'Every surgeon carries within himself a small cemetary...a place of bitterness and regret, where he must look for an explanation for his failures.' This quote by René Leriche, which prefaced H. Marsh's 'Do No Harm' (shortlisted for Costa Book Awards 2014) remained with me while I read the famous neurosurgeon's fascinating tales of triumph, defeat and day to day life in the hospital.
Marsh's autobiographical work penetrates the veil which stands between the patient and the doctor. Although in a recent interview for BBC Radio 4's Book Club, Marsh acknowledges that in medicine 'self-deceit is an important clinical attribute' if one wants to progress, he also admits that mistakes are incredibly valuable too. The doctor is not God-like at all, as many of us like to believe when we become patients, but simply human (albeit a superbly skilled one) with the ability to make mistakes, despite the consequences being much graver than in many other professions. Throughout the collection, the scales of a relationship between a doctor and a patient often tip towards compassion or towards detachment. As Marsh commented in the same interview - one of the constant fears throughout his career has been to become too de-sensitised. Responding to a reader's question of where the happy balance lies, Marsh commented that there is none - medicine is a constant struggle at leveling the scales. What makes it worse is that, when the scales do tip towards compassion, the suffering of a doctor feels invalid - he has no right to suffer compared to the patient who is the one coping with the dreadful illness.
Marsh further commented that it is often the decision-making between life and death that keeps him up at night. Being a senior doctor often means claiming the responsibility for affecting your patients' decisions. In his book, Marsh describes a conversation with a junior doctor over one of the cases, as part of a training session. Marsh stressed how, depending on how the junior doctor phrased the prognosis, the patient's decision would be swayed towards whether to operate and have a chance at life, albeit in a severely disabled condition, or to accept that it was time to die. The responsibility, therefore, of a a patient's decision, often lies with the doctor. And even doctors are left dumb-struck at illnesses which seem to pick their victims at random and with a degree of heartless irony - as in the case of a successful, energetic female journalist who was left in a convent hospital, nursed by monks, as she was reduced to a vegetative state, unable to move or speak.
Does a doctor ever get better at making the right decision? Marsh describes a particularly moving case with a Ukrainian patient Tanya - a young girl who was transported from Horodok, a small village in Ukraine, to Marsh's hospital in London for an operation on her brain tumor. Confirming Marsh's foreboding about the case, Tanya spent 'six horrible months' at the hospital only to return to Ukraine where she eventually died only eighteen months later. And another case described a family who had decided to operate on a very young child on several occasions, hoping for a miracle, though it may have caused less suffering if the family had faced the fact that the child would inevitably die, from the start. But a statement like this verges on the brink of cruelty. Who wouldn't try to save their loved one, and hope against hope? Marsh argues that a part of a doctor's responsibility is to leave their patient with a degree of hope, however small, in the worst of circumstances. Is it selfish of us to cling to life of our loved ones? Marsh shares his painfully honest observations that if people didn't cling onto life so much, much suffering could be avoided. But he never fails to stress that, if the roles were reversed, and a member of his family became a patient (a case which he has also described in the book), any logic would simply vanish in the face of emotions and love.
But when is the right time to die? Marsh's stories cover a range of characters, from drunks (on whom junior doctors, in the strict hierarchy of the NHS, often practice as their cases would result in the least feedback) to successful business-men, young men and women in their prime of life, elderly ladies, children and even babies. And while we might pity a baby more than a drunk, the hand of death seems to make no such distinction. And who truly deserves to die, and how does a doctor deal with drawing that line of telling a patient that it is time to go? The thought is as surreal as the idea that our 'memories, dreams and reflections should consist of jelly,' which Marsh has to cut through with a sucker, searching for the tumor.
The setting of an NHS hospital, the sharp contrast between private care and fragments of Marsh's time in Ukraine (also documented in the award-winning film The English Surgeon) makes an interesting back-drop to the book. Throughout the stories, I got a strong impression that things were better in 'the good old days' when Marsh started out as a doctor, though, interestingly, Marsh does not admit to that during the interview. Instead, he explained that in the past things were different only in the sense that doctors and senior consultants were given more authority. In my mind, the power seems to have shifted to the emotionally sterile, forever concerned face of a policy-making manager. The scales have leaned towards detachment - not only in medicine, but all areas of modern life, where ridiculous laws and policies drive our society from perceiving each other as individuals with emotions and empathy, towards soulless standards, tick-boxes and mistrust. Let's hope that one day the 'happy balance' may be restored.