And Finally: Matters of Life and Death

by Henry Marsh

‘Two things fill the mind with ever new and increasing admiration and awe, the more often and steadily we reflect on them: the starry heavens above me and the moral law within me.’ Immanuel Kant, Critique of Practical Reason

‘We are such stuff as dreams are made on, and our little lives are rounded with a sleep.’ William Shakespeare, The Tempest

when you are operating you do not want to distract yourself with philosophical thoughts about the profound mystery of how the physical matter of our brains generates thought and feeling, and the puzzle of how this is both conscious and unconscious.

If we make it to eighty, we have a one in six risk of developing dementia, and the risk gets greater if we live longer. It is true that a so-called ‘healthy lifestyle’ reduces the risk of dementia to a certain extent (some researchers suggest 30 per cent) but however carefully we live, we cannot escape the effects of ageing. We can only delay them if we are lucky. Long life is not necessarily a good thing. Perhaps we should not seek it too desperately.

The problem is that our true self, our brain, has changed, and as we have changed with our brains, we have no way of knowing that we have changed. It is the old philosophical problem – when I wake in the morning, how can I be certain I am the same person today that I was yesterday? And as for ten years ago?

Hope is one of the most precious drugs doctors have at their disposal.

Hope is not a question of statistical probability or utility. Hope is a state of mind, and states of mind are physical states in our brains, and our brains are intimately connected to our bodies (and especially to our hearts).

And in the modern era, of course, the brain has been seen as a computer.

Daniel Everett, the Christian missionary turned anthropologist,

Our hearts will beat, on average, about 4 billion times (and it is roughly the same for most animals – a mouse’s heart beats at 500 times a minute, the long-lived Galapagos turtles at four times a minute).

I find it very hard to comprehend that ‘I’ am the 86 billion nerve cells of my brain.

As a doctor, you could not do the work if you were truly empathic – if you literally felt yourself what your patient was feeling. Empathy, like exercise, is hard work, and it is normal and natural to avoid it. You have to practise instead a limited form of compassion, without losing your humanity in the process.

A much greater sin than detachment is complacency.

Sleep deprivation will prove fatal if sufficiently prolonged.

If people are deprived of REM sleep, they will enter into it increasingly quickly, as if they hunger for it. And deprivation of REM sleep reduces resistance to infection, showing that sleep matters for not only the brain.

Disturbed sleep is a well-recognised feature of Alzheimer’s, although whether as cause or effect is not known .

But the most interesting question to me remains unanswered – do my dreams mean anything?

The classical distinction between reason and emotion is mistaken. They work together, not in conflict. There are a few people who have lost their amygdala to a rare degenerative disease called Urbach–Wiethe disease. The amygdalae are crucial to experiencing emotion, especially fear. Such people can reason logically but are hopeless at making decisions.

You possess your home so completely, it becomes so much a part of you, that it is hard to imagine that anybody else once felt the same about it. You feel a little threatened by the thought of their past presence, just as you resent the thought of strangers living in a house you once lived in yourself, especially if it was your childhood home. And then you wonder who will take your place, and to whom your home will be passed on.

Apart from being deaf in one ear – the commonest problem with these tumours – she was remarkably well.

Acoustic neuroma

‘Climate change?’ my Ukrainian friends say with a laugh. ‘We have more immediate problems to worry about.’

When we are medical students we enter a new world – a world of illness and death. We learn about all manner of frightening diseases, and how they usually start with trivial symptoms. Many students, in response to a few minor aches and pains, become convinced that they have developed a catastrophic illness. In order to survive, they have to believe that diseases only happen to patients and not to themselves.

Doctors with cancer are often said to present with advanced disease, having dismissed and rationalised away the early symptoms for far too long.

Research in America by Roger Ulrich – the founder and doyen of the study of the impact of the hospital environment on patients – has shown that what we want to see, when ill and anxious in hospital, are pictures of landscapes, ideally with water and paths leading away into the sunlit distance. Or smiling faces.

