Do No Harm – Henry Marsh

20 February 2015
Preface and Chapters 1-8 (of 25)
I’m as impressed by the way Henry Marsh, brain surgeon, has chosen to present his memoir as I am by the content. In bite-sized chapters that each include at least one self-contained story based on his own experience, Marsh lets the reader get to know him one bit at a time. It’s like meeting someone you think you’re going to like. He’s modest enough to be appealing, but at the same time knows that what he has to tell us about his field is going to hook our attention. The title – a quotation from Hippocrates – and the opening paragraphs of the Preface establish the self-effacing tone. Patients eager for reassurance want to see every surgeon as a hero but ‘The reality, of course, is entirely different. Doctors are human, just like the rest of us.’

At first, he firmly leaves the autobiographical details to one side. By the time we hear about his early training as a doctor we’re a third of the way through the book, having already been taken through a lot of operations. He describes these, often in graphic detail, but his surgical experiences are never presented in merely procedural terms. There’s always the context of what it feels like to work in a service that is under constant political and financial pressure, having to contend with patients and their relatives who combine almost blind faith in any surgeon’s skill with deep misgivings. We might not know a huge amount about Marsh himself, but very quickly – and this is the really clever part – we think we know how it feels to be a brain surgeon.

Each chapter follows a similar pattern although, clever writer that he is, Marsh is good at ringing a few changes. Each chapter is named for the key medical condition described in it – there are often others as well – followed by a one-sentence definition. This is the beginning of the demystification. Pineocytoma (Chapter 1) might look daunting, but we know what a ‘slow-growing tumour’ is, and the procedure is deliberately described in such a way that we know, kind of, what the surgery involves. Marsh always does this, adding new details in each chapter about the familiar feel of the operating chair and his trusty binocular microscope that makes it feel like the exploration of a mysterious cave.

Of course, it isn’t so mysterious to him. He regularly lets us know how much experience he has gained over 30-odd years, and how familiar the terrain often is. But he also reminds us how it’s never entirely possible to predict how an operation will go. Will the tumour, if that’s what he’s dealing with, be easy to loosen from the brain it is pressing on, or will it be sticky, hard to prise away, risking damage to the brain and therefore paralysis? He likes words like loosen and sticky. They get him away from medical terminology, and from the idea that what he does is more than a set of skills, however long it has taken him to refine them.

But he also constantly reminds us that he’s dealing with human beings. His explorations might seem to lead him into an underworld of caves, but there is often the chance of a sudden haemorrhage, and the excavations he makes might lead to brain damage or even death. He doesn’t overstate the risks, and most of the procedures he describes in the early chapters have happy outcomes. But, from the Preface onwards, he lets us know that living with the results of unforeseen complications and his own mistakes is a big part of his life. ‘All I can see in front of me is matter. Yet I know that if I stray into the wrong area… I will be faced by a damaged and disabled patient when I go round to the Recovery Ward.’ Reader, he is saying right from the start, this is serious.

From the scraps that Marsh allows to fall, we piece together a patchy biography and an impression of what life in the National Health Service is like. His early uncertainty about what branch of medicine to specialise in, his even earlier uncertainty what to do with his life at all – he was a PPE student at Oxford before discovering medicine by way of a stint as a hospital porter – add to the charm of the modest-seeming man writing all this. He is frank about the privilege of his life compared to that of, say the doctor in Ukraine he met whilst visiting that country almost accidentally and with whom he worked for many years afterwards. It’s part of his cleverness that he makes it all sound as though he knows it’s not impressive really. He’s just doing a job, can become as exasperated as anybody else, and when the anaesthetist tells him that a childcare problem means he really can’t let that operation go on after 5.00, well, doesn’t everybody have problems like these in the real world?

I’m not surprised this book has won so much praise.

