Henry Marsh: ‘Preparing to die has a lot to do with having had a good life’

Neurosurgeon Henry Marsh (Oxford, 73 years old), author of Do No Harm: Stories of Life, Death, and Brain Surgery, was writing a book about the brain. He thought that his, being so active, surely wouldn’t have shrunk like everyone else’s, which end up the size of a walnut, and he had a CT scan done to verify it. What he found was a tumor; he tells about it in And Finally: Matters of Life and Death.

He lives alone in Wimbledon, south London, in a semi-detached house where he has built almost everything from the bookshelves to the skylight in the bright kitchen. He also planted the camellia in the garden. Logs burn in the fireplace. “I light it up when someone comes,” he says. He wears his pants tucked into his socks. “I just came from the 8.00pm meeting at the hospital.” He is reviewing a book by Freud, he says. “It is not science, it is literature. That is the key: he was a very good writer.”

“I am a person who experiences ups and downs, and I have learned to accept it,” he reflects. “As a friend once told me: it is impossible to feel very optimistic and very pessimistic at the same time.” He continues: “Emotions have guided me. the psychiatric term would be cyclothymic. My life has been intense. That’s why I became a neurosurgeon. Most doctors don’t want to be surgeons, and most surgeons don’t want to be neurosurgeons. If you don’t like risk, you don’t choose this profession. Risk implies the possibility of the best, which only exists, of course, because the opposite exists.”

Question. In Do No Harm you claim that death is not the worst diagnosis. Do you still think so, even having cancer?

Answer. Yes. As a neurosurgeon you could save a life of a person who would not want you to. It’s a tough decision for the family – if you can find them. The question is: do you know this person well enough to know if they would want to live in these conditions of dependency? Or: do you love this person enough to take care of them if they can’t do it themselves?

Q. You wrote that if you were diagnosed with a brain tumor, you would surely take your own life. You haven’t.

A. I defend the right to euthanasia. We must be able to look death in the eye. It is part of existence. When I was diagnosed with the tumor I became obsessed, until I thought: I am 73 years old and I’ve had a difficult life, but a long and good one. I thought about my young patients who died. And about their parents, who would never know them as adults. The drive to survive is in our DNA. The problem is that that made sense when people died at 40 years old. Now the concern is becoming a burden for your loved ones. There are so many treatments that knowing when to stop has become a problem.

Q. When to stop?

A. Many treatments are expensive, and the public health system cannot afford them. More diapers are sold for the elderly than for children. 30 years ago I would have died of cancer; now I will die with cancer, but not of cancer. Cancer is, fundamentally, a disease of the elderly. The probability of having it at 70 is a thousand times higher than that of having it at 20. But dementia terrifies me more. I couldn’t bear to become a nuisance.

Q. Why are we afraid to bother?

A. I would not want my children to see me as I saw my father when he was 96. He didn’t know who he was.

Q. You became a doctor due to a life crisis.

A. I started political science and philosophy, but it was all verbal analysis. Then I went to Ghana for a year as a volunteer with white, Catholic priests. I am not religious, but that experience shaped me. Then I went to work as a stretcher-bearer.

Q. You ran away from Oxford after a heartbreak.

A. I was very immature. I fell madly in love. I had spent my teenage years reading poetry and, well… it was embarrassing. She was a family friend.

Q. Was she married?

A. Yes. Typical of adolescence. I couldn’t get over my obsession. I even tried to commit suicide! I know what it means to be madly in love... and I don’t trust madness. I believe that, in functioning relationships, love is work. But then I became obsessed with that rigid American poet, Sylvia Plath.

Q. Does she seem rigid to you?

A. She wrote very well. But she was a narcissist. And to me, narcissism is only excusable when it leads you to make the world a better place.

Q. A doctor.

A. Well... I wanted to know real suffering, not the one that had invaded my head. And I found work in the operating rooms of a hospital north of Newcastle. Then I went back to Oxford, studied like a madman and met my first wife – a troubled relationship from the beginning.

