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| Henry Marsh: ‘The mind-matter problem is not a problem for me – mind is matter’ | Henry Marsh: ‘The mind-matter problem is not a problem for me – mind is matter’ |
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| Sun 16 Jul 2017 08.00 BST | |
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| Henry Marsh made the decision to become a neurosurgeon after he had witnessed his three-month-old son survive the complex removal of a brain tumour. For two decades he was the senior consultant in the Atkinson Morley wing at St George’s hospital in London, one of the country’s largest specialist brain surgery units. He pioneered techniques in operating on the brain under local anaesthetic and was the subject of the BBC documentary Your Life in Their Hands. His first book, Do No Harm: Stories of Life, Death, and Brain Surgery, was published in 2014 to great acclaim, and became a bestseller across the world. Marsh retired from full-time work at St George’s in 2015, though he continues with long-standing surgical roles at hospitals in the Ukraine and Nepal. He is also an avid carpenter. Earlier this year he published a second volume of memoir, Admissions: a Life in Brain Surgery, in which he looks back on his career as he takes up a “retirement project” of renovating a decrepit lock-keeper’s cottage near where he grew up in Oxfordshire. He lives with his second wife, the social anthropologist and author Kate Fox. They have homes in Oxford, and in south London, which is where the following conversation took place. | Henry Marsh made the decision to become a neurosurgeon after he had witnessed his three-month-old son survive the complex removal of a brain tumour. For two decades he was the senior consultant in the Atkinson Morley wing at St George’s hospital in London, one of the country’s largest specialist brain surgery units. He pioneered techniques in operating on the brain under local anaesthetic and was the subject of the BBC documentary Your Life in Their Hands. His first book, Do No Harm: Stories of Life, Death, and Brain Surgery, was published in 2014 to great acclaim, and became a bestseller across the world. Marsh retired from full-time work at St George’s in 2015, though he continues with long-standing surgical roles at hospitals in the Ukraine and Nepal. He is also an avid carpenter. Earlier this year he published a second volume of memoir, Admissions: a Life in Brain Surgery, in which he looks back on his career as he takes up a “retirement project” of renovating a decrepit lock-keeper’s cottage near where he grew up in Oxfordshire. He lives with his second wife, the social anthropologist and author Kate Fox. They have homes in Oxford, and in south London, which is where the following conversation took place. |
| Have you officially retired now? Well, I still do one day a week for the NHS, though apparently they want a “business case” for it, so I’m not getting paid at present. | Have you officially retired now? Well, I still do one day a week for the NHS, though apparently they want a “business case” for it, so I’m not getting paid at present. |
| They don’t make it any easier, do they?No. It started when [then health secretary] Ken Clarke introduced that pseudo internal market into health based on a crackpot idea by an American economist. As far as I know there has never been any evidence to justify it at all. | They don’t make it any easier, do they?No. It started when [then health secretary] Ken Clarke introduced that pseudo internal market into health based on a crackpot idea by an American economist. As far as I know there has never been any evidence to justify it at all. |
| Are you starting to feel out of the loop?Not really. I spent the last two weeks out in the Ukraine operating, as I have for years, and I was at St George’s this morning. And then I work in Nepal and elsewhere. Technical progress in neurosurgery is on the whole mainly making neurosurgery redundant, so it’s not as though there are many developments you miss. I could easily step back. But I like to keep up with St George’s because it has been like a family. | Are you starting to feel out of the loop?Not really. I spent the last two weeks out in the Ukraine operating, as I have for years, and I was at St George’s this morning. And then I work in Nepal and elsewhere. Technical progress in neurosurgery is on the whole mainly making neurosurgery redundant, so it’s not as though there are many developments you miss. I could easily step back. But I like to keep up with St George’s because it has been like a family. |
