Do No Harm: Stories of Life, Death, and Brain Surgery

by Henry Marsh

‘You could operate…’ ‘But should I?’ ‘I don’t know.’

A famous English surgeon once remarked that a surgeon has to have nerves of steel, the heart of a lion and the hands of a woman.

I decide at some unconscious place within myself, where all the ghosts have assembled to watch me,

Psychological research has shown that the most reliable route to personal happiness is to make others happy.

We have achieved most as surgeons when our patients recover completely and forget us completely.

Whereas the surgeon, for a while, has known heaven, having come very close to hell.

I arrived at work feeling cheerful. There was a solid cerebellar haemangioblastoma on the list.

His face was now hidden by broad swathes of sticking plaster, protecting his eyes and keeping the anaesthetic gas tubing and facial muscle monitoring wires in position. This metamorphosis from person to object is matched by a similar change in my state of mind. The dread has gone, and has been replaced by fierce and happy concentration.

‘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.

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

I usually say that I hope that I would commit suicide but you never know for certain what you will decide until it happens.

What if she wakes up and finds that we aren’t here? It would be so frightening for her although I know she kept on telling us last week that she did not want to be a burden to us.’ ‘But love is unconditional,’ I said and he burst into tears again.

huge and ugly building with the endless corridors that are the curse of all large hospitals.

Having spent six months watching surgeons operating I decided that this was what I should do. I found its controlled and altruistic violence deeply appealing.

‘The operating is the easy part, you know,’ he said. ‘By my age you realize that the difficulties are all to do with the decision-making.’

‘Do you think I have said sorry enough?’ I asked him. ‘Yes,’ he replied.

‘It looks very straightforward. It’s going to be easy,’ I added. This was a lie and I did not expect Rachel to believe it. Few anaesthetists believe what surgeons tell them.

One particularly catatonic patient – he had been lobectomized many years ago – could sit immobile for hours on end and served as a backrest for one of the therapists, as she sat on the burnt grass, her back resting comfortably against his as she did her knitting.

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.

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.

Denial is not always a bad thing. Her family were devoted to her and, while thanking me effusively whenever I had seen them, would look at me with such an intensity of hope and desperation that their eyes felt like nail guns fixing me to the wall.

With slowly progressive cancers it can be very difficult to know when to stop. The patients and their families become unrealistic and start to think that they can go on being treated forever, that the end will never come, that death can be forever postponed.

wondered, yet again, as I walked away down the dark hospital corridor, at the 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.

most patients and their families will research their disease online and the paternalistic white lies of the past will no longer be believed.

‘We’ll get you home as soon as we can,’ I said. ‘Any questions?’ I resisted the temptation to get up and walk to the door as I asked the question – an unconscious trick all doctors have to fight against when faced by a painful conversation.

The snow was still falling and I thought yet again of how I hate hospitals.

As with all NHS chief executives in my experience (I have now got through eight) they do the rounds of the hospital departments when they are appointed and then one never sees them again, unless one is in trouble, that is. This is called Management, I believe.

The fact of the matter was that we already knew the diagnosis from the scan and any operation would be something of a charade.

If I’d had sciatica for six months I would have the op, I said. I wouldn’t be happy about it, but I’d have it although, like most doctors, I am a coward.

Doctors need to be held accountable, since power corrupts. There must be complaints procedures and litigation, commissions of enquiry, punishment and compensation. At the same time if you do not hide or deny any mistakes when things go wrong, and if your patients and their families know that you are distressed by whatever happened, you might, if you are lucky, receive the precious gift of forgiveness.

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

I think, despite our intense emotions. It’s not that we felt anxious – the three of us knew she was dying – I suppose what we felt was simply intense love, a love quite without ulterior motive, quite without the vanity and self-interest of which love is so often the expression.

Your face becomes that of Everyman, close to death, a face we all know, if only from the funeral art of Christian churches.

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

Are they in some kind of perpetual dream state? Are they in heaven, or in hell?

could see the motionless forms of the patients in their beds. Beside each door was an enamelled plaque with the patient’s name; because they are there for so many years, until they die, they can have proper plaques rather than just the paper labels you find in an ordinary hospital. To my dismay I recognized at least five of the names as former patients of mine. One

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

They called him “the Butcher” because he trashed so many patients as he perfected his technique with these really difficult cases. And he still gets some terrible complications. Doesn’t seem to trouble him much though.’

Most medical students go through a brief period when they develop all manner of imaginary illnesses – I myself had leukaemia for at least four days

The surgeon treating a fellow surgeon feels anxious because the usual rules of detachment have broken down and he feels painfully exposed. He knows that his patient knows that he is fallible.

When I went to see the eye surgeon a few days after the operation, sporting my eye patch, he looked dubiously at me. ‘Drama queen,’ he said, but otherwise reported himself to be happy with the state of my eyeball.

Few people outside medicine realize that what tortures doctors most is uncertainty, rather than the fact they often deal with people who are suffering or who are about to die.

Hope is beyond price and the pharmaceutical companies, which are run by businessmen not altruists, price their products accordingly.

‘Yes, I bloody well have.’ ‘Well, try Mr Johnston’s. That usually works. Fuck Off 45. He hates computers.’ ‘Why forty-five?’ ‘It’s the forty-fifth month since we signed onto that hospital’s system and one has to change the password every month,’ Caroline replied.