmorningarrived,Idiscoveredthathehadnotorderedthemedication.EmmadroppedintosayhelloandtoldmeshewouldsortouttheTarceva

order.Shewishedmeaspeedyrecoveryandapologizedforthefactthatshewasheading out of town for a week. Over the course of the day I began todeteriorate, my diarrhea rapidly worsening. I was being rehydrated, but notquicklyenough.Mykidneysbegantofail.MymouthbecamesodryIcouldnotspeakorswallow.Atthenextlabcheck,myserumsodiumhadreachedanear-fatallevel.IwastransferredtotheICU.Partofmysoftpalateandpharynxdiedfromdehydrationandpeeledoutofmymouth. Iwas inpain, floating throughvarying levels of consciousness, while a pantheon of specialists was broughttogether to help: medical intensivists, nephrologists, gastroenterologists,endocrinologists, infectious disease specialists, neurosurgeons, generaloncologists, thoracic oncologists, otolaryngologists. Lucy, thirty-eight weekspregnant,stayedwithmebydayandsecretlymovedintomyoldcallroom,stepsfromthe ICU,soshecouldcheckonmeatnight.Sheandmyfatheralso lenttheirvoices.

During lucid moments, I was acutely aware that with this many voices,cacophonyresults. Inmedicine, this isknownas theWICOSproblem:WhoIstheCaptainOftheShip?ThenephrologistsdisagreedwiththeICUdoctors,whodisagreedwith the endocrinologists, who disagreedwith the oncologists, whodisagreedwiththegastroenterologists.Ifelttheresponsibilityofmycare:duringboutsofconsciousness, I typedout the sequentialdetailsofmycurrent illnessand, with Lucy’s help, tried to corral all the doctors to keep the facts andinterpretations straight. Later,while half asleep, I could dimly hearmy fatherandLucydiscussingmyconditionwitheachteamofdoctors.Wesuspectedthatthe main plan should just be to treat me with fluids until the effects of thechemotherapy wore off. But each group of specialists had to allow for moreesotericpossibilitiesandadvocatetestsandtreatmentsforthem,someofwhichseemed unnecessary and ill-advised. Sampleswere taken, scanswere ordered,medicationsweregiven;Ibeganlosingtrackofeventsandtime.Irequestedthatthese plans be explained tome, but sentences would become slippery, voiceswoulddampenandmuffle,anddarknesswoulddescendinthemidstofdoctors’speechesasIwobbledinandoutofcoherence.IdesperatelywishedEmmawerethere,incharge.

Suddenly,sheappeared.

“You’rebackalready?”Isaid.“You’ve been in the ICU for over a week,” she said. “But don’t worry.

You’regettingbetter.Mostofyourlabshavenormalized.You’llbeoutofheresoon.”She’dbeenintouchwithmydoctorsoveremail,Ilearned.

“Youknowhowyouoffered to just be thedoctor and I could just be thepatient?”Iasked.“I think that’smaybeagood idea. I’vebeenreadingscienceandliteraturetryingtofindtherightperspective,butIhaven’tfoundit.”

“I’m not sure that’s something you can find by reading about it,” shereplied.

Emmawasnowthecaptainoftheship,lendingasenseofcalmtothechaosofthishospitalization.T.S.Eliotsprangtomind:

Damyata:TheboatrespondedGaily,tothehandexpertwithsailandoarTheseawascalm,yourheartwouldhaverespondedGaily,wheninvited,beatingobedientTocontrollinghands

I leanedback inmyhospitalbedandclosedmyeyes.As thedarknessofdeliriumdescendedagain,Ifinallyrelaxed.

—

Lucy’sduedatecameandwentwithoutlabor,andIwasfinallyscheduledtobedischargedfromthehospital.Ihadlostoverfortypoundssincebeingdiagnosed,fifteeninthelastweek.IweighedasmuchasIhadineighthgrade,thoughmyhairhadconsiderablythinnedsincethosedays,mostlyinthepastmonth.Iwasawakeagain,alerttotheworld,butwithered.Icouldseemybonesagainstmyskin,alivingX-ray.Athome,simplyholdingmyheadupwastiring.Liftingaglassofwaterrequiredbothhands.Readingwasoutofthequestion.

Bothsetsofparentswereintowntohelp.Twodaysafterdischarge,Lucyhadher first contractions.She stayedhomewhilemymother droveme tomyfollow-upappointmentwithEmma.

“Frustrated?”Emmaasked.“No.”“Youshouldbe.It’sgoingtobealongrecovery.”

“Well,yes,okay.Iamfrustratedonthebigpicture.Butontheday-by-day,I’mreadytogetbacktophysicaltherapyandstartrecovering.Ididitonce,soitshouldbeoldhat,right?”

“Didyouseeyourlastscan?”sheasked.“No,I’vekindofstoppedlooking.”“It looks good,” she said. “The disease looks stable,maybe even slightly

shrinking.”Wetalkedthroughsomeofthecominglogistics;chemotherapywouldbeon

holduntilIwasstronger.Experimentaltrialswouldn’tacceptmeinmycurrentstate,either.Treatmentwasn’tanoption—notuntil I regainedsomestrength. Ileanedmyheadagainstthewalltosupporttheflaggingmusclesofmyneck.Mythoughtswereclouded.Ineededthatoracletoscryagain,togathersecretsfrombirdsorstarcharts,frommutantgenesorKaplan-Meiergraphs.