| The writing must keep you engaged. I imagine the impetus for the books was holding on to and making sense of all that experience you gainedI have always written diaries, since I was 12 years old, piles of them. I just thought my poor children would inherit them all. But as a surgeon you do lead an interesting life, and I thought there might be some interest in it. Particularly in neurosurgery – because every day it is not just people’s lives, but their very being that is at risk. | The writing must keep you engaged. I imagine the impetus for the books was holding on to and making sense of all that experience you gainedI have always written diaries, since I was 12 years old, piles of them. I just thought my poor children would inherit them all. But as a surgeon you do lead an interesting life, and I thought there might be some interest in it. Particularly in neurosurgery – because every day it is not just people’s lives, but their very being that is at risk. |
| That comes across in the books as both a practical and a troublingly philosophical question…Yes, well, people talk about the mind-matter problem – it’s not a problem for me: mind is matter. That’s not being reductionist. It is actually elevating matter. We don’t even begin to understand how electrochemistry and nerve cells generate thought and feeling. We have not the first idea. The relation of neurosurgery to neuroscience is a bit like the relationship between plumbing and quantum mechanics. | That comes across in the books as both a practical and a troublingly philosophical question…Yes, well, people talk about the mind-matter problem – it’s not a problem for me: mind is matter. That’s not being reductionist. It is actually elevating matter. We don’t even begin to understand how electrochemistry and nerve cells generate thought and feeling. We have not the first idea. The relation of neurosurgery to neuroscience is a bit like the relationship between plumbing and quantum mechanics. |
| It seems, reading the book, you have become more emotional about your vocation as you have got olderSurgeons on the whole do not talk about the emotional side of the work. It’s rather like if you are applying for medical school – the one thing you can’t say is “I want to help people”. But that is why most of us do become doctors. | It seems, reading the book, you have become more emotional about your vocation as you have got olderSurgeons on the whole do not talk about the emotional side of the work. It’s rather like if you are applying for medical school – the one thing you can’t say is “I want to help people”. But that is why most of us do become doctors. |
| Why is it taboo to admit that? I think we have a very complicated relationships with patients. That is because as soon as we have any interaction with patients, we start lying. We have to. There is nothing more frightening for a patient than an anxious or doubtful doctor. And of course the best way of deceiving others is to deceive oneself. We develop a split consciousness. | Why is it taboo to admit that? I think we have a very complicated relationships with patients. That is because as soon as we have any interaction with patients, we start lying. We have to. There is nothing more frightening for a patient than an anxious or doubtful doctor. And of course the best way of deceiving others is to deceive oneself. We develop a split consciousness. |
| Does the sheer size of the new “centre of excellence” hospitals militate against camaraderie?Very large hospitals have an enormous cost in terms of humanity in my view. It is hard to judge whether there is an overall benefit. Part of it is tied up with the limits on junior doctor hours, too. When I was a junior doctor, you lived in the hospital virtually, and there was a continuity of care. Now with shorter hours, you have a lot of locums, and a patient will get through three doctors in 24 hours. When I go to the States, which I do a lot, the juniors still work 80-plus hours a week. They are proud to work long hours, as I was. It is only if people are demoralised that they resent hard work. | Does the sheer size of the new “centre of excellence” hospitals militate against camaraderie?Very large hospitals have an enormous cost in terms of humanity in my view. It is hard to judge whether there is an overall benefit. Part of it is tied up with the limits on junior doctor hours, too. When I was a junior doctor, you lived in the hospital virtually, and there was a continuity of care. Now with shorter hours, you have a lot of locums, and a patient will get through three doctors in 24 hours. When I go to the States, which I do a lot, the juniors still work 80-plus hours a week. They are proud to work long hours, as I was. It is only if people are demoralised that they resent hard work. |
| It does seem to me increasingly that the two markers of a civilised society are bicycles and doctor-assisted suicide | It does seem to me increasingly that the two markers of a civilised society are bicycles and doctor-assisted suicide |