She learned with our divorce. She became a marriage counselor. We had three children. She kicked me out of the house; I don’t blame her. I would arrive at night, receive a call from the hospital and leave again. I was obsessed with my patients. I put them before everything.

Q. Is that why you don’t live with your second wife?

A. Kate Fox is a brilliant anthropologist. Her book Watching the English is a mega-bestseller [he gets up and hands me a copy]. Separate lives make a happy marriage. We don’t live together because she has Crohn’s disease.

Q. Again, the fear of disturbing.

A. Living with a chronic illness is difficult for everyone. As a doctor I get alarmed; as a partner I must respect it.

Q. You studied medicine without knowing that your maternal great-grandfather had been a doctor.

A. My mother was German, and before she died she decided to put in writing that she stopped talking to her family because they chose to join the Nazi party and she did not.

Q. Do we wait until the end to ask ourselves the most important questions?

A. Preparing to die has a lot to do with having had a good life. I am privileged. I have loved being a doctor and building wooden tables. And that has everything to do with how lucky you were as a child. That is, poor people are not lucky. Therefore, we have an obligation to treat them better. As a doctor it’s automatic, a matter of ethics. To extend life, what should be done is to improve the first years.

Q. Do we carry the ignorance of our own past to the history of our country?

A. As you get older you realize how little you have questioned everything you have learned. Kate made me realize that the slave trade was what financed the industrial revolution. Many current problems derive from mistakes like that. But it is easier to feel proud than ashamed, and historical reparations are complicated. Where does one stop?

Q. What is a good death?

A. The one that allows you to look back and think: I have said what I had to say.

Q. We are incapable of accepting death. As if there was another possibility…

A. Our nature separates us from pain. It is not rational to worry about something that, whatever you do, will happen. That is why we live in the present.

Q. Are we living in the present?

A. I am, ever since I was diagnosed with cancer. Also every time I fall in love. It has happened to me several times, but I’ve always regarded it with suspicion. You have to let six months pass for the hormonal system and the brain to calm down. Then the work begins. What we mean by love is quite selfish. Love consists in making the loved one happy.

Q. Do you have a good relationship with your children?

A. I used to bear the guilt of my absences. I had problems with my son William, a great guy, lonely, childless. But he underwent psychotherapy and it went as well for him as it did for me.

Q. Why did you go to therapy?

A. When I came back from Africa I was 22 and I didn’t know what to do with my life. I didn’t support myself. Going to the psychiatrist was like a religious conversion. After the first session I spent the night crying. At dawn I had dark circles under my eyes, but I had cried it all out. William James describes religious conversion as forgiveness, knowledge and truth. It wasn’t the crying, it was admitting that I needed help, finding it, accepting my fragility and letting go of my anger. You have to be very strong to come to terms with your fragility. It is a paradox, like many psychological truths.

Q. Your career has its ups and downs.

A. When you face a bad result, you forget what you have solved. Self-criticism is painful and people tend to either avoid it or destroy themselves. It’s about learning from your mistakes in order to grow. I learned, for example, that I cannot operate while listening to music.

Q. Your operations can last 15 hours.

A. They are a team effort. A union would force a change of doctor after eight hours. Would a patient want that? To a great degree, medicine is a vocational profession. But passion is a personal choice. You cannot expect such devotion in the new generation of neurosurgeons, the personal price is high. I prefer to operate with a colleague, do it together, support each other and be able to rest. The golden rule of humanity is to learn from our own mistakes and those of others. But… it’s unusual that all doctors cooperate. There is a lot of narcissism in my profession. Egos must be set aside in order for a committee to work, and in countries like Sudan or Ukraine the competition is economic: they only teach family, nobody wants to teach the competition.

Q. You defend doubt. Do we allow doctors to doubt?

A. Patients want certainty, and doctors deal with uncertainties. When I became a patient I knew that no one ever knows how much time you have left, unless it’s two days. And yet I couldn’t help but ask the oncologist. Uncertainty is difficult to live with and all cancer patients must learn to do so. I try to be useful: I teach, and I’ve been going to Ukraine for 21 years.