“Emma,”Isaid,“what’sthenextstep?”“Getstronger.That’sit.”“Butwhenthecancerrecurs…Imean,theprobabilities…”Ipaused.First-

linetherapy(Tarceva)hadfailed.Second-linetherapy(chemo)hadnearlykilledme.Third-line therapy, if I could even get there,made fewpromises.Beyondthat,thevastunknownofexperimentaltreatments.Phrasesofdoubtfellfrommymouth.“Imean,gettingbacktotheOR,ortowalking,oreven—”

“Youhavefivegoodyearsleft,”shesaid.Shepronouncedit,butwithouttheauthoritativetoneofanoracle,without

the confidence of a true believer. She said it, instead, like a plea. Like thatpatientwhocouldspeakonlyinnumbers.Likeshewasnotsomuchspeakingtomeaspleading,amerehuman,withwhateverforcesandfatestrulycontrolthesethings. There we were, doctor and patient, in a relationship that sometimescarriesamagisterialairandothertimes,likenow,wasnomore,andnoless,thantwopeoplehuddledtogether,asonefacestheabyss.

Doctors,itturnsout,needhope,too.

—

OnthewayhomefromtheappointmentwithEmma,Lucy’smomcalledtosaytheywereheadedtothehospital.Lucywasinlabor.(“Makesureyouaskaboutthe epidural early,” I told her. She had suffered enough.) I returned to thehospital,pushedbymyfatherinawheelchair.Ilaydownonacotinthedeliveryroom,heatpacksandblanketskeepingmyskeletalbodyfromshivering.Forthenexttwohours,IwatchedLucyandthenursegothroughtheritualoflabor.Asa

contraction built up, the nurse counted off the pushing: “And a one two threefourfivesixseveneightnineandaten!”

Lucyturnedtome,smiling.“ItfeelslikeI’mplayingasport!”shesaid.Ilayonthecotandsmiledback,watchingherbellyrise.Therewouldbeso

many absences in Lucy’s andmy daughter’s life—if this was as present as Icouldbe,thensobeit.

Sometimeaftermidnight, thenursenudgedmeawake.“It’salmost time,”shewhispered.Shegatheredtheblanketsandhelpedmetoachair,nexttoLucy.Theobstetricianwasalreadyintheroom,noolderthanI.Shelookedupatmeasthebabywascrowning.“Icantellyouonething:yourdaughterhashairexactlylikeyours,”shesaid.“Andalotofit.”Inodded,holdingLucy’shandduringthelastmomentsofherlabor.Andthen,withonefinalpush,onJuly4,at2:11A.M.,thereshewas.ElizabethAcadia—Cady;wehadpickedthenamemonthsbefore.

“Canweputheronyourskin,Papa?”thenurseaskedme.“No, I’m too c-c-cold,” I said,my teeth chattering. “But Iwould love to

holdher.”Theywrappedherinblanketsandhandedhertome.Feelingherweightin

one arm, and gripping Lucy’s hand with the other, the possibilities of lifeemanatedbeforeus.Thecancercellsinmybodywouldstillbedying,orthey’dstart growing again. Looking out over the expanse ahead I saw not an emptywastelandbutsomethingsimpler:ablankpageonwhichIwouldgoon.

—

Yetthereisdynamisminourhouse.Daytoday,weektoweek,Cadyblossoms:afirstgrasp,afirstsmile,afirst

laugh. Her pediatrician regularly records her growth on charts, tick marksindicatingherprogressovertime.Abrighteningnewnesssurroundsher.Asshesitsinmylapsmiling,enthralledbymytunelesssinging,anincandescencelightstheroom.

Time forme is nowdouble-edged: every day bringsme further from thelowofmylastrelapsebutclosertothenextrecurrence—and,eventually,death.Perhaps later than I think, but certainly sooner than I desire. There are, Iimagine, two responses to that realization. The most obvious might be animpulsetofranticactivity:to“livelifetoitsfullest,”totravel,todine,toachieveahostofneglectedambitions.Partofthecrueltyofcancer,though,isnotonlythatitlimitsyourtime;italsolimitsyourenergy,vastlyreducingtheamountyoucansqueezeintoaday.It isatiredharewhonowraces.AndevenifIhadthe

energy, I prefer a more tortoiselike approach. I plod, I ponder. Some days, Isimplypersist.

If timedilateswhenonemovesathighspeeds,does itcontractwhenonemovesbarelyatall?Itmust:thedayshaveshortenedconsiderably.

With little to distinguish one day from the next, time has begun to feelstatic.InEnglish,weusethewordtimeindifferentways:“Thetimeistwoforty-five”versus“I’mgoingthroughatoughtime.”Thesedays,timefeelslesslikethe ticking clock andmore like a state of being.Languor settles in. There’s afeelingofopenness.Asasurgeon,focusedonapatientintheOR,Imighthavefound the position of the clock’s hands arbitrary, but I never thought themmeaningless.Nowthetimeofdaymeansnothing,thedayoftheweekscarcelymore. Medical training is relentlessly future-oriented, all about delayedgratification;you’realwaysthinkingaboutwhatyou’llbedoingfiveyearsdowntheline.ButnowIdon’tknowwhatI’llbedoingfiveyearsdowntheline.Imaybedead.Imaynotbe.Imaybehealthy.Imaybewriting.Idon’tknow.Andsoit’snotall thatuseful to spend time thinkingabout the future—that is,beyondlunch.

Verbconjugationhasbecomemuddled,aswell.Whichiscorrect:“Iamaneurosurgeon,” “Iwas aneurosurgeon,”or “I hadbeen aneurosurgeonbeforeand will be again”? GrahamGreene once said that life was lived in the firsttwentyyearsandtheremainderwasjustreflection.SowhattenseamIlivinginnow?HaveIproceededbeyondthepresenttenseandintothepastperfect?Thefuture tense seems vacant and, on others’ lips, jarring. A few months ago, Icelebratedmyfifteenthcollege reunionatStanfordandstoodouton thequad,drinking awhiskey as a pink sun dipped below the horizon;when old friendscalled out parting promises—“We’ll see you at the twenty-fifth!”—it seemedrudetorespondwith“Well…probablynot.”

