Do No Harm: Stories of Life, Death and Brain Surgery - as seen on 'life-changing' BBC documentary Confessions of a Brain Surgeon

by Henry Marsh

anxious. It is easier to carry out difficult operations if you have told the patient beforehand that the operation is terribly dangerous and quite likely to go wrong

They certainly sounded harmless in retrospect. If headaches have a serious cause it is usually obvious from the nature of the headaches.

If patients were thinking rationally they would ask their surgeon how many operations he or she has performed of the sort for which their consent is being sought, but in my experience this scarcely ever happens.

As patients we are deeply reluctant to offend a surgeon who is about to operate on us.

‘Well done!’ I replied, as I think patients need to be congratulated for their surviving just as much as the surgeons should be congratulated for doing their job well.

The eyes are said by poets to be the windows to the soul but they are also windows to the brain: examining the retina gives a good idea of the state of the brain as it is directly connected to it. The miniature blood vessels in the eye will be in a very similar condition to the blood vessels in the brain.

Doctors and nurses enjoy dramatic cases like this and there was a carnival-like atmosphere to the morning.

The right frontal lobe of the human brain does not have any specific role in human life that is clearly understood. Indeed, people can suffer a degree of damage to it without seeming to be any the worse for it, but extensive damage will result in a whole range of behavioural problems that are grouped under the phrase ‘personality change’.

Great Patriotic War, as the Russians call the Second World War.

Everything was grey, colourless and drab in the way that only Soviet cities could be.

There is a flower section – the Ukrainians give flowers to each other on any social occasion

was best to see medicine as a form of craft, neither art nor science –

As a surgeon one has to learn real anatomy all over again – the anatomy of a living, bleeding body is quite different from the greasy, grey flesh of cadavers embalmed for dissection.

The reality of cardio-pulmonary resuscitation is very different from what is shown on TV. Most attempts are miserable, violent affairs, and can involve breaking the ribs of elderly patients who would be better left to die in peace.

My wife and I spent the next few weeks in that strange world one enters when you fear for your child’s life – the outside world, the real world, becomes a ghost world, and the people in it remote and indistinct. The only reality is intense fear, a fear driven by helpless, overwhelming love.

As a practical brain surgeon I have always found the philosophy of the so-called ‘Mind-Brain Problem’ confusing and ultimately a waste of time. It has never seemed a problem to me, only a source of awe, amazement and profound surprise that my consciousness, my very sense of self, the self which feels as free as air, which was trying to read the book but instead was watching the clouds through the high windows, the self which is now writing these words, is in fact the electrochemical chatter of one hundred billion nerve cells.

‘You won’t believe this,’ one of the other registrars broke in. ‘I was on yesterday evening and took the call. They sent the scan on a CD but because of that crap from the government about confidentiality they sent two taxis. Two taxis! One for the fucking CD and one for the little piece of paper with the fucking encryption password! For an emergency! How stupid can you get?’

I told her that what the family wanted would be entirely determined by what she said to them. If she said ‘we can operate and remove the damaged brain and he may just survive’ they were bound to say that we should operate. If, instead, she said ‘If we operate there is no realistic chance of his getting back to an independent life. He will be left profoundly disabled. Would he want to survive like that?’ the family would probably give an entirely different answer. What she was really asking them with the first question was ‘Do you love him enough to look after him when he is disabled?’ and by saying this she was not giving them any choice. In cases like this we often end up operating because it’s easier than being honest and it means that we can avoid a painful conversation. You might think the operation has been a success because the patient leaves the hospital alive but if you saw them years later – as I often do – you would realize that the result of the operation was a human disaster.

one of the unwritten rules of English medicine is that one never openly criticizes or overrules a colleague of equal seniority,

Most neurosurgeons become increasingly conservative as they get older – meaning that they advise surgery in fewer patients than when they were younger. I certainly have – but not just because I am more experienced than in the past and more realistic about the limitations of surgery. It is also because I have become more willing to accept that it can be better to let somebody die rather than to operate when there is only a very small chance of the person returning to an independent life. I have not become better at predicting the future but I have become less anxious about how I might be judged by others. The problem, of course, is that so often I do not know just how small the chance of a good recovery might be because the future is always uncertain. It is much easier just to operate on every case and turn one’s face away from the fact that such unquestioning treatment will result in many people surviving with terrible brain damage.

so many of the head injuries have terrible lives. If neurosurgeons followed up the severe head injuries they treated I’m sure they’d be more discriminating in whom they operated upon.’

