Admissions

by Henry Marsh

  I wish I were a sea squirt,

  If life became a strain,

  I’d veg out on the nearest rock

  And reabsorb my brain.

  The slow and relentless decline into the vegetative existence that comes with dementia cannot be stopped, although it can sometimes be slowed down. Some cancers in old age can be cured and most can be treated, but only a few of us will be long-term survivors, who then live on to die from something else. And if we are already old, the long term is short.

  We have to choose between probabilities, not certainties, and that is difficult. How probable is it that we will gain how many extra years of life, and what might the quality of those years be, if we submit ourselves to the pain and unpleasantness of treatment? And what is the probability that the treatment will cause severe side effects that outweigh any possible benefits? When we are young it is usually easy to decide – but when we are old, and reaching the end of our likely lifespan? We can choose, at least in theory, but our inbuilt optimism and love of life, our fear of death and the difficulty we have in looking at it steadily, make this very difficult. We inevitably hope that we will be one of the lucky ones, one of the long-term survivors, at the good and not the bad tail-end of the statisticians’ normal distribution. And yet it has been estimated that in the developed world, 75 per cent of our lifetime medical costs are incurred in the last six months of our lives. This is the price of hope, hope which, by the laws of probability, is so often unrealistic. And thus we often end up inflicting both great suffering on ourselves and unsustainable expense on society.

  In every country, health-care costs are spiralling out of control. Unlike our ancestors, who had no choice in these matters, we can – at least in principle – decide when our lives should end. We do not have to undergo treatment to postpone fatal diseases in old age. But if we decide to let nature take its course, and refuse treatment for a fatal disease such as cancer, most of us are still faced with the prospect of dying miserably, as in only a few countries is euthanasia – a good death – allowed. So, if euthanasia is not permitted, we are faced with the choice of dying miserably now, or postponing it for a few months or longer, to die miserably at a later date. Not surprisingly, most of us choose the latter option and undergo treatment, however unpleasant it might be.

  Our fear of death is deeply ingrained. It has been said that our knowledge of our mortality is what distinguishes us from other animals, and is the motive force behind almost all human action and achievement. It is true that elephants can mourn their dead and console each other, but there is no way of knowing whether this means that, in some way, they know that they themselves will die.

  Our ancestors feared death, not just because dying in the past without modern medicine must have been so terrible but also for fear of what might come after death.

  But I do not believe in an afterlife. I am a neurosurgeon. 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 with a near-infinite number of synapses (or however many of them are left as I get older). When my brain dies, ‘I’ will die. ‘I’ am a transient electrochemical dance, made of myriad bits of information; and information, as the physicists tell us, is physical. What those myriad pieces of information, disassembled, will recombine to form after my death, there is no way of knowing. I had once hoped it would be oak leaves and wood. Perhaps now it will be walnut and apple in the cottage garden, if my children choose to scatter my ashes there. So there is no rational reason to fear death. How can you be afraid of nothing? But of course I am still frightened by the prospect. I also greatly resent the fact that I will never know what happened – to my family, my friends, to the human race. But my instinctive fear of death now takes the form of fear of dying, of the indignity of being a helpless patient at the mercy of impersonal doctors and nurses, working shifts in a factory-like hospital, who scarcely know me. Or, even worse, of dying incontinent and demented in a nursing home.

  My mother was a deeply fastidious person. In the last few days of her life, as she lay dying in her bed in her room in the house at Clapham, with its wood-panelled walls and tall, shuttered sash windows that look out on the Common’s trees, she became doubly incontinent. ‘The final indignity,’ she said, not without some rancour, as my sister and I cleaned her. ‘It really is time to go.’

  I doubt if she would have wanted to bring her life to a quick end with a suitable pill if she had been given the choice. She strongly disapproved of suicide. But for myself, I see little merit or virtue in the physical indignity which so often accompanies our last few days or weeks of life, however good the hospice care which a minority of us might be lucky enough to receive. Perhaps I am unrealistic and romantic to hope that in future the law in England will change – that I might be able to die in my own bed, with my family beside me, as my mother did, but quickly and peacefully, truly falling asleep, as the tombstone euphemisms put it, rather than incontinent and gasping with the death rattle – at first demonstrating the O-sign, as doctors call it, of the mouth open but with the tongue not visible, to be followed by the Q-sign, which heralds death, with the furred and dried tongue hanging out.

  For those who believe in an afterlife, must we suffer as we lie dying, if we are to earn our place in heaven? Must the soul undergo a painful birth if it is to survive the body’s death, and then ascend to heaven? Is it yet more magic and bargaining – if we suffer now, we will not suffer in the future? We will not go to hell or linger as unhappy ghosts? Is it cheating, to have a quick and easy death? But I do not believe in an afterlife – my concern is simply to achieve a good death. When the time comes, I want to get it over with. I do not want it to be some prolonged and unpleasant experience, presided over by terminal-care professionals, who derive their own sense of meaning and purpose from my suffering. The only meaning of death is how I live my life now and what I will have to look back upon as I lie dying. If euthanasia is legalized, this question of how we can have a good death, for those of us who want it, with pointless suffering avoided, can be openly discussed, and we can make our own choice, rather than have it imposed upon us. But too often we prefer to avoid these questions, as I did with the poor man at the beginning of my surgical career. It’s as though it is better to die miserably than to admit to the inevitability of death and look it in the face.