Everyonesuccumbstofinitude.IsuspectIamnottheonlyonewhoreachesthis pluperfect state.Most ambitions are either achieved or abandoned; eitherway,theybelongtothepast.Thefuture,insteadoftheladdertowardthegoalsoflife, flattens out into a perpetual present. Money, status, all the vanities thepreacher ofEcclesiastes described hold so little interest: a chasing afterwind,indeed.

Yetonethingcannotberobbedofherfuturity:ourdaughter,Cady.IhopeI’lllivelongenoughthatshehassomememoryofme.WordshavealongevityIdonot.IhadthoughtIcouldleaveheraseriesofletters—butwhatwouldtheysay? Idon’tknowwhat thisgirlwill be likewhen she is fifteen; I don’t evenknowifshe’lltaketothenicknamewe’vegivenher.Thereisperhapsonlyone

thingtosaytothisinfant,whoisallfuture,overlappingbrieflywithme,whoselife,barringtheimprobable,isallbutpast.

Thatmessageissimple:Whenyoucometooneofthemanymomentsinlifewhereyoumustgive

anaccountofyourself,providealedgerofwhatyouhavebeen,anddone,andmeant to theworld,donot, Ipray,discount thatyoufilledadyingman’sdayswithasatedjoy,ajoyunknowntomeinallmyprioryears,ajoythatdoesnothungerformoreandmorebutrests,satisfied.Inthistime,rightnow,thatisanenormousthing.

EPILOGUELucyKalanithi

Youleftme,sweet,twolegacies,—AlegacyofloveAHeavenlyFatherwouldcontent,Hadhetheofferof;

YouleftmeboundariesofpainCapaciousasthesea,Betweeneternityandtime,Yourconsciousnessandme.

—EmilyDickinson

PAULDIEDONMONDAY,March9,2015, surroundedbyhis family, in ahospitalbed roughly two hundred yards from the labor and delivery ward where ourdaughter, Cady, had entered the world eight months before. Between Cady’sbirth and Paul’s death, if you’d seen us sucking on ribs at our local barbecuerestaurant and smiling over a shared beer, a dark-haired baby with longeyelashesnappinginherstrollerbesideus,you’dneverhaveguessedthatPaullikelyhadlessthanayeartolive,northatweunderstoodthat.

ItwasaroundCady’s firstChristmas,whenshewas fivemonthsold, thatPaul’scancerbegantoresistthethird-linedrugsrecommendedafterTarcevaandthenchemotherapyhadstoppedworking.Cadytriedherfirstsolidfoodduringthatholidayseason,snugincandy-cane-stripedpajamas,gummingmashedyamsas family gathered at Paul’s childhood home inKingman,Arizona, the houseaglowwithcandlesandchatter.Hisstrengthwanedoverthefollowingmonths,butwecontinuedtoexperiencejoyfulmoments,eveninthemidstofoursorrow.We hosted cozy dinner parties, held each other at night, and delighted in ourdaughter’sbrighteyesandcalmnature.And,ofcourse,Paulwrote,reclininginhis armchair, wrapped in a warm fleece blanket. In his final months, he wassingularlyfocusedonfinishingthisbook.

As winter turned to spring, the saucer magnolias in our neighborhoodbloomed large and pink, but Paul’s health was declining rapidly. By lateFebruary,heneededsupplementaloxygen tokeephisbreathingcomfortable. Iwasaddinghisuntouched lunch to the trashcanatophisuntouchedbreakfast,andafewhourslaterI’daddanuntoucheddinnertothepile.Heusedtolovemybreakfastsandwiches—egg,sausage,andcheeseonaroll—butwithhiswaning

appetitewe’dchangedtoeggsandtoast,thenjusteggs,untileventhosebecameintolerable.Evenhisfavoritesmoothies,theglassesIfilledwithasteadystreamofcalories,wereunappetizing.

Bedtime crept earlier, Paul’s voice slurred intermittently, and his nauseabecameunremitting.ACTscanandbrainMRIconfirmedworseningcancer inPaul’s lungs and new tumors that had landed in his brain, includingleptomeningealcarcinomatosis,arareandlethalinfiltrationthatbroughtwithitaprognosisofonly severalmonths and the looming shadowof swift neurologicdecline.ThenewshitPaulhard.Hesaidlittle,butasaneurosurgeon,heknewwhatlayahead.AlthoughPaulacceptedhis limitedlifeexpectancy,neurologicdecline was a new devastation, the prospect of losing meaning and agencyagonizing. We strategized with Paul’s oncologist about his top priority:preservingmental acuityas longaspossible.Wearrangedentry intoaclinicaltrial, consultation with a neuro-oncology specialist, and a visit with hispalliative-careteamtodiscusshospiceoptions,allinserviceofmaximizingthequality of his remaining time. My heart swelled even as I steeled myself,anticipating his suffering, worrying that he had only weeks left—if that. Ienvisioned his funeral as we held hands. I didn’t know that Paul would diewithindays.

