For me, Admissions illustrates a great tension that exists in medicine. The need to feel, to be sensitive, to be humane, versus the need to be impervious to tragedy and move on to the next case. In describing his work in three countries (UK, Nepal, Ukraine), and the many successes and failures inherent in neurosurgery, Henry Marsh presents a poetic and deeply reflective character, while at the same time exhibiting a functional and cold attitude in certain awful circumstances. It is hard to escape the conclusion that repeated exposure to death has shaped this duality.
He cannot be accused of accepting duality, or dualism, of another type – that of body and soul. He does not believe in the soul, in God, or in life after death,
…I am a neurosurgeon. I frequently see people whose fundamental moral and social nature has been changed for the worse, often grotesquely so, by physical damage… It is hard to believe in an immortal soul, and any life after death, when you see such things. [p142]
…I do not believe in an afterlife… I know that everything I am everything I think and feel, consciously or unconsciously, is the electrochemical activity of my billions of brain cells, joined together in near infinite number of synapses… a transient electrochemical dance… [p266]
Thus, he can be unsentimental about his own inevitable death (he kept a ‘suicide kit’ so that he could hasten it, if necessary) and sometimes his patients’. He calls out medical futility when he sees it, and has no difficulty in recommending a conservative, or palliative approach I certain situations. In the case of children, this is quite hard to read.
There’s tumour left behind, she’s almost certainly going to be left very damaged, and all we have done is slow down her dying. [p106]
‘I think I’d get an MRI scan,’ I eventually said. ‘If it shows severe brain damage, perhaps it is better to the let the child die.’ [p120]
‘It’s best if we let her die, isn’t it?’ [p123]
In making the assessment of futility, he imagines what it might be like to live with severe neurological disability after surgery that delays death,
‘Would she want to survive like that?’ I asked. ‘That’s the question you and the rest of family should be asking yourselves. I would not want to live like that,’ I added [p76]
And such is the number of cases, especially when working in a developing healthcare system such as Nepal’s, his matter of fact approach can come across harshly.
‘She’ll never recover from that,’ I said. ‘What’s the next case.’ [p150]
Yet Marsh has empathy, some derived from personal experience.
‘My son had a brain tumour, ‘ I told him, ‘I know what you are feeling.’ [p111]
In fact, he feels that doctors are generally over-burdened with it,
For most of us, when we become doctors, we have to supress our empathy if we are to function effectively. Empathy is not something we have to learn – it is something we have to unlearn [p118]
And he is deeply affected by the suffering of others when near to it, or when he feels responsible, wholly or in part, for it. When called about a patient whose brain had suddenly started to swell while awaiting surgery, he agonises over what to do, having rushed to the phone at home, naked…
I remained on the kitchen chair for a long time, staring at the kitchen wall. [p228]
In the end he drives into the hospital in the middle of the night to make sure the operation is done properly. He reflects on the helplessness he feels when seeing someone who has come out of surgery unable to see,
…but it is a deeply painful experience to stand next to a patient at the bedside and see their blank, blind eyes fruitlessly casting about. [p242]
He is unflinchingly honest when things have gone wrong,
Their eyes were fixed on me as I told them that her death had been avoidable, because her blood sugar hadn’t been checked… [p231]
…and he prides himself on always telling his patient the truth about their prognosis.
These many experiences and reflections, combined with a resolutely pragmatic approach, build towards a final chapter setting out the rights of people to choose the time and place of their own death. He recalls earlier times, when death could be hastened without fear of accusation, for instance this patient who bled from oesophageal varices all night, until their overly diluted blood ran thin
My registrar drew up a syringe full of morphine to ‘ease the passing’. I cannot remember which one of us administered it. [p260]
Marsh is a well-known supporter of assisted dying (AD). Reading this book, I wondered if a lifetime’s exposure to death, futility and suffering, had led to a long slow burn out. His final falling out with the NHS, encapsulated in a much-regretted loss of temper with an ICU nurse, seemed to be a symptom of ‘administrative’ burn-out. Is his support of AD a symptom of medical/emotional burn-out? If so, does that undermine his point of view? This question is important, as those of us who likewise support AD have to be sure that we are not just expressing a reaction to the numerous deaths that we have seen on the wards.
Now working outside the NHS, and with time to spend on other pleasurable projects, Marsh has written two marvellous books that contain appreciations of the beauty of nature and life in general…
So I sit by myself and watch dust devils spiral up off the dry ground, driven by the wind, as the light slowly fades. [p212]
The buds on the young apple trees, a few millimetres in size, are just starting to open, and I can see miniature petals, tightly furled in layers of pink and white, starting to appear, full of enthusiasm to enter the outside world [p269]
In the end, Marsh has found balance. Somehow, this man who has lived to work, who can admit the mistakes he has made in both professional and personal spheres, and whose great disillusionment with aspects of the NHS is so palpable, can look back on a fascinating life through a fairly straightforward prism:
It is enough that I am well for a little longer, that I have been lucky to be part of a family – past, present, future – that I can still be useful, that there is still work to be done.