22 February
Chapters 9-17
These middle chapters are more stark than ever. The fallibility of surgeons has become the main subject so that now, every chapter seems to contain at least one of his own past mistakes. And whenever he does this he also gives us details about the person being treated, and the terrible disabilities they will now have to live with. He describes a lecture of his in the US, focused entirely on his own errors and on how the culture of cover-ups needs to change. The audience responds with stunned silence, and I’m not surprised. It isn’t that I think Marsh is wrong. But there can be few things less conducive to polite applause than the horrifying prospects for patients’ future lives of what are sometimes tiny errors, and are not always the surgeon’s fault.

Fault and blame haunt these pages. As often as not, it’s about Marsh blaming himself. He goes over how any one of the constant irritations of life in his particular hospital can – and sometimes does – lead to a lack of concentration. Or a cursory glance at what looks like an unremarkable scan – always because there’s something else bearing down on his attention – might lead to a vital detail being missed. We find out what it feels like to be sued – Marsh doesn’t even attempt to contest the justice of the case – but also what it feels like to lose the trust of a patient or family members when the outcome is entirely out of his hands.

And then there are the deaths. There is the cyclist who hadn’t been wearing a helmet – just as Marsh doesn’t, as his secretary reminds him – brought in with brain injuries that will leave him terribly disabled for life if any surgeon chooses to operate. Marsh doesn’t, but someone else does. Marsh is relieved when he hears that the covered body he sees later in an adjoining operating theatre is that of the cyclist, his vital organs having been ‘snatched’ – the medics’ own word – by the transplant team. There is another patient he has got to know well over ten years and several operations, who has reached what he thinks of as the end of the road. He can operate again, knows that there are cancer specialists who will consider a few months’ extension of her life a triumph for medicine, but considers it pointless. She and her family fall into the ‘unrealistic’ category, unable to face the fact that she will soon be dead. And, very occasionally – a handful of times in his whole career – there are those who die on the operating table. These aren’t his fault, but that doesn’t stop them being upsetting. And so on.

But sometimes the alternatives to death are worse. He presents us with outcomes in which the patient lives on, a burden to their family for the rest of all their lives. In one case, he describes how he has to find a form of words in which to ask the question, Do you love him enough to condemn yourself to a life of constant caring? (This might have been the injured cyclist.) He has developed such forms of words over the years, but sometimes it’s easier to avoid the conversation, do the operation, and change the lives of a whole family for the worse. Surgeons never keep in touch with the families in such cases, do not have to live such lives when death would have been a better outcome. It’s another issue, along with the fallibility of doctors, that makes his colleagues uneasy and that that Marsh won’t let go.

I’ve mentioned from the start the cleverness of Marsh’s writing. His honesty over cases in which a mistake of his leads to the ruin of someone’s life wins us over. We believe it when he explains why a certain problem really wasn’t his fault because there are enough times when he lets us know all too definitely that he was to blame. The reader has no idea whether the persona he presents is the real man – opinionated, impatient with managers and anyone else getting in the way of what he loves to do, but also scrupulously honest – but it fits his agenda. He is a character in a book, and Marsh has made him fully rounded enough to be absolutely believable. Here is a man, we are forced to decide, that we can definitely trust.

We find out a few more details of his autobiography, especially when they have a bearing on the recent history of the treatment of mind and brain. The job he had as hospital porter was in a mental institution in which twenty-six doubly incontinent old men were bathed, changed and left to sit about. This appears in a chapter concerning leucotomy, the generic procedure for separating brain tissue that includes lobotomy. While the passage of time has led to great progress, he is always keen not to overstate how far neurosurgery has come. And he is willing to leave aside the question of how the organic matter that he works with daily can possibly be the seat of consciousness and identity. One day, he is reading an article in which someone attempts to show that he has demonstrated the nature of the link. As we have come to expect by now, Marsh is contemptuous. Sometimes he writes as though nobody else knows anything – but, by now, we’re willing to forgive him.

23 February
Chapters 18-25 – to the end
I was writing about death. Chapter 18 is a kind of coda to the death-ridden middle chapters that come before. The subtitle has nothing to do with neuroscience – it’s Carcinoma – and we get an episode from Marsh’s own family life. The cancer is his mother’s, but she was 86 and considered she’d had a good life. And hers is what Marsh calls a good death, in her own home surrounded by a loving family. It contrasts with what so many have to confront in an NHS in which the urge to operate and resuscitate squeezes out any discussion of what would be best. Marsh’s mother could have had another operation, but it would only have given her a few more months and no added quality of life.