We spentPaul’s lastSaturdaywith family in thenestofour living room,PaulholdingCadyinhisarmchair;hisfatheronmynursingglider;hismotherandIonsofasnearby.PaulsangtoCadyandbouncedhergentlyinhislap.Shegrinnedwidely, oblivious to the tubing that delivered oxygen to his nose.Hisworldbecame smaller; I deflectednonfamilyvisitors,Paul tellingme, “Iwanteveryone to know that even if I don’t see them, I love them. I cherish theirfriendship, andonemoreglassofArdbegwon’t change that.”Hedidn’twriteanythingthatday.Themanuscriptforthisbookwasonlypartiallyfinished,andPaul now knew that he was unlikely to complete it—unlikely to have thestamina,theclarity,thetime.

Topreparefortheclinicaltrial,Paulhadstoppedtakingthedailytargeted-therapypillthathadbeeninsufficientlycontrollinghiscancer.Therewasariskthat thecancermightgrowrapidly,or“flare,”afterhestoppedthemedication.Therefore,Paul’soncologisthadinstructedmetovideotapehimdaily,doingthesame task, to track any deficits in his speech or gait. “April is the cruellestmonth,”PaulreadaloudinthelivingroomthatSaturdayasIfilmed,choosingT.S.Eliot’sTheWasteLand ashis script. “Mixingmemoryanddesire, stirring /Dullrootswithspringrain.”Thefamilychuckledwhen,thoughitwasnotpartoftheassignment,hesetthebookfacedownonhislapandinsistedonreciting

frommemory.“Solikehim!”hismothersaid,smiling.Thenextday,Sunday,wehopedforacontinuationofthecalmweekend.If

Paulfeltwellenough,wewouldattendchurch,thentakeCadyandhercousintothe baby swings at the park up the hill. We’d continue to absorb the recentpainfulnews,sharethesorrow,savorourtimetogether.

Butinstead,timespedup.Early Sunday morning, I stroked Paul’s forehead and found it scorching

withfever,104degrees,thoughhewasrelativelycomfortableandfreeofothernew symptoms.Wemade it in and out of the emergency roomwithin a fewhours,Paul’sfatherandSumanwithus,returninghometotherestofthefamilyafter starting antibiotics in case of pneumonia (Paul’s chest X-ray was densewithtumors,whichcouldobscureaninfection).Butwasthis,instead,thecancerprogressing rapidly? Paul napped comfortably in the afternoon, but he wasgravely ill. Istarted tocryasIwatchedhimsleep, thencreptout toour livingroom,wherehisfather’stearsjoinedmine.Ialreadymissedhim.

Sundayevening,Paul’sconditionworsenedabruptly.Hesatontheedgeofourbed,strugglingtobreathe—astartlingchange.Icalledanambulance.Whenwereenteredtheemergencyroom,Paulonagurneythistime,hisparentsclosebehindus,heturnedtowardmeandwhispered,“Thismightbehowitends.”

“I’mherewithyou,”Isaid.ThehospitalstaffgreetedPaulwarmly,asalways.Buttheymovedquickly

once they sawhis condition.After initial testing, they placed amask over hisnoseandmouthtohelphisbreathingviaBiPAP,abreathingsupportsystemthatsuppliedastrongmechanized flowofaireach timehe inhaled,doingmuchofthe work of breathing for him. Though it helps with respiratory mechanics,BiPAPcanbehardwork for a patient—noisy and forceful, blowingone’s lipsapartwitheachbreathlikethoseofadogwithitsheadoutacarwindow.Istoodclose,leaningoverthegurney,myhandinPaul’sasthesteadywhoosh,whooshofthemachinebegan.

Paul’s blood carbon dioxide level was critically high, indicating that theworkofbreathingwasoverwhelminghim.Blood tests suggested that someoftheexcesscarbondioxidehadbeenaccumulatingoverdaystoweeks,ashislungdisease and debility had advanced. Because his brain had slowly becomeacclimated to higher-than-normal levels of carbon dioxide, he remained lucid.He observed. He understood, as a physician, the ominous test results. Iunderstood them, too,walkingbehindhimashewaswheeled to an intensive-careroom,onewheresomanyofhisownpatientshadstruggledbeforeorafter

neurosurgery,theirfamiliesassembledinvinylchairsbytheirbedsides.“WillIneed to be intubated?” he askedmebetweenBiPAPbreathswhenwe arrived.“ShouldIbeintubated?”

Throughthenight,Pauldiscussedthatquestioninaseriesofconversationswithhisphysicians,hisfamily,andthenjustme.Aroundmidnight,thecritical-careattending,alongtimementortoPaul,cameintodiscusstreatmentoptionswith the family.BiPAPwasa temporarysolution,hesaid.Theonly remaininginterventionwould be for Paul to be intubated—put on a ventilator.Was thatwhathewanted?

The key question quickly came into view: Could the sudden respiratoryfailurebereversed?

Of concernwaswhether Paul would remain too ill to ever come off theventilator—wouldhebe lost todeliriumand thenorgan failure, firstmindandthenbodyslippingaway?We’dwitnessedthisagonizingscenarioasphysicians.Paul explored the alternative: in lieu of intubation, he could choose “comfortcare,” though death would comemore surely and swiftly. “Even if I make itthroughthis,”hesaid,thinkingofthecancerinhisbrain,“I’mnotsureIseeafuture that includesmeaningful time.”Hismother chimed in,desperately. “Nodecisionstonight,Pubby,”shesaid.“Let’sallgetsomerest.”Afterensuringhis“donot resuscitate” status,Paul agreed.Sympatheticnursesbroughthimextrablankets.Iswitchedoffthefluorescentlights.

