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

A book review by Bobulous

On a Sunday evening just over thirteen years ago I was sat in an NHS hospital bed, being told by a neurosurgical consultant that the operation I was to undergo the next morning had a two to three percent chance of resulting in blindness, deafness, permanent vegetative state, or outright death. From his bedside manner the impression I got of the consultant was of a man who was humble but wise, and I was left feeling entirely confident that this was someone who knew their job.

That consultant was Mr1 Henry Marsh, and in his long career he has performed hundreds of neurosurgical operations. While he could easily fill a book with tales of flawless procedures which led to success and glory, his autobiographical work Do No Harm: Stories of Life, Death and Brain Surgery is instead a much more open, honest, reflective work, filled with the tales which still haunt him and his frustrations at how the modern NHS fails to live up to the old standards it once held proud.

In fact his honesty in this book is surprising. Whereas public perception has it that medical professionals deny all liability when things go wrong, for fear of lawsuits, in this book Henry Marsh recounts at least two cases where he urged the patients to sue the NHS Trust for which he worked, admitting that error on his part was the cause of catastrophe. One example describes a disaster when his trainee cut through a root nerve in the spine, paralysing a patient below one ankle, and Mr Marsh takes full responsibility for this awful outcome, making no attempt to disguise it as an unavoidable complication. Conversely, he admits to being frustrated in other cases where patients or families pursued legal action even though a procedure went as smoothly as it could have done, and plain bad luck meant that the patient suffered or died without a clear cause.

There are plenty of happy outcomes described in the pages of this book, but it's clear that Henry Marsh feels more keenly the failures, knowing that after each catastrophe he will have to face the patient and/or their family and explain that things did not go well. Each chapter tends to focus on a particular area of neuropathology, starting with aneurysm and moving through numerous types of brain tumour, benign and malignant. Many types of tumour are inoperable, forcing the consultant to tell the patient that nothing can be done for them. Surprisingly it is not this outcome which seems to most haunt Mr Marsh; instead he explains that the worst outcome is the situation where there is uncertainty, where he has to approve or reject surgery in cases where it's not clear what is the best course of action. He confesses to having a fear of failing to satisfy a balance between hope and realism, and tells of cases where he got the balance wrong and pursued hope unrealistically, notably in the case of a young girl in Ukraine whom he desperately wanted to help even though the chances seemed poor.

Another strong theme of the book is Mr Marsh's lament at how poorly the modern NHS measures up against the high standards of the NHS he used to know. He suggests that service is suffering because of a potent combination of bed shortages, excessive health & safety regulations, poorly implemented computer systems, multi-tiered hierarchies of health managers, and support staff who watch the clock rather than the patients. But he doesn't single out anyone for blame, and even finds himself surprised to admit that he could not fill the boots of the hospital chief executive (who admits in turn to feeling the same about the role of brain surgeon).

Interestingly, despite the image that surgeons have for always wanting to charge in and save the day, Henry Marsh admits that as he matured in his career he found that more and more often he was advising that a patient be spared surgery in cases where he knew the chance of success was small and the chance of simply extending the patient's suffering was high. He admits that it is often the fear of having such difficult conversations with patients and family members that leads surgeons to take the surgical route even when there is little hope of real benefit. Along these same lines of thinking he describes the role he plays at NICE, advising on whether a new drug offers any real benefit to a patient so that the board can decide whether to fund the drug or not. Despite the awful reputation NICE has (described as a "death panel" by critics in the USA), Mr Marsh is impressed with the seriousness and competence with which the institute performs in its aim of getting the most out of pharmaceutical companies, who would otherwise charge the Earth for new drugs regardless of their actual benefit to patients.

When I awoke after surgery on the Monday afternoon I was delighted to find my eyesight fully restored, and I suffered no ill consequences as a result of the procedure. I knew even then that I was lucky, but reading this book gives a clear and fascinating illustration of just how big a role luck plays, even in the hands of a passionate, experienced, empathic surgeon such as Mr Henry Marsh. Even though a hack journalist could take any number of tales from this book and paint a picture of a surgeon or a health trust which should be put out of business, the fact is that luck is an unavoidable part of life, and simply painting a surgeon as either hero or villain based on the result of his latest procedure is to give in to fear and emotion. The real question should be how many other people could have done a better job? And after having met Henry Marsh and having read his fascinating autobiography, I suspect there are very few people who could do the job better.

1. For historical reasons, surgical consultants in the UK use the title "Mr" and not the title "Dr".