  Once again there is an aneurysm to do. I feel anxious, but also proud that I still have such difficult work to perform, that I might fail, that I am still held to account, that I can be of service. Each time I scrub up, I am frightened. Why am I continuing to inflict this on myself, when I know I can abandon neurosurgery at any time? Part of me wants to run away, but I scrub up nevertheless, pull on my surgical gown and gloves and walk up to the operating table. The registrars are opening the patient’s head but I will not be needed yet, so I sit on a stool and lean the back of my head against the wall. I keep my gloved hands in front of my chest with the palms pressed together, as though I were praying – the pose of the surgeon, waiting to operate. Next to me the operating microscope also waits, its long neck folded back on itself, ready to help me. I don’t know for how much longer I will feel able to be of use here, or whether I will return, but it seems I am still wanted.

  It is hot and dusty outside in the city; the rains are late, the air is yellow with dust and pollution. The haze is so bad that even the nearby foothills are hidden. It gets worse every year. As for the celestial, snow-covered Himalayas, it’s almost as though they had never existed. The glaciers are said to be retreating more quickly than in even the gloomiest predictions. It will not be so very long before the rivers run dry.

  As I doze, leaning against the theatre wall, I long to return home. I think of the cottage. I walk around the wild, green garden in my imagination. The buds on the young apple trees, a few millimetres in size, are just starting to open, and I can see the miniature petals, tightly furled in layers of pink and white, starting to appea
r, full of enthusiasm to enter the outside world. It is raining, and the air is wet and smells of spring. The rain forms a million brief circles on the lake, and the two swans are there, looking a little disdainful as always, cruising regally past the reed beds. Perhaps they will make a nest this year among the reeds. I will have made an owl box and put it in the tall willow tree beside the lake. At night I will practise on the owl whistle I recently bought, hoping to persuade an owl to make its home there. The weeds are starting to reclaim the garden again, but I will have used my book of wild flowers and I will have studied them with great care and learnt all their names. Grass is starting to appear between the red bricks that form the floor of the old pigsty which I spent many days clearing, and weeds are growing back between the cobblestones in front of the drinking troughs. Perhaps the rare vine loved by the foragers will be there as well. I will have brought up the beehives from the garden in London, and I can see the bees coming out of the hives to explore their new home and return with bright-yellow pollen on their legs, now that the winter is past. Perhaps I will buy a small boat, and when my granddaughter Iris is a little older, I will take her rowing on the lake. Even better, perhaps I will make the boat myself, if I have been given the time to build my workshop by then, and all my sharpened tools will be neatly hung and stored, and the place will smell of sawn oak and cedar wood. The windows of the workshop will look out over the lake. In summer there are yellow flags and lilies growing at the side of the lake, just beyond the window. And then there is the derelict, ramshackle cottage, to which I will have given a new life. Perhaps the vandals will have finally left it in peace.

  There will be much that needs doing when I return. There will be many things to make or repair, and many things to give or throw away, as I try to establish what I will leave behind. But it seems to me now that it no longer matters if I never finish. I will try not to wait for the end, but I hope to be ready to leave, booted and spurred, when it comes. It is enough that I am well for a little longer, that I have been lucky to be part of a family – past, present and future – that I can still be useful, that there is still work to be done.

  ACKNOWLEDGEMENTS

  It is only when you write a book yourself that you understand just how important and heartfelt are the acknowledgements. Whatever the quality of this book might be, it would have been many times worse without the comments and encouragement of many friends – in particular Robert McCrum, Erica Wagner, Geoffrey Smith, and my brother Laurence Marsh. My excellent agent Julian Alexander was always on hand to provide wise advice and my wonderful editor Bea Hemming transformed a rather chaotic manuscript into what is, I hope, a proper book. Alan Samson, Jenny Lord and Holly Harley at Weidenfeld & Nicolson gave me further help and advice with the manuscript. I am deeply in debt to my patients and colleagues in London, Kiev and Kathmandu and especially to Upendra and Madhu Devkota, whose exceptional hospitality and kindness make my trips to Nepal so rewarding. I am indebted to Catriona Bass who found the lock-keeper’s cottage for me. Most important of all, however, has been the help of my wife Kate, who once again came up with the title and who has been involved in every aspect of the book, as both subject, critic, muse and wife.

  By Henry Marsh

  Do No Harm

  Copyright

  First published in Great Britain in 2017 by Weidenfeld & Nicolson

  This ebook first published in 2017 by Weidenfeld & Nicolson

  an imprint of The Orion Publishing Group Ltd

  Carmelite House, 50 Victoria Embankment

  London EC4Y 0DZ

  An Hachette UK Company

  Copyright © Henry Marsh 2017

  The moral right of Henry Marsh to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act of 1988.

  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of both the copyright owner and the above publisher of this book.

  A CIP catalogue record for this book is available from the British Library.

  ISBN: 978 1 4746 0388 1

  Typeset by Input Data Services Ltd, Bridgwater, Somerset

  www.orionbooks.co.uk