Paulmanaged todozeuntil sunrise,his fathersittingvigilwhile Inappedbrieflyinanadjacentroom,hopingtopreservemymentalstrength,knowingthatthefollowingdaymightbethehardestofmylife.IcreptbacktoPaul’sroomatsixA.M., the lights still low, the intensive-caremonitorschiming intermittently.Paul opened his eyes. We talked again about “comfort care”—avoidingaggressiveattemptstoforestallhisdecline—andhewonderedaloudwhetherhecouldgohome.HewassoillthatIworriedhemightsufferanddieontheway.However, I said Iwould do everything possible to take himhome if thatwasmostimportanttohim,noddingthatyes,comfortcaremightbethedirectionwewereheaded.Orwas theresomeway to re-createhomehere?BetweenBiPAPpuffs,heanswered:“Cady.”

Cady arrived in short order—our friend Victoria had retrieved her fromhome—andbeganherownunwitting,cheerfulvigil,happilynestledinthecrookof Paul’s right arm, tugging at her tiny socks, batting at his hospital blankets,smilingandcooing,unbotheredbytheBiPAPmachineasitcontinuedtoblow,keepingPaulalive.

Themedical team came by on rounds, discussing Paul’s case outside the

room,wherehis familyand I joined them.Paul’sacute respiratory failurewaslikely rapid cancer progressing. His carbon dioxide level was rising still—ahardeningindicationforintubation.Thefamilywastorn:Paul’soncologisthadphoned in, hopeful that the acute problem could be ameliorated, but thephysicians present were less optimistic. I entreated them to weigh in with asmuchconvictionaspossibleonthechanceofreversinghisabruptdecline.

“He doesn’t want a HailMary,” I said. “If he doesn’t have a chance ofmeaningfultime,hewantstotakethemaskoffandholdCady.”

IreturnedtoPaul’sbedside.Helookedatme,hisdarkeyesalertabovethenosebridgeoftheBiPAPmask,andsaidclearly,hisvoicesoftbutunwavering,“I’mready.”

Ready,hemeant,toremovethebreathingsupport,tostartmorphine,todie.The family gathered together. During the precious minutes after Paul’s

decision,weallexpressedour loveandrespect.Tearsglistened inPaul’seyes.Heexpressedgratitudetohisparents.Heaskedustoensurethathismanuscriptbe published in some form. He told me a last time that he loved me. Theattending physician stepped inwith strengtheningwords: “Paul, after you die,your family will fall apart, but they’ll pull it back together because of theexampleofbraveryyouset.”Jeevan’seyesweretrainedonPaulasSumansaid,“Goinpeace,mybrother.”Withmyheartbreaking,Iclimbedintothelastbedwewouldshare.

Ithoughtofotherbedswe’dshared.Eightyearsprior,asmedicalstudents,we’dslept similarlyensconced ina twinbednext tomygrandfatherashe laydyingathome,havingcutourhoneymoonshorttohelpwithcaregivingduties.We awakened every few hours to give him medications, my love for Pauldeepening as I watched him lean in and listen closely to my grandfather’swhisperedrequests.We’dneverhaveimaginedthisscene,Paul’sowndeathbed,sonear inour future.Twenty-twomonthsago,we’dcried inabedonanotherfloor of this same hospital as we learned of Paul’s cancer diagnosis. Eightmonthsago,we’dbeentogetherhereinmyhospitalbedthedayafterCadywasborn,bothnapping,thefirstgood,longsleepI’dhadsinceherbirth,wrappedineachother’sarms.Ithoughtofourcozybedemptyathome,rememberedfallinginloveinNewHaventwelveyearsearlier,surprisedrightawaybyhowwellourbodiesandlimbsfittogether,andthoughtofhoweversince,we’dbothsleptbestwhenentwined.IhopedwithallIhadthathefeltthatsamerestfulcomfortnow.

Anhourlater,themaskandmonitorswereoff,andmorphinewasflowingthrough Paul’s IV. He was breathing steadily but shallowly, and he appearedcomfortable.Nonetheless, Iaskedhimwhetherheneededmoremorphine,and

he nodded yes, his eyes closed.Hismother sat close; his father’s hand restedatophishead.Finally,heslippedintounconsciousness.

Formore than nine hours, Paul’s family—his parents, brothers, sister-in-law, daughter, and I—sat vigil as Paul, unconscious, now drew increasinglyhalting, infrequent breaths, his eyelids closed, his face unburdened. His longfingersrestedsoftlyinmine.Paul’sparentscradledCadyandthenputherinthebed again to snuggle, nurse, nap. The room, saturatedwith love,mirrored themanyholidaysandweekendswehadallspenttogetherovertheyears.IstrokedPaul’shair,whispering,“You’reabravePaladin”—mynicknameforhim—andsinging quietly into his ear a favorite jingle we’dmade up over the previousmonths,itscoremessagebeing“Thankyouforlovingme.”Aclosecousinandunclearrived,andthenourpastor.Thefamilysharedlovinganecdotesandinsidejokes;thenwealltookturnsweeping,studyingPaul’sfaceandeachother’swithconcern, steeped in the preciousness and pain of this time, our last hours alltogether.

Warm rays of evening light began to slant through the northwest-facingwindowof the roomasPaul’sbreathsgrewmorequiet.Cady rubbedhereyeswithchubbyfistsasherbedtimeapproached,andafamilyfriendarrivedtotakeherhome.IheldhercheektoPaul’s,tuftsoftheirmatchingdarkhairsimilarlyaskew, his face serene, hers quizzical but calm, his beloved baby neversuspectingthatthismomentwasafarewell.SoftlyIsangCady’sbedtimesong,toher,tobothofthem,andthenreleasedher.

Astheroomdarkenedintonight,alowwalllampglowingwarmly,Paul’sbreathsbecamefalteringandirregular.Hisbodycontinuedtoappearrestful,hislimbs relaxed. Just before nine o’clock, his lips apart and eyes closed, Paulinhaledandthenreleasedonelast,deep,finalbreath.