Hospitals always remind me of prisons. These are places where your clothes are taken away, you are given a number and you are put in a small, confined space. You must obey orders. And then you are subjected to a rectal examination – well, perhaps not always.

patients often ask each other exactly the same question as prisoners: ‘What are you in for?’

The word ‘hospital’ derives from the Latin word hospes – meaning guest.

We are tribal animals – we are happiest in relatively small groups.

It is difficult to show in a rigorous, scientific way that we are hardwired by evolution to feel happiest when surrounded by green, living things.

I would like to think that the love of Nature is innate in most of us. So why are most hospitals so often so horrible? Why is it that it is only when we are dying in hospices, that gardens and flowers and trees are allowed to re-enter our life, just as we are leaving it?

The nurse returned. ‘You can go,’ was all she said. Ah, I thought, I have crossed to the other side. I have become just another patient, another old man with prostate cancer, and I knew I had no right to claim that I deserved otherwise.

The one thing I did not do was ask the question ‘Why me?’ As a doctor, I knew that the answer was very simple: ‘Why not?’

We are the products of our genes, our culture and our early environment. Success is more about luck than hard work (though hard work is necessary) and is rarely deserved, as having the ability to work hard is itself a question of luck, as is living in a society where hard work of certain kinds is so well rewarded.

I will be missed after my death, but I will miss nothing.

I do not want to look back on the present time, when I am still relatively well, and feel I wasted it by allowing myself to become miserable at the thought that, sooner or later, I will be lying on my deathbed. I have a duty to my future self to make the most of my life at the moment, both for myself and for others.

One of the worst aspects of being a patient is waiting – waiting in drab outpatient waiting areas, waiting for appointments, waiting for the results of tests and scans.

I derived very real consolation from the thought of how all these composers had died – indeed, there is a countless army of people who have died before me. Death comes to us all, sooner or later, one way or another, I told myself, and is part of life. I will be keeping good company.

Evolutionary anthropologists have convincingly argued that we evolved to dislike exercise.

And indeed, most surveys show people become happier as they enter old age – probably because we need no longer strive and compete, and have come to accept our lot, whatever it might be, until our bodies become too much of a burden and nuisance and start to dominate our lives to the exclusion of everything else. But despite the evidence in front of our eyes – that our bodies are wearing out, or that they are starting to be invaded by cancer – the wish to go on living remains as intense as ever.

This feeling of well-being after exercise is now attributed to the endocannabinoid system in the brain, a system of neurotransmitters and enzymes that are mimicked by marijuana. Like so much about the brain, it is not fully understood.

I do not believe in an afterlife, and it makes no sense to be afraid of nothing. And although my fear of death now takes the form of fear of dying, I suspect that beneath this there is still a deep, irrational fear of death itself, of nothingness, of having no future.

The history of science is largely a history of the refutation of human exceptionalism – the earth is not the centre of the universe; human beings are animals. As the great zoologist J. Z. Young observed, we are risen apes, not fallen angels.

As the philosopher David Hume observed on his deathbed, the thought of his no longer existing once he had died, bothered him no more than the thought that he had not existed before he was born.

So perhaps I am a Boltzmann brain, and what I think is the real world is just a pattern of electrochemical impulses in my brain, formed by randomly self-assembled particles of matter. Which, in a sense, it is, whether you believe in the possibility of Boltzmann brains or not.

But even if human beings – though perhaps only very wealthy ones – are soon all living to 150, will their suffering at the end be any less, just because they lived so many extra years?

Will our lives be any more meaningful, just because we have managed to postpone death?

How does consciousness arise, and from where? Despite all the research and writing, we really have very little idea. And this is rather extraordinary when you stop to think about it – that we understand so little about the most important aspect of being alive.

As the evolutionary biologist J. B. S. Haldane observed, it’s not just that the universe might be stranger than we think, but that it might be stranger than we can think.

With the nocebo effect you feel worse, because you expect to.

It is easier to carry on forward with blind optimism than to doubt yourself and go back self-critically. This is why good colleagues in medicine are so important, with whom you can discuss difficult cases and who will point out your mistakes to you.