Occasionally I wonder about the point of fiction. Why make stuff up when there is reality itself out there to write about? I bought Emma Donoghue’s novel Room, for instance, but once I’d read Natascha Kampusch’s amazing 3,096 Days - few books have made a bigger impression on me: I wrote not one but three posts about it here – I was just no longer interested in reading a piece of fiction about being confined to a single room, however interestingly written or well-reviewed it was.
Do No Harm is a series of scenes from the professional life of a consultant neurosurgeon, a brain surgeon, and, like many other people, I found it utterly compelling reading in a way that I’ve not found any book for a long time. Why sit behind the eyes of constructed phantoms, I find myself thinking, when you can sit behind the eyes of a real flesh and blood human being? (I hope this mood will pass! It’s a bit like being a vicar who suddenly doubts the existence of God.)
As a general rule, I am not very interested in medical matters. Having been brought up by a doctor, I feel I’ve had enough of the whole medical worldview to last me a lifetime. Brain surgery, though, is a particularly pure and existential activity, not only because it involves working with the seat of consciousness itself, but because the decisions and actions of the surgeon, second by second, can have huge life-long consequences both negative and positive. It was this that fascinated me: the business of working in a field where decisions are necessarily probabilistic, and practitioners have to cope with that fact.
In one chapter for instance, Marsh describes the case of a woman who discovers she has an aneurysm (a bulge coming out of a blood vessel, which can burst at any time). She is perfectly fit and well, and the options facing her are (a) doing nothing, and living with the relatively small possibility that the aneurysm may at some point suddenly burst causing a stroke which may lead to death, paralysis, inability to speak, or a vegetative state, or (b) having the aneurysm closed off with a tiny clamp which, if successful, will remove that long-term threat, but carries a small risk of causing a catastrophic haemorrhage which will have any one of the above effects not in the future but immediately. The woman elects to take the risks of surgery, and it pays off. She doesn’t know how close it came to going wrong, when the clamp malfunctioned and refused to detach itself from the instrument used to put it in place. In a lifetime of neurosurgery, Marsh has of course had to deal with many situations where the dice came down the other way: he’s had to go and see patients who’d been functioning perfectly normally who his own interventions have (in his own blunt but completely accurate word) wrecked. He’s had patients thanking him for transforming their lives, but also patients angrily accusing him of negligence and incompetence when things didn’t work out so well. The title, taken from the Hippocratic Oath, is ironic. It is impossible to do no harm.
Marsh is disarmingly frank about the psychology of all this, the manoeuvres he uses to distance himself, the dread he feels at having to face patients and relatives when things have gone badly, the cockiness when things go well. He admits on one occasion to reducing a man to a vegetative state when he went too far on a tumour removal operation (it had been going on for 18 hours!) and that part of his motivation had been to impress a senior. He admits to sometimes carrying out operations that his head says will do no good at all, simply because he can’t face closing off the last avenue of hope for desperate people. Its a very human voice throughout, and often funny, specially about the idiocies of managerialism.
I don’t know whether I possess the intellectual ability necessary for brain surgery, but I know for certain I don’t have the manual dexterity (do they actually test for this, I’ve often wondered: the book doesn’t say!) I also don’t have the steadiness of nerve required to keep on going, without panicking, whether things are going well or not, or the resilience required to live with the memories of all those ‘wrecked’ people, and all those angry grief-stricken loved ones. However, as a child and family social worker and social work manager, I did work for 18 years in a field which was similarly involved in making huge decisions in conditions of uncertainty. No one died, as far as I know, as a result of decisions I played a part in, but there are certainly a lot of people who might have grown up in completely different families if it wasn’t for me. I find that quite haunting enough.
Marsh says somewhere in the book that the hardest part of being a brain surgeon is the fact, per se, of dealing with suffering and death, but the decision-making, the knowledge that however hard you try, there may be bad outcomes for which you will be responsible. I’m put in mind of a quote from Theodore Roosevelt which one of my daughters used to have pinned up on her wall:
“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”
Rather purple prose perhaps, but I think what fascinates about Marsh’s book is the perspective of someone who is, in Roosevelt’s words, “actually in the arena” and therefore necessarily “comes short again and again”.