—

When Breath Becomes Air is, in a sense, unfinished, derailed by Paul’s rapiddecline,butthatisanessentialcomponentofitstruth,oftherealityPaulfaced.During the last year of his life, Paul wrote relentlessly, fueled by purpose,motivatedbyatickingclock.Hestartedwithmidnightburstswhenhewasstillaneurosurgerychiefresident,softlytappingawayonhislaptopashelaynexttome in bed; later he spent afternoons in his recliner, drafted paragraphs in hisoncologist’swaitingroom,tookphonecallsfromhiseditorwhilechemotherapydripped intohisveins, carriedhis silver laptopeverywherehewent.Whenhisfingertips developed painful fissures because of his chemotherapy, we foundseamless, silver-lined gloves that allowed use of a trackpad and keyboard.

Strategiesforretaining themental focusneededtowrite,despite thepunishingfatigueofprogressivecancer,werethefocusofhispalliative-careappointments.Hewasdeterminedtokeepwriting.

Thisbookcarries theurgencyof racingagainst time,ofhaving importantthingstosay.Paulconfronteddeath—examinedit,wrestledwithit,acceptedit—asaphysicianandapatient.Hewantedtohelppeopleunderstanddeathandfacetheirmortality.Dying inone’s fourthdecade isunusualnow,butdying is not.“Thethingaboutlungcanceristhatit’snotexotic,”Paulwroteinanemailtohisbest friend, Robin. “It’s just tragic enough and just imaginable enough. [Thereader]cangetintotheseshoes,walkabit,andsay,‘Sothat’swhatitlookslikefromhere…soonerorlaterI’llbebackhereinmyownshoes.’That’swhatI’maiming for, I think. Not the sensationalism of dying, and not exhortations togatherrosebuds,but:Here’swhatliesupaheadontheroad.”Ofcourse,hedidmorethanjustdescribetheterrain.Hetraverseditbravely.

Paul’sdecisionnot toaverthiseyes fromdeathepitomizesa fortitudewedon’tcelebrateenough inourdeath-avoidantculture.His strengthwasdefinedbyambitionandeffort,butalsobysoftness,theoppositeofbitterness.Hespentmuchofhislifewrestlingwiththequestionofhowtoliveameaningfullife,andhisbookexploresthatessentialterritory.“Alwaystheseerisasayer,”Emersonwrote.“Somehowhisdreamistold;somehowhepublishesitwithsolemnjoy.”Writingthisbookwasachanceforthiscourageousseertobeasayer,toteachustofacedeathwithintegrity.

Most of our family and friends will have been unaware, until thepublicationofthisbook,ofthemaritaltroublePaulandIweatheredtowardtheend of his residency.But I amgladPaulwrote about it. It’s part of our truth,another redefinition, a piece of the struggle and redemption and meaning ofPaul’slifeandmine.Hiscancerdiagnosiswaslikeanutcracker,gettingusbackintothesoft,nourishingmeatofourmarriage.Wehungontoeachotherforhisphysical survival and our emotional survival, our love stripped bare.We eachjokedtoclosefriendsthatthesecrettosavingarelationshipisforonepersontobecome terminally ill. Conversely, we knew that one trick to managing aterminal illness is to be deeply in love—to be vulnerable, kind, generous,grateful. A few months after his diagnosis, we sang the hymn “The ServantSong”whilestandingsidebysideinachurchpew,andthewordsvibratedwithmeaningaswe faceduncertaintyandpain together:“Iwill shareyour joyandsorrow/Tillwe’veseenthisjourneythrough.”

When Paul toldme, immediately after his diagnosis, to remarry after hedied, it exemplified the way he would, throughout his illness, work hard to

securemyfuture.Hewasfiercelycommittedtoensuringthebestforme,inourfinances,mycareer,whatmotherhoodwouldmean.Atthesametime,Iworkedhard to secure his present, to make his remaining time the best it could be,trackingandmanagingeverysymptomandaspectofhismedicalcare—themostimportantdoctoringroleofmylife—whilesupportinghisambitions,listeningtohis whispered fears as we embraced in the safety of our darkened bedroom,witnessing, acknowledging, accepting, comforting.We were as inseparable aswehadbeen asmedical students,whenwewould hold hands during lectures.Nowweheldhandsinhiscoatpocketduringwalksoutsideafterchemotherapy,Paulinawintercoatandhatevenwhentheweatherturnedwarm.Heknewhewouldneverbealone,neversufferunnecessarily.Athomeinbedafewweeksbeforehedied,Iaskedhim,“Canyoubreatheokaywithmyheadonyourchestlikethis?”Hisanswerwas“It’stheonlywayIknowhowtobreathe.”ThatPaulandIformedpartofthedeepmeaningofeachother’slivesisoneofthegreatestblessingsthathasevercometome.

Both of us drew strength from Paul’s family, who bolstered us as weweatheredhisillnessandsupportedusinbringingourownchildintothefamily.Despite stunning grief over their son’s illness, his parents remained anunwavering sourceof comfort and security.Rentinganapartmentnearby, theyvisitedoften,Paul’sfatherrubbinghisfeet,hismothermakinghimIndiandosawithcoconutchutney.Paul,Jeevan,andSumanloungedonoursofas,Paul’slegsproppeduptoalleviatehisbackpain,discussingthe“syntax”offootballplays.Jeevan’swife,Emily,andIlaughednearbywhileCadyandhercousins,EveandJames, napped. On those afternoons, our living room felt like a small, safevillage. 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 snappedphotos.Suchsimplemomentsswelledwithgraceandbeauty,andevenluck, ifsuchaconceptcanbesaidtoexistatall.Andyetwedidfeellucky,grateful—forfamily,forcommunity,foropportunity,forourdaughter,forhavingrisentomeet each other at a time when absolute trust and acceptance were required.Although these last few years have been wrenching and difficult—sometimesalmostimpossible—theyhavealsobeenthemostbeautifulandprofoundofmylife,requiringthedailyactofholdinglifeanddeath,joyandpaininbalanceandexploringnewdepthsofgratitudeandlove.