Q. Why did you start going?

A. It has to do with my father and his defense of human rights. From him I learned that democracy is not possible with a corrupt judicial system. And what did Putin and Yanukovych do? Corrupt the judicial system.

Q. In Ukraine, you don’t only teach how to heal.

A. I advise young doctors not to speak hurriedly. To sit down, even if they are in a hurry. To look into people’s eyes.

Q. Did you hesitate to tell the stories of your patients?

A. No. I have been writing a diary since I was 12 years old. I buried 10 years of my life there, and I’m still ashamed to read what a fool I was. But the stories that have obsessed me are also there. Each story is a person. Kate read it because our courtship was in writing: via email. And she told me she had a book. The only way to learn to be a neurosurgeon is by operating. And… by making mistakes. Experience is about making mistakes.

Q. “Bureaucracy costs lives.”

A. The fundamental problems of public health are the increase in the number of patients (and their lifespan) and the increase in technology — as well as its high price. It is necessary to find a balance between the freedom of the patient and the medical organization to try to heal. Organization is key in the war in Ukraine. The Russians obey a hierarchy; they don’t have independence of command. The Ukrainian army changed in 2014. It follows the German model: officers at the front can make decisions. Medicine is the same: you have to give some independence to the doctors and nurses in the trenches of the disease. 40 years ago, doctors had too much independence. Today we are at the other end of the spectrum. Autonomy is essential to be decisive and to preserve your mental health: to take care of yourself.

Q. Do we spend our lives trying to correct our mistakes?

A. In neurosurgery, it is easy to think: it was going to happen anyway. You have to fight yourself so you can ask: could I have done better?

Q. How do you do it?

A. Asking the friends I trust. Flattery cancels thought. The more you inquire, the more complicated your life becomes. You open a door and arrive at a place with more doors. Apparently, Freud was very dogmatic, and when he gave lectures he did not take questions. The questions are the doors.

Q. The more check-ups, the more diseases are found?

A. False positives happen every day. And they arise from bad practices. This morning a woman came in to get a CT for a headache. Either the family doctor was ignorant, or he was lazy. You cannot keep accumulating X-rays in your body, and in a CT scan abnormal forms can appear that cannot be treated unless they develop. How do you tell the patient? You can’t tell them that they have nothing and at the same time nothing can be done about their lump. Poking around too much has emotional consequences: you generate an anxiety that can change their life. If you don’t need a brain scan, don’t get it! I, like so many cancer patients, now live in limbo. All I can do is not think about the examinations until the day comes. My brain tumor originated in the prostate, and hormone therapy is basically castration. And it’s not a sexual thing. It’s not that you don’t like how your body is – I didn’t like it before either – it’s that the muscles weaken and that affects you. I thought I was unhappy because I had cancer. I realized I was in bad shape because I didn’t exercise. The good thing about hormone therapy, which is like aging rapidly, is that when you finish it, it’s like living backwards: I get younger every day!

Q. Which country has the best public health?

A. The public health system is a reflection of society, and the Scandinavian is rich.

Q. Norway was poor 100 years ago.

A. They invested the oil money in improving the country. Its prisons are veritable re-education centers. And they are used to paying taxes to maintain their services. They have much less inequality than the rest of the world. I am not an extreme leftist, but I do believe in the need to tax wealth.

Q. Does the pharmaceutical industry decide our worth?

A. They are not charity workers, they are companies, and many cancer drugs are prohibitively expensive because they need to make a return on their investment. We need their research. But they must not forget that they benefit from the investment that governments make in universities. My stance is that they should abstain from advertising and reduce prices.

Q. Does private healthcare overdiagnose more than public healthcare?

A. In the private sector, the risk of not operating is overestimated and that of operating is underestimated. I don’t think many doctors think about making money. But if they know they’re going to make money with a patient, they may be more amicable. We are that way.

Q. At the end of Do No Harm, you ask the readers: what are you doing with the time you have left?

A. I started an organization to support palliative care in Ukraine. I want to write a fairy tale for my granddaughters. I still teach at the hospital. And I make shelves. I live in the present.

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