Doctor’s Orders: Henry Marsh’s Do No Harm

In Do No Harm, Henry Marsh, neurosurgeon with the UK’s National Health Service, draws on three decades of experience “cutting through the stuff that creates thought, feeling, and reason”. The book spans his career from training to near-retirement, covering operations both heart-breaking and successful; his personal experiences as doctor, patient, and worried family member; his frustrations with ‘political meddling’ in the NHS; and his charitable work in Ukraine. It gets deep into the squishy details — often several inches deep into the brain itself — as well as into some of the most unanswerable philosophical and ethical questions in medicine. Marsh is blunt, eloquent, sardonic, grumpy, and searingly honest throughout.

I thought this would be worthy but dry book; it was immediately absorbing. It helps that the subject matter of neurosurgery provides all the ingredients for gripping drama. Like Shakespeare and soap opera, it deals with mortality, love, hope and despair. For the individual patients and for their families, the stakes couldn’t be higher. For the surgeon, it means taking responsibility for life-and-death decisions in a field of practice which is still risky and uncertain. Do No Harm is an example of non-fiction that is as absorbing and (melo-)dramatic as the best fiction.

Like Shakespeare and soap opera, it deals with mortality, love, hope and despair.

In one example, Marsh is interviewed by TV writers who want to introduce neurosurgery to their medically-themed soap opera series. He shares an anecdote of a young woman who begins to go blind while expecting her first baby due to a brain tumour that is advancing with frightening speed. The woman is wheeled into surgery, clutching her tearful husband’s hand, desperately concerned for her unborn child. Marsh operates, saving her sight and her life. Roll credits.

But most of Marsh’s cases are messier. ‘Do no harm’ is the first principle of western medicine, but as Marsh is keenly aware, brain surgery often does harm, terrible harm — and even when it succeeds, it can do more harm than if it was never attempted at all. We still know so little about the brain and how to fix it; mistakes can happen so easily. And then there are the unpredictable complications, the false hopes, and the unnecessarily drawn-out deaths. This isn’t a wholly bleak book: it is shot through with love, saved lives, hilarious bureaucratic cock-ups. But Marsh’s awareness of the risks involved in surgery, and its often diminishing returns, runs throughout.

Marsh records everything from his fatal slips of the hand to doubts over whether operating was the right decision. He discusses cases where hubris, pity, or just everyday grumpiness clouded his decisions. He describes operating against his own better judgement on a Ukrainian child he could not save and whose suffering he may have inadvertently exacerbated. He gives page-space to the patients he has ‘wrecked’, who will never emerge from comas, whose language, awareness, and memory may be irrevocably destroyed. He describes visiting a care home for hopeless cases, which he realises is full of his former patients, an embodiment of the ‘cemetery’ of failures which all surgeons carry with them (according to the René Leriche quote with which the book opens).

There are gradations of survival. The advances of modern medicine mean we are getting better not just at saving lives but at keeping the physical vital processes going in bodies in which the presence of life is ambiguous. Marsh, with his decades of medical experience, sees death as a better option than some of these forms of survival.

I was left all too aware of the precariousness of the quality of our lives, and perhaps of our entire selves

Marsh isn’t religious. For him, the closest thing we have to a soul is our consciousness. This arises, mysteriously but not miraculously, from the electro-chemical chatter of millions of nerve endings. It is entirely dependent on the physical integrity of the brain. I was left all too aware of the precariousness of the quality of our lives, and perhaps of our entire selves: Our consciousness, ability to reason, to remember, express emotion, move, and communicate, all rely on a weird and fragile lump of greyish-pink matter. As Marsh says, “The idea that emotions and reason, that memories, dreams and reflections should consist of jelly is simply too strange to understand.” Perhaps even more disconcerting is the fact that consciousness is dependent on this stuff which can and does go wrong. Bad things can happen in your head.

So much of modern medicine is attempting to quantify what is unquantifiable (and, finding spare beds). There is a fascinating chapter on his work helping to inform decisions on what medicines the NHS can fund. How much is an extra year of human life worth, and how do you rate quality of life? Marsh comments that the value of this medicine is not in giving the patients an extra year, but in giving them hope. But as he makes clear in his pre-surgery discussions with his patients, hope can be a double-edged sword.

These are just some the many dilemmas on which Marsh touches — when and if to operate, especially given the role of chance and the uncertainty involved; what medicines to fund; consent; whether and to what extent surgeons should practice on difficult cases to gain valuable experience, but which carry a high risk of a bad outcome for the patient…

I am not, of course, qualified to review Marsh as a surgeon — I wouldn’t know which end of a scalpel to grasp — but I did wonder about similarities in his approach to his two careers, writing and neurosurgery. His honesty, his continual questioning, and his care for his patients come across in the pages and no doubt in his practice.

Appropriately for a book about brains, this will make you think (and possibly make you a hypochondriac — don’t read it with a headache, however confidently you can trace it back to what you drank the night before). It’s not for the squeamish, but if you want to know more about the brain; about the self, life, and death — and are prepared to realise instead just how much we don’t know — then come and pick up this book.


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