Relyingonhisownstrengthandthesupportofhisfamilyandcommunity,Paulfacedeachstageofhisillnesswithgrace—notwithbravadooramisguidedfaith that hewould “overcome” or “beat” cancer butwith an authenticity thatallowedhimtogrievethelossofthefuturehehadplannedandforgeanewone.

Hecriedonthedayhewasdiagnosed.Hecriedwhilelookingatadrawingwekeptonthebathroommirrorthatsaid,“Iwanttospendall therestofmydaysherewithyou.”Hecriedonhislastdayintheoperatingroom.Helethimselfbeopen andvulnerable, let himself be comforted.Evenwhile terminally ill, Paulwas fully alive; despite physical collapse, he remained vigorous, open, full ofhopenotforanunlikelycurebutfordaysthatwerefullofpurposeandmeaning.

Paul’svoiceinWhenBreathBecomesAirisstronganddistinctive,butalsosomewhat solitary. Parallel to this story are the love and warmth andspaciousness and radical permission that surrounded him. We all inhabitdifferentselvesinspaceandtime.Hereheisasadoctor,asapatient,andwithinadoctor-patientrelationship.Hewrotewithaclearvoice,thevoiceofsomeonewithlimitedtime,aceaselessstriver,thoughtherewereotherselvesaswell.NotfullycapturedinthesepagesarePaul’ssenseofhumor—hewaswickedlyfunny—or his sweetness and tenderness, the value he placed on relationships withfriendsandfamily.Butthisisthebookhewrote;thiswashisvoiceduringthistime; thiswas hismessage during this time; thiswaswhat hewrotewhen heneededtowriteit.Indeed,theversionofPaulImissmost,moreeventhantherobust,dazzlingversionwithwhomIfirstfellinlove,isthebeautiful,focusedmanhewasinhislastyear,thePaulwhowrotethisbook—frailbutneverweak.

Paul was proud of this book, which was a culmination of his love forliterature—heoncesaidthathefoundpoetrymorecomfortingthanScripture—andhisabilitytoforgefromhislifeacogent,powerfultaleoflivingwithdeath.When Paul emailed his best friend in May 2013 to inform him that he hadterminalcancer,hewrote,“ThegoodnewsisI’vealreadyoutlivedtwoBrontës,Keats,andStephenCrane.ThebadnewsisthatIhaven’twrittenanything.”Hisjourneythereafterwasoneof transformation—fromonepassionatevocationtoanother, fromhusband to father, and finally, of course, from life to death, theultimate transformation thatawaitsusall. I amproud tohavebeenhispartnerthroughout, includingwhilehewrotethisbook,anactthatallowedhimtolivewithhope,withthatdelicatealchemyofagencyandopportunity thathewritesaboutsoeloquently,untiltheveryend.

—

Paul was buried in a willow casket at the edge of a field in the Santa CruzMountains, overlooking the Pacific Ocean and a coastline studded withmemories—briskhikes, seafood feasts,birthdaycocktails.Twomonthsbefore,onawarmweekendinJanuary,we’ddippedCady’schubbyfeetintothebrinywateratabeachbelow.Hewasunattachedtothefateofhisbodyafterhedied,

and he left it to us tomake decisions on his behalf. I believewe chosewell.Paul’sgravelookswest,overfivemilesofgreenhillcrests,totheocean.Aroundhimarehillscoveredinwildgrass,coniferoustrees,andyelloweuphorbia.Asyou sit down, you hear wind, chirping birds, the scuffling of chipmunks. Hemade it here on his own terms, and his grave site feels appropriately full ofruggednessandhonor,aplacehedeservestobe—aplacewealldeservetobe.Iam reminded of a line from a blessing my grandfather liked: “We shall riseinsensibly,andreachthetopsoftheeverlastinghills,wherethewindsarecoolandthesightisglorious.”

Andyetthisisnotalwaysaneasyplacetobe.Theweatherisunpredictable.BecausePaul is buried on thewindward side of themountains, I have visitedhim in blazing sun, shrouding fog, and cold, stinging rain. It can be asuncomfortable as it is peaceful, both communal and lonely—like death, likegrief—butthereisbeautyinallofit,andIthinkthisisgoodandright.

I visit his grave often, taking a small bottle ofMadeira, thewine of ourhoneymoondestination.Eachtime,IpoursomeoutonthegrassforPaul.WhenPaul’sparentsandbrothersarewithme,wetalkasIrubthegrassasifitwerePaul’shair.Cadyvisitshisgravebeforehernap,lyingonablanket,watchingthecloudspassoverheadandgrabbingattheflowerswe’velaiddown.TheeveningbeforePaul’smemorialservice,oursiblingsandIgatheredwithtwentyofPaul’soldest,closestfriends,andIwonderedbrieflyifwe’dmarthegrassbecausewepouredoutsomuchwhiskey.

OftenIreturntothegraveafterleavingflowers—tulips,lilies,carnations—tofindtheheadseatenbydeer.It’sjustasgoodausefortheflowersasany,andone Paul would have liked. The earth is quickly turned over by worms, theprocesses of naturemarching on, remindingme ofwhat Paul saw andwhat Inowcarrydeep inmybones, too: the inextricabilityof life anddeath, and theabilitytocope,tofindmeaningdespitethis,becauseofthis.WhathappenedtoPaulwastragic,buthewasnotatragedy.

