Literature to Neuroscience

Growing up, Paul Kalanithi admired literary greats like Orwell, Camus, Sartre, Poe, and Thoreau. This fascination led him to choose literature as his major in college. However, before college, he stumbled upon a new interest: human biology. While preparing to attend Stanford, Kalanithi received a book from his then-girlfriend titled œSatan: His Psychotherapy and Cure by the Unfortunate Dr. Kassler, J.S.P.S by Jeremy Leven. The book captivated him with the idea that the brain functions as a biological machine that supports the human mind. This inspired him to enroll in courses in biology and neuroscience. 

Throughout college, he grappled with profound questions like, œWhat infuses life with meaning? He sought answers in both literature and neuroscience. To him, fiction was a powerful expression of the mind and, therefore, human significance. Though understanding meaning is complex, he found guidance in writers like T. S. Eliot, especially in œThe Waste Land, which links meaninglessness to isolation. Kalanithi concluded that genuine meaning arises from human relationships. Yet, literature was just one part of the puzzle; he recognized the importance of studying neuroscience. He believed that since the brain enables the mind, our capacity to connect with others stems from our brain's functions.

His insights deepened through experiences such as a visit to a facility for people with brain injuries, where he noticed the patients struggled to form relationships. Neuroscience provided him with a framework to understand the brain's laws, crucial to his grasp of meaning. Driven by this interest, he decided to apply to medical school, knowing that only through practical experience could he truly comprehend the meanings of life and death.

Kalanithi's Exploration of Existence and Finality in Medical Education

After months of tough medical school applications, Kalanithi finally secured a spot at the Yale School of Medicine. In the anatomy lab, he faced the stark realities of life and death. He spent countless hours dissecting cadavers, cutting through skin and tissue, and sawing through bone. While the medical students kept the faces of these bodies covered and didn™t know their names, Kalanithi felt a deep sense of their humanity. One day, while opening the stomach of a cadaver, he discovered a few undigested pills” a sign of life even within the dead. 

But Kalanithi's encounters with life and death extended beyond the anatomy lab. As a medical student, he frequently had experiences that highlighted these powerful themes. For instance, on his first day in the labor and delivery ward, he learned about a young woman who was expecting twins but had been hospitalized for premature labor. She was only 23.5 weeks pregnant, and the doctors were fighting to keep the pregnancy viable.

Sadly, an emergency cesarean section was needed. Kalanithi witnessed the operation and saw the tiny, nearly transparent infants as they were taken from the womb. Due to their premature condition, their organs could not sustain them, and the twins ultimately died, leaving Kalanithi with the powerful image of life one day and death the next.

Pursuit of Neurosurgical Expertise

In his fourth year of medical school, Kalanithi chose to specialize in neurosurgery. He understood this was a tough decision, but he felt drawn to the field. After graduating, he started a seven-year residency at Stanford. Soon, he faced the pressure of real responsibilities, which he had only briefly experienced in medical school. One day, a young boy named Matthew came in with a headache. After an examination, Kalanithi discovered Matthew had a large brain tumor, and it was up to him to decide what to do next.

Completely removing the tumor could restore Matthew's childhood, but since it was located in the hypothalamus”the part of the brain that controls basic functions like hunger and sleep”even a tiny mistake could lead to severe consequences. After careful consideration, Kalanithi decided to operate and successfully removed the tumor. However, during his first year of residency, he witnessed many deaths, both in the hospital and among his patients. 

He saw fatalities from head injuries, gunshot wounds, fights, and car accidents. One patient, an alcoholic, died when his blood lost the ability to clot, leading to a fatal bleed. Kalanithi also observed a medical professional who specialized in diseases die from pneumonia, later sent for an autopsy in the same lab where she had worked for many years. His first year was tough, and the following five years would be equally challenging.

The Heavy Burden of Decisions in Medicine

During his second year of residency, Kalanithi was put on call, meaning he was the first to respond in emergencies. Thankfully, as his skills improved, his responsibilities increased. However, he now had to make tough decisions about whether patients should be saved. One time, a patient with severe brain trauma was rushed into the operating room. Although the team managed to save him, the patient lost the ability to speak or eat on his own and would need to be institutionalized for the rest of his life. 

Kalanithi questioned whether it was right to save a life under such circumstances. Long hours and exhaustion made him wonder if he was truly respecting the humanity of his patients. Like his peers, he worked around a hundred hours a week, leaving him constantly tired. His head often hurt, and he relied on energy drinks to stay awake, even taking naps in his car before driving home.

This exhaustion led him to rush through patient interactions, even in tough situations. Once, after a woman learned she had brain cancer, he hurriedly told her that surgery was the best option, not fully considering her fear and uncertainty. Later, guilt washed over him as he recalled that he chose medicine to form meaningful connections. He needed to prioritize those relationships with his patients.

Neuroscience and Surgery

During his fourth year of residency, Kalanithi trained in a field outside his specialty. He joined a neuroscience lab at Stanford to study as a neuroscientist, focusing on the nervous system, including the structure and chemistry of neurons and their connections. Balancing the roles of both a neurosurgeon and a neuroscientist was both prestigious and challenging. Unlike his peers, who explored technologies to help paralyzed individuals control computers or robotic limbs with their thoughts, Kalanithi was intrigued by a different angle. He focused on neuromodulation, which looks at how to send signals from robotic limbs back to the brain. 