| The demoralisation, it seems to me, stems from wider inequalities. When you were starting out, I guess doctors might have expected a similar level of reward to lawyers or bankers. Now that idea seems absurd…That’s one reason you lost that feeling you were doing something special. I mean the other thing was that you had this firm, when you began, led by a consultant. If the consultant was a shit then that was a problem, but by and large you had an enormous sense of belonging. It was master and apprentice. All that has been destroyed. | The demoralisation, it seems to me, stems from wider inequalities. When you were starting out, I guess doctors might have expected a similar level of reward to lawyers or bankers. Now that idea seems absurd…That’s one reason you lost that feeling you were doing something special. I mean the other thing was that you had this firm, when you began, led by a consultant. If the consultant was a shit then that was a problem, but by and large you had an enormous sense of belonging. It was master and apprentice. All that has been destroyed. |
| Wilfully so?Yes. I would say wilfully. The European Working Time directive was seized upon by [then health secretary] Virginia Bottomley and health administrators with great enthusiasm because it was a way of diminishing the power of doctors, dumbing them down. It felt like a kind of class warfare. | Wilfully so?Yes. I would say wilfully. The European Working Time directive was seized upon by [then health secretary] Virginia Bottomley and health administrators with great enthusiasm because it was a way of diminishing the power of doctors, dumbing them down. It felt like a kind of class warfare. |
| And that undermined the profession?It did. And then that twat David Cameron started talking about the NHS needing to have a principle of “zero harm”. You can’t have zero harm in a hospital! Every time you operate there is enormous risk of harm. Medicine is never about certainty, it is about the balance of probabilities and risk. And that is why we get it so wrong. We are not grown up enough to discuss that. | And that undermined the profession?It did. And then that twat David Cameron started talking about the NHS needing to have a principle of “zero harm”. You can’t have zero harm in a hospital! Every time you operate there is enormous risk of harm. Medicine is never about certainty, it is about the balance of probabilities and risk. And that is why we get it so wrong. We are not grown up enough to discuss that. |
| That sense is heightened in neurosurgery because the brain doesn’t heal in the way other organs do. You must have worked in the knowledge that every time you operated you might inflict some lasting damage as well as hopefully a cure All neurosurgeons get more conservative as they get older. That is because the disasters slowly accumulate. A 1 or 2% chance of failure doesn’t sound much in theory, but when you have operated for many years, you experience that 1 or 2% for yourself. And when you do, it changes how you think about those risks. | That sense is heightened in neurosurgery because the brain doesn’t heal in the way other organs do. You must have worked in the knowledge that every time you operated you might inflict some lasting damage as well as hopefully a cure All neurosurgeons get more conservative as they get older. That is because the disasters slowly accumulate. A 1 or 2% chance of failure doesn’t sound much in theory, but when you have operated for many years, you experience that 1 or 2% for yourself. And when you do, it changes how you think about those risks. |
| Unavoidably I guess, you confess in the book to a slight paranoia about your own brain health, alert for signs of decay…I do. I generally think it is very important in life to leave too early rather than too late. Whether you are talking about a dinner party or your career. | Unavoidably I guess, you confess in the book to a slight paranoia about your own brain health, alert for signs of decay…I do. I generally think it is very important in life to leave too early rather than too late. Whether you are talking about a dinner party or your career. |
| There has been a slew of books about that old-fashioned idea of what makes “a good death” recently. Do you welcome them?I think Atul Gawande is a very good writer, but I didn’t get on with his book Being Mortal that much. He only very grudgingly says that maybe doctor-assisted suicide is a good idea. I am a great proponent, to the extent I feel I would take it up myself – though you never know, when push comes to shove, what you will decide. But it does seem to me increasingly that the two markers of a civilised society are bicycles and doctor-assisted suicide. It is not about licensing doctors to kill people. It is about allowing everyone with mental capacity to make a choice about how they would like to end. | There has been a slew of books about that old-fashioned idea of what makes “a good death” recently. Do you welcome them?I think Atul Gawande is a very good writer, but I didn’t get on with his book Being Mortal that much. He only very grudgingly says that maybe doctor-assisted suicide is a good idea. I am a great proponent, to the extent I feel I would take it up myself – though you never know, when push comes to shove, what you will decide. But it does seem to me increasingly that the two markers of a civilised society are bicycles and doctor-assisted suicide. It is not about licensing doctors to kill people. It is about allowing everyone with mental capacity to make a choice about how they would like to end. |