I expected to feel only empty and heartbroken after Paul died. It neveroccurred tome thatyoucould lovesomeone thesamewayafterhewasgone,that I would continue to feel such love and gratitude alongside the terriblesorrow,thegriefsoheavythatattimesIshiverandmoanundertheweightofit.Paulisgone,andImisshimacutelynearlyeverymoment,butIsomehowfeelI’m still taking part in the life we created together. “Bereavement is not thetruncationofmarriedlove,”C.S.Lewiswrote,“butoneofitsregularphases—like thehoneymoon.Whatwewant is to liveourmarriagewell and faithfullythrough that phase too.” Caring for our daughter, nurturing relationships with

family, publishing this book, pursuingmeaningfulwork, visiting Paul’s grave,grieving and honoring him, persisting…my love goes on—lives on—in awayI’dneverexpected.

When I see the hospital where Paul lived and died as a physician and apatient,Iunderstandthathadhelived,hewouldhavemadegreatcontributionsasaneurosurgeonandneuroscientist.Hewouldhavehelpedcountlesspatientsandtheirfamiliesthroughsomeofthemostchallengingmomentsoftheirlives,thetaskthatdrewhimtoneurosurgeryinthefirstplace.Hewas,andwouldhavecontinued tobe,agoodpersonandadeep thinker. Instead, thisbook isanewway for him to help others, a contribution only he could make. This doesn’tmakehisdeath,ourloss,anylesspainful.Buthefoundmeaninginthestriving.Onpage115of thisbook,hewrote,“Youcan’tever reachperfection,butyoucanbelieveinanasymptote towardwhichyouareceaselesslystriving.”Itwasarduous,bruisingwork,andhenever faltered.Thiswas the lifehewasgiven,andthisiswhathemadeofit.WhenBreathBecomesAiriscomplete,justasitis.

TwodaysafterPauldied,IwroteajournalentryaddressedtoCady:“Whensomeonedies,peopletendtosaygreatthingsabouthim.Pleaseknowthatallthewonderfulthingspeoplearesayingnowaboutyourdadaretrue.Hereallywasthatgoodandthatbrave.”Reflectingonhispurpose,IoftenthinkoflyricsfromthehymnderivedfromThePilgrim’sProgress:“Whowould truevaloursee, /Lethimcomehither…/Thenfanciesflyaway,/He’llfearnotwhatmensay,/He’lllabournightandday/Tobeapilgrim.”Paul’sdecisiontolookdeathintheeyewasatestamentnotjusttowhohewasinthefinalhoursofhislifebutwhohe had always been. For much of his life, Paul wondered about death—andwhetherhecouldfaceitwithintegrity.Intheend,theanswerwasyes.

Iwashiswifeandawitness.

ForCady

ACKNOWLEDGMENTS

ThankyoutoDorianKarchmar,Paul’sagentatWilliamMorrisEndeavor,whosefierce support and nurturing gave Paul the confidence that he could write animportant book. And to Andy Ward, Paul’s editor at Random House, whosedetermination,wisdom,andeditorial talentmadePauleager toworkwithhim,andwhosehumorandcompassionmadePaulwanttobefriendhim.WhenPaulaskedhisfamily—literallyhisdyingwish—toshepherdthisbooktopublicationposthumously,Iwasabletopromisehimthatwewould,becauseofoursharedconfidence inDorianandAndy.At that time, themanuscriptwas justanopenfileonhiscomputer,butthankstotheirtalentanddedication,IbelievePauldiedknowingthatthesewordswouldmaketheirwayintotheworldandthat,throughthem,ourdaughterwouldcometoknowhim.ThankyoutoAbrahamVergheseforaforewordthatwouldhavethrilledPaul(myonlyobjectionbeingthatwhatDr.Verghesejudgedtobea“prophet’sbeard”wasreallyan“I-don’t-have-time-to-shave”beard!).IamgratefultoEmilyRappforherwillingnesstomeetmeinmygriefandcoachme through theepilogue, teachingme,asPauldid,whatawriterisandwhywriterswrite.Thankyoutoallwhohavesupportedourfamily,includingthereadersofthisbook.Finally,thankyoutotheadvocates,clinicians,andscientistsworkingtirelesslytoadvancelungcancerawarenessandresearch,aimingtoturnevenadvancedlungcancerintoasurvivabledisease.

LucyKalanithi

PHOTO:©SUSZILURIEMCFADDEN

PAUL KALANITHI was a neurosurgeon and writer. He grew up in Kingman, Arizona, andgraduated from StanfordUniversitywith a BA andMA in English literature and a BA in humanbiology.HeearnedanMPhilinhistoryandphilosophyofscienceandmedicinefromtheUniversityofCambridgeandgraduatedcumlaudefromtheYaleSchoolofMedicine,wherehewas inductedintotheAlphaOmegaAlphanationalmedicalhonorsociety.HereturnedtoStanfordtocompletehisresidency training in neurological surgery and a postdoctoral fellowship in neuroscience, duringwhichhereceivedtheAmericanAcademyofNeurologicalSurgery’shighestawardforresearch.HediedinMarch2015.Heissurvivedbyhis large, lovingfamily, includinghiswife,Lucy,andtheirdaughter,ElizabethAcadia.

What’snextonyourreadinglist?

Discoveryournextgreatread!

Getpersonalizedbookpicksandup-to-datenewsaboutthisauthor.

Signupnow.