Success in this area could lead to artificial limbs that help the brain interpret the environment, allowing an amputee to navigate uneven surfaces more easily with feedback from an artificial foot. Despite the exciting work in the lab, Kalanithi returned to the hospital after nearly two years as chief resident. At this point in his training as a neurosurgeon, he had to be both quick and precise while taking on even more responsibility. It was during this time that he understood the importance of technical skills in medicine. 

With so much on the line for patients and their families, having good intentions wasn't enough”skills were essential. For instance, Kalanithi learned that Matthew, a young boy he had treated years before, was now facing serious challenges. He was becoming violent and uncontrollable, ultimately needing to be placed in a permanent care facility. Kalanithi realized he had inadvertently caused damage to a part of Matthew™s brain while removing a tumor.

Struggles and Triumphs

Kalanithi faced mistakes, but he also achieved great things. Despite the immense pressure, his hard work paid off. As his residency was nearing its end, he had overcome numerous challenges and completed all the required surgeries. He even earned prestigious awards and gained the respect of senior doctors. Stanford had offered him a perfect position as a neurosurgeon neuroscientist, focusing on neuromodulation. However, just 15 months before completing his residency, Kalanithi™s life took a shocking turn.

For six months, he had been losing significant weight and experiencing severe back pain, which was unusual for him. After visiting a doctor and getting X-rays, he was told he had simply overworked himself. Kalanithi was doubtful but returned to his work, determined to finish his residency. However, the pain worsened and shifted to his chest. His weight continued to drop, reaching just 145 pounds, and he had a persistent cough. Kalanithi knew his symptoms pointed toward cancer.

Eventually, his doctor reviewed a chest scan and noticed it was oddly blurred. Kalanithi instantly realized what that meant: his lungs were filled with tumors. The cancer had spread to his spine and liver, and his condition was terminal.

Life-Changing Decision

If you knew your time on earth was going to be cut dramatically short, how would you spend your remaining days? This question weighed heavily on Kalanithi during his treatment, leaving him unsure about how to proceed with his life and career. In conversations with his doctor, Emma, whom he felt close to, he expressed how unsettling it was to be uncertain about how much time he had left. If he had decades to live, he would continue practicing neurosurgery, but if he had only one or two years, he would likely focus on writing. Literature and writing held great importance for him, and Emma encouraged him to concentrate on what truly mattered. 

His situation was also confusing. How could he be both a doctor and a patient? As a doctor, he would search medical books for answers, but as a patient, he looked for deeper understanding in the literature he loved. Meanwhile, a pressing question remained: Should he and his wife, Lucy, have children before it was too late? After his diagnosis, the couple visited a sperm bank to explore the safest options. Although they had always planned to have kids, the uncertainty of Kalanithi's future made them hesitant. Ultimately, they chose life. To avoid any issues with the medication Kalanithi would take, they froze his sperm before treatment, and later, Lucy was inseminated and became pregnant.

Kalanithi's Final Months

On July 4, 2014, Kalanithi's daughter, Elizabeth Acadia, known as Cady, was born. Although he lived long enough to see her birth, he was in very poor health. When Lucy went into labor, Kalanithi was weak and had been frequently hospitalized. Despite a brief recovery, he was extremely thin and had to lie on a cot in the delivery room, unable to stand as Lucy gave birth. 

Afterward, he returned home with his family, still shaky and unable to do basic tasks like sitting, reading, or drinking. However, around Christmas, five months after Cady's birth, Kalanithi's cancer worsened significantly. The cancer began resisting treatment; neither the medications nor chemotherapy worked. As a result, he grew weaker in the following months. 

Despite the sadness his family felt, they found moments to enjoy life, such as inviting friends over for dinner and playing with baby Cady. By February, Kalanithi's condition deteriorated further, leaving him exhausted and nauseous, and eventually, he lost his appetite altogether. Hospital scans showed that the cancer had spread to his lungs and tumors had developed in his brain. Kalanithi realized that this would eventually affect his mind, as the neurological damage from the tumors would take away his ability to think clearly and find meaning in life.

A Story of Love, Loss, and Legacy

Eight months after Lucy gave birth to their daughter Cady, Paul Kalanithi was rushed to the emergency room with severe breathing problems. His condition would not improve. In the hospital, he was placed on breathing support but knew this would only be temporary. After talking through his treatment options, he decided to be taken off life support. Kalanithi understood that choosing a ventilator might mean he would never come off it. He realized that as his time was losing its meaning, there was little reason to keep his heart beating.

Surrounded by family, he was removed from breathing support and given morphine to ease his pain. Friends and loved ones came to say their goodbyes and offer love. As time passed, his breathing became irregular, and at around 9 p.m. on March 9, 2015, at age 37, Paul Kalanithi passed away. Though devastated by his death, Lucy remembers their final months together as filled with love and meaning. In the time leading up to his death, she and Kalanithi became as close as they had been when they first met in school. His family also found strength in each other. Kalanithi™s parents and brothers stayed with him, Lucy, and Cady at the hospital, talking about football, reading books, and enjoying his mother™s homemade Indian dosa. 

Lucy found comfort in ensuring Kalanithi™s œunfinished manuscript was published. While he wasn™t able to finish it as he had hoped, the book captures the reality of facing death. Lucy believes that through his book, Kalanithi achieved his goal: to help others understand and accept death as a part of life, while showing that it™s possible to live with integrity and meaning, even in the face of death.