Perhaps I was going to operate because I couldn’t face confronting the family and telling them it was time for Helen to die.

‘It’s not going to heal very well, is it?’ he commented, young enough still to enjoy the drama and tragedy of medicine.

way we cling so tightly to life and how there would be so much less suffering if we did not. Life without hope is hopelessly difficult but at the end hope can so easily make fools of us all.

Surgeons must always tell the truth but rarely, if ever, deprive patients of all hope. It can be very difficult to find the balance between optimism and realism.

I have little direct contact with death in my work despite its constant presence. Death has become sanitized and remote. Most of the patients who die under my care in the hospital have hopeless head injuries or cerebral haemorrhages. They are admitted in coma and die in coma in the warehouse space of the Intensive Care Unit after being kept alive for a while by ventilators. Death comes simply and quietly when they are diagnosed to be brain dead and the ventilator is switched off. There are no dying words or last breaths – a few switches are turned and the ventilator then stops its rhythmic sighing.

It is remarkable how much difference clothing makes.

I have learned over the years that when ‘breaking bad news’ as it is called, it is probably best to speak as little as possible. These conversations, by their very nature, are slow and painful and I must overcome my urge to talk and talk to fill the sad silence.

It had been inspired by Daniel Kahneman’s book Thinking, Fast and Slow, a brilliant account, published in 2011, of the limits of human reason, and of the way in which we all suffer from what psychologists call ‘cognitive biases’. I found it consoling, when thinking about some of the mistakes I have made in my career, to learn that errors of judgement and the propensity to make mistakes are, so to speak, built in to the human brain. I felt that perhaps I could be forgiven for some of the mistakes I have made over the years.

Everybody accepts that we all make mistakes, and that we learn from them. The problem is that when doctors such as myself make mistakes the consequences can be catastrophic for our patients. Most surgeons – there are always a few exceptions – feel a deep sense of shame when their patients suffer or die as a result of their efforts, a sense of shame which is made all the worse if litigation follows. Surgeons find it difficult to admit to making mistakes, to themselves as well as to others, and there are all manner of ways in which they disguise their errors and try to put the blame elsewhere.

Surgeons are supposed to talk about their mistakes at regular ‘Morbidity and Mortality’ meetings, where avoidable mistakes are discussed and lessons learned, but the ones I have attended, both in America and in my own department are usually rather tame affairs, with the doctors present reluctant to criticize each other in public. Although there is much talk of the need for doctors to work in a ‘blame-free’ culture it is very difficult in practice to achieve this. Only if the doctors hate each other, or are locked in furious competition (usually over private practice, which means money), will they criticize each other more openly, and even then it is more often behind each other’s backs.

To the man with a hammer, it is said, all things look like nails. When brain surgeons look at brain scans they see things that they think require surgery and I am, alas, no exception.

(On the other hand, some of the nicer post-Soviet professors would welcome me in the morning with vodka.)

They had both looked at me afterwards with the same terrible dumb anger and fear, a look of utter horror – unable to talk, unable to understand speech – the look of the damned in some medieval depiction of hell.

embracing. It is difficult to explain, let alone to understand, what it must be like to have no language – to be unable either to understand what is said to one, or put one’s thoughts into words.

Coning refers to the way in which the brain is squeezed like toothpaste out of the hole in the base of the skull when the pressure in the skull becomes very high. The extruded part of the brain is cone-shaped. It is a fatal process.

In fact the brain cannot itself feel pain since pain is a phenomenon produced within the brain. If my patients’ brains could feel me touching them they would need a second brain somewhere to register the sensation. Since the only parts of the head that feel pain are the skin and muscles and tissues outside the brain it is possible to carry out brain surgery under local anaesthetic with the patient wide awake.

They were very polite but quite without smiles.