| I guess religion still partly gets in the way of that ideaIt seems to me that the only rational case for theism is that God is a complete bastard. I have seen a lot of children die with inoperable brain tumours, particularly one horrible one called a diffuse intrinsic pontine glioma, for which there is no treatment. When I go out to Ukraine their parents are lining up to see me in the hope of a miracle. It just seems the proof for God is so very thin. “There’s a friend for little children above the bright blue sky.” I mean, really? | I guess religion still partly gets in the way of that ideaIt seems to me that the only rational case for theism is that God is a complete bastard. I have seen a lot of children die with inoperable brain tumours, particularly one horrible one called a diffuse intrinsic pontine glioma, for which there is no treatment. When I go out to Ukraine their parents are lining up to see me in the hope of a miracle. It just seems the proof for God is so very thin. “There’s a friend for little children above the bright blue sky.” I mean, really? |
| You are perhaps lucky in that you must feel that yours has been a meaningful life, though…It’s true, you rarely go home at night wondering about the value of what you do. But really doctors are a means to an end, to allow other people to lead productive and interesting lives. | You are perhaps lucky in that you must feel that yours has been a meaningful life, though…It’s true, you rarely go home at night wondering about the value of what you do. But really doctors are a means to an end, to allow other people to lead productive and interesting lives. |
| I enjoyed reading about your escape from the day job, into your cottage renovation project. Are you still doing it all yourself? I have made all the windows and staircases now, but to my wife’s relief I am also employing someone. In my first book there is a chapter about a bloke who was a plumber who had a difficult brain tumour. I was reluctant to operate. But he insisted I do it; it went OK until right at the end when he had this bleed from the artery that keeps the brain stem alive and I was convinced I had killed him. But he survived. God knows how. I had prepared myself for weeks of misery seeing him in a coma on the ward. Anyway, he lives only up the road from the cottage I am renovating so he is working on the plumbing, which is nice. I’m paying him, obviously. He’s a lovely guy. | I enjoyed reading about your escape from the day job, into your cottage renovation project. Are you still doing it all yourself? I have made all the windows and staircases now, but to my wife’s relief I am also employing someone. In my first book there is a chapter about a bloke who was a plumber who had a difficult brain tumour. I was reluctant to operate. But he insisted I do it; it went OK until right at the end when he had this bleed from the artery that keeps the brain stem alive and I was convinced I had killed him. But he survived. God knows how. I had prepared myself for weeks of misery seeing him in a coma on the ward. Anyway, he lives only up the road from the cottage I am renovating so he is working on the plumbing, which is nice. I’m paying him, obviously. He’s a lovely guy. |
| Your woodworking is much more than a hobby?It’s an obsession. In some ways, it is more demanding than surgery because wood doesn’t heal. It’s all down to you. | Your woodworking is much more than a hobby?It’s an obsession. In some ways, it is more demanding than surgery because wood doesn’t heal. It’s all down to you. |
| Are there things you have made that you couldn’t improve on?I made one chest that I was very proud of. There’s a Zen thing about woodworking; my default position, whether it’s talking to patients or operating or woodwork, is that I could always do better. | Are there things you have made that you couldn’t improve on?I made one chest that I was very proud of. There’s a Zen thing about woodworking; my default position, whether it’s talking to patients or operating or woodwork, is that I could always do better. |