There’s more autobiography in these final chapters. Sometimes Marsh is a patient himself, and he writes engagingly about his personal experiences. The operations he performs are described just as personally in these later chapters, but not usually in a good way. You know that a chapter entitled Hubris is not going to end happily. It turns out to be the story of how his determination as a young surgeon to leave no trace of a particular tumour led directly to his patient being reduced to a vegetative state. In the previous chapter we’ve briefly seen the pitiful grey shell of humanity the patient had become seven years later…. We also find out a little more (not much) about the Ukraine project, still ongoing at the time of writing. The main story, inevitably, is a heart-rending one. It concerns a girl brought over from her little village in Ukraine, but for whom he couldn’t do very much in the end. Years later, when appearing in a documentary about the project, he visits the mother’s house and the girl’s grave. Her father had been murdered trying to make a living in Poland, and his grave is next to hers. So it goes in the dark world of Marsh-land.

Have you had enough yet? There are other harrowing stories of failed or misguided operations, but the story about his mother brings to the foreground a meditation on death that has been bubbling under all along. Earlier in the book, Marsh has glided over the dilemma: leaving a terminal illness to take its course would usually simply be ‘better’ than operating – although, as often as not, this judgment can only be made with hindsight, after the operation has proved to be useless. Now, he deals with the question more openly, and brings into play the idea of quality of life. In the bureaucratic dystopia of the modern NHS, decisions are often made by committee. He describes the day-long presentations and discussions about a new but expensive drug, and the workings of the often arbitrary mathematical criteria used are not pretty. But surgeons are faced with questions of life and death almost daily, and have to make quick decisions. The process reaches its ugly apotheosis in Ukraine, where Marsh is forced to decide on cases that warrant proper consideration in a matter of moments. He decides who might live, and also who will definitely die.

Marsh, approaching the end of his career, is only 20-odd years younger than his mother was when she died. He is an atheist, and has no time for the concept of an eternal soul when, every day, he sees how our identity entirely depends on the ‘matter’ he works with. He doesn’t know how it works but, as he muses on another once lively human being now lying in the mortuary, when the brain dies, so does everything. The approach of old age gives a greater urgency to these late chapters. They become a contemplation on the meaning of his own life, mainly in the confessional tone we’ve come to recognise but also, almost in passing, including little references to his own achievements. Sometimes these are self-deprecatory. The way he makes a new ‘SHO’ squirm during his first meeting shows him as the irascible professor – but he’s also teaching the young man how to be more humane in his dealings with patients. And he worries away at the idea that he will never be like the ‘great’ surgeons because, unlike him, they perfect their skills by ignoring harsh truths. They seem able to forget that they are dealing with human beings, and the potentially catastrophic effects on people’s lives. Marsh describes how one of them manages to forget all about a patient he has left brain-dead a few hours earlier.

The self-deprecation masks a genuine feeling for his fellow human beings. We hear much more about the difficult work he’s done in Ukraine, how he constantly fights against the idiocies of NHS bureaucracy, how he genuinely keeps worrying away at the importance of treating people properly. Kindness and fellow-feeling, he seems to be saying, are not the exclusive province of those who believe in a higher power. Who was it who got an ugly and padlocked balcony turned into a roof garden? Who is it who confronts the managers with the absurdity of rules that make patients’ experience worse instead of better? Who, even in his private life – he mentions the bee hives, the morning runs, the staircase and loft conversion he built himself – is the one who gets things done?

So, among all the other things it is, this book is Marsh’s justification for his own life. I’m ok with that. He certainly had a privileged upbringing and is now no doubt well rewarded for the work he does, but in this book he makes a convincing case that he has given a huge amount back. All I can do is stand in envy of a man who has been able to achieve so much.