‘It’s the professional shame that hurts the most,’

‘Vanity really. As a neurosurgeon you have to come to terms with ruining people’s lives and with making mistakes. But one still feels terrible about it and how much it will cost.’

‘You can’t stay pleased with yourself for long in neurosurgery,’ my colleague said. ‘There’s always another disaster waiting round the corner.’

Dying is rarely easy, whatever we might wish to think. Our bodies will not let us off the hook of life without a struggle. You don’t just speak a few meaningful last words to your tearful family and then breathe your last. If you don’t die violently, choking or coughing, or in a coma, you must gradually be worn away, the flesh shrivelling off your bones, your skin and eyes turning deep yellow if your liver is failing, your voice weakening, until, near the end, you haven’t even the strength to open your eyes, and you lie motionless on your death bed, the only movement your gasping breath. Gradually you become unrecognizable – at least you lose all the details that made your face characteristically your own, and the contours of your face are worn away down to the anonymous outlines of your underlying skull. You now look like the many old people, with drawn and dehydrated faces, identical in their hospital gowns, to whose bedside I would be summoned in the early hours when I worked as a junior doctor, down the long and empty hospital corridors, to certify death. Your face becomes that of Everyman, close to death, a face we all know, if only from the funeral art of Christian churches.

And now all those brain cells are dead – and my mother – who in a sense was the complex electrochemical interaction of all these millions of neurons – is no more. In neuroscience it is called ‘the binding problem’ – the extraordinary fact, which nobody can even begin to explain, that mere brute matter can give rise to consciousness and sensation.

What makes for a good death? Absence of pain, of course, but there are many aspects to dying and pain is only one part of it.

was indeed lucky to die in the way that she did. If I ever think about my own death – which, like most people, I try to avoid – I hope for a quick end, with a heart attack or stroke, preferably while asleep. But I realize that I may not be so fortunate. I may very well have to go through a time when I am still alive but have no future to hope for and only a past to look back on. My mother was lucky to believe in some kind of life beyond death but I do not have this faith. The only consolation I will have, if I do not achieve instant extinction, will be my own last judgement on my life as I look back on it. I must hope that I live my life now in such a way that, like my mother, I will be able to die without regret. As

‘It’s been a wonderful life. We have said everything there is to say.’

Neuroscience tells us that it is highly improbable that we have souls, as everything we think and feel is no more or no less than the electrochemical chatter of our nerve cells. Our sense of self, our feelings and our thoughts, our love for others, our hopes and ambitions, our hates and fears all die when our brains die. Many people deeply resent this view of things, which not only deprives us of life after death but also seems to downgrade thought to mere electrochemistry and reduces us to mere automata, to machines. Such people are profoundly mistaken, since what it really does is upgrade matter into something infinitely mysterious that we do not understand. There are one hundred billion nerve cells in our brains. Does each one have a fragment of consciousness within it? How many nerve cells do we require to be conscious or to feel pain? Or does consciousness and thought reside in the electrochemical impulses that join these billions of cells together? Is a snail aware? Does it feel pain when you crush it underfoot? Nobody knows.

Patients in persistent vegetative state – or PVS as it is called for short – seem to be awake because their eyes are open, yet they show no awareness or responsiveness to the outside world. They are conscious, some would say, but there is no content to their consciousness. They have become an empty shell, there is nobody at home. Yet recent research with functional brain scans shows this is not always the case. Some of these patients, despite being mute and unresponsive, seem to have some kind of activity going on in their brains, and some kind of awareness of the outside world. It is not, however, at all clear what it means. Are they in some kind of perpetual dream state? Are they in heaven, or in hell? Or just dimly aware, with only a fragment of consciousness of which they themselves are scarcely aware?

There have been several high-profile court cases in recent years as to whether treatment that keeps these people alive – since they cannot eat or drink – should be withdrawn or not, whether they should be left to die or not. In several cases the judges decided that it was reasonable to withdraw treatment and let the vegetative patients die. This does not happen quickly – instead the law, solemn and absurd, insists that the patients are slowly starved and dehydrated to death, a process that will take several days.

‘Great surgeons,’ he then added, ‘tend to have bad memories.’