| Has that self-critical habit always been as strong?I think there was a period where I was too self-confident and pleased with myself. In the years before I got divorced, actually. The divorce had a therapeutic effect on me. My first wife behaved badly and I did as well. We were both very silly and she was right to end the marriage. I don’t regret it, but it was extremely painful. The thing about that is that when you know you have failed and been stupid, you immediately stop judging other people. You have been there yourself. No one is immune from stupidity. | Has that self-critical habit always been as strong?I think there was a period where I was too self-confident and pleased with myself. In the years before I got divorced, actually. The divorce had a therapeutic effect on me. My first wife behaved badly and I did as well. We were both very silly and she was right to end the marriage. I don’t regret it, but it was extremely painful. The thing about that is that when you know you have failed and been stupid, you immediately stop judging other people. You have been there yourself. No one is immune from stupidity. |
| You teach young doctors now; is that one of the lessons you try to convey?I spend most of my time trying to get them to think, not narrowly about scans but about the patient’s whole situation: “If that was your father what would you do?’ It is difficult because really engaging with patients is emotionally exhausting. As my career went on I tried to see fewer patients and spend longer with them and do all the follow-up myself. I had the same secretary for 30 years who helped with that, so we really tried to run an old-fashioned practice | You teach young doctors now; is that one of the lessons you try to convey?I spend most of my time trying to get them to think, not narrowly about scans but about the patient’s whole situation: “If that was your father what would you do?’ It is difficult because really engaging with patients is emotionally exhausting. As my career went on I tried to see fewer patients and spend longer with them and do all the follow-up myself. I had the same secretary for 30 years who helped with that, so we really tried to run an old-fashioned practice |
| You created a garden for your patients at St George’s – why?Because these big hospitals are horrible places really – the very last thing you get in an English hospital is peace, rest or quiet, which are the things you need most. The unique thing about the garden at St George’s is that it was directly outside the ward. In the summer I tried to get all the patients outside, with their families. It is probably the thing I am proudest of. | You created a garden for your patients at St George’s – why?Because these big hospitals are horrible places really – the very last thing you get in an English hospital is peace, rest or quiet, which are the things you need most. The unique thing about the garden at St George’s is that it was directly outside the ward. In the summer I tried to get all the patients outside, with their families. It is probably the thing I am proudest of. |
| You clearly left the NHS dispirited. Can you see grounds for optimism?I am afraid I don’t. Politicians seem unable to stand up to the public and say: if you want better health care you are going to have to pay for it. Instead they still say it is all about management and reorganisation. The evidence is clearly out there in the other wealthy European countries, though: we spend far less on healthcare in both absolute and per capita terms than they do, and almost across the board you see that in the relative outcomes. | You clearly left the NHS dispirited. Can you see grounds for optimism?I am afraid I don’t. Politicians seem unable to stand up to the public and say: if you want better health care you are going to have to pay for it. Instead they still say it is all about management and reorganisation. The evidence is clearly out there in the other wealthy European countries, though: we spend far less on healthcare in both absolute and per capita terms than they do, and almost across the board you see that in the relative outcomes. |
| Have the powers that be reached out to tap you for your four decades of wisdom?No. Never. I was on Newsnight once with Jeremy Hunt and Andy Burnham, before the 2015 election. Hunt came up to me afterwards and said, will you help me with whatever? I said of course I would. Obviously, I never heard from him again. | Have the powers that be reached out to tap you for your four decades of wisdom?No. Never. I was on Newsnight once with Jeremy Hunt and Andy Burnham, before the 2015 election. Hunt came up to me afterwards and said, will you help me with whatever? I said of course I would. Obviously, I never heard from him again. |
| • Admissions: A Life in Brain Surgery by Henry Marsh is published by Weidenfeld & Nicolson, £16.99. To order a copy for £14.44 go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99 | • Admissions: A Life in Brain Surgery by Henry Marsh is published by Weidenfeld & Nicolson, £16.99. To order a copy for £14.44 go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99 |
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