Do No Harm

Do No Harm Plot Summary

Introduction

On a warm Monday in June, Henry Marsh cycled to work carrying a boxful of fruit and chocolates for the theatre staff. He had meticulously selected music for what promised to be a lengthy operation—a dangerously large petro-clival meningioma nestled at the base of a patient's skull. The procedure began in an almost festive spirit, with music playing as the surgical team worked their way through the patient's brain tissue. By midnight, after fifteen hours of operating, Marsh had removed most of the tumor, the patient's cranial nerves still intact. He was beginning to feel that he was joining the ranks of truly great neurosurgeons. But neurosurgery exists in a delicate balance between triumph and tragedy. In pursuing complete removal of the tumor, Marsh tore a small perforating branch off the basilar artery—a catastrophe that left the patient in a permanent coma. This single moment encapsulates the unique burden carried by neurosurgeons: the ability to heal and the power to devastate, sometimes separated by mere millimeters of brain tissue. Throughout his illustrious career spanning over three decades, Marsh's journey illuminates the profound human drama at the heart of brain surgery—where technical mastery meets humility, where life-or-death decisions are made daily, and where even the most skilled hands must acknowledge the limits of medical intervention when confronting the mysterious landscape of the human brain.

Chapter 1: Finding Purpose: From Uncertain Beginnings to Neurosurgery

Henry Marsh did not begin his career with a clear vocation for medicine. Until the age of twenty-one, he followed a path laid out by his privileged English education—studying Politics, Philosophy and Economics at Oxford after years devoted to Latin, Greek, English, and History. With a father who was an eminent human rights lawyer and academic, and a mother who was a German refugee from Nazi Germany, there was little in his family background to suggest a future in medicine, let alone neurosurgery. His path took a dramatic turn when, driven by unrequited love and self-pitying despair, he abandoned university and ran away to work as a hospital porter in a mining town in northern England. For six months, he spent his days lifting patients on and off operating tables, cleaning walls and equipment, and assisting anesthetists. Living in a small room in a semi-derelict old fever hospital with a corrugated iron roof, he was profoundly lonely yet found himself drawn to the controlled environment of surgery. As he later reflected, "I found its controlled and altruistic violence deeply appealing. It seemed to involve excitement and job security, a combination of manual and mental skills, and power and social status as well." After completing his degree at Oxford, Marsh was accepted to study medicine at the Royal Free Medical School—the only medical school in London that took students without scientific qualifications. The interview lasted just five minutes with an elderly, pipe-smoking Scot who told him to see medicine as a form of craft, neither art nor science. Marsh would come to agree with this assessment in later years. The following years saw him gradually progress through his medical education, from the pre-clinical studies of anatomy, physiology, biochemistry, and pharmacology to the clinical work in hospitals. Despite initially choosing surgery, Marsh remained uncertain about his specific path until a pivotal moment eighteen months after qualifying as a doctor. While working as a senior house officer in intensive care, he witnessed a neurosurgeon operate on a woman with a ruptured cerebral aneurysm. Unlike the bloody incisions and slippery body parts of general surgery, this operation was performed with an operating microscope through a small opening in the woman's head using only fine microscopic instruments. The surgeon was cautiously stalking beneath the patient's brain toward the aneurysm, trying not to disturb it before trapping and obliterating it with a titanium clip. The experience was transformative. "The operation was elegant, delicate, dangerous and full of profound meaning," Marsh recalls. "What could be finer, I thought, than to be a neurosurgeon? I had the strange feeling that this was what I had wanted to do all my life, even though it was only now that I had realized it. It was love at first sight." That evening, he announced to his wife that he was going to be a brain surgeon—unaware that his obsession with neurosurgery would eventually contribute to the end of their marriage twenty-five years later.

Chapter 2: The Craft of Brain Surgery: Technical Excellence and Human Error

Brain surgery represents perhaps the most technically demanding of all surgical specialties—requiring not only exceptional manual dexterity and precision but also the ability to make critical decisions under immense pressure. As Marsh describes it, "With a pair of diathermy forceps I coagulate the beautiful and intricate red blood vessels that lie on the brain's shining surface. I cut into it with a small scalpel and make a hole through which I push with a fine sucker—as the brain has the consistency of jelly, a sucker is the brain surgeon's principal tool." Despite modern technological advances like computer navigation systems (Marsh calls it "a form of GPS for brain surgery"), awake surgery, and electrical stimulation methods, neurosurgery remains inherently dangerous. The brain does not come with dotted lines saying "Cut here" or "Don't cut there," and tumors usually look, more or less, like the brain itself. The surgeon must develop an almost intuitive sense of when to continue and when to stop. As Marsh's old boss would say, "If the patient's going to be damaged, I'd rather let God do the damage than do it myself." The technical demands of neurosurgery are matched by the psychological burden it places on surgeons. When operating on aneurysms—balloon-like blow-outs on cerebral arteries that can cause catastrophic hemorrhages—Marsh describes the procedure as "akin to bomb disposal work." If the surgeon ruptures the aneurysm before clipping it, the patient will usually die or suffer a devastating stroke. Such high-stakes situations require what Marsh calls "a delicate tight-rope walking act," made all the worse by constant pressure to get patients in and out of hospital quickly. Yet for all the sophisticated technology and technical skill, human error remains an unavoidable aspect of neurosurgery. Marsh recounts operating on a mountain biker with a simple disc prolapse—a routine procedure he would normally delegate to his juniors. His registrar completely misunderstood the anatomy and severed a nerve root, leaving the patient with a permanently paralyzed ankle and a lifelong limp. "So much for the mountain bike championships," Marsh lamented. Such mistakes haunt surgeons throughout their careers, forming what the French surgeon René Leriche called "a small cemetery, where from time to time he goes to pray." Over decades of practice, Marsh developed his technical skills to a remarkable degree, but also came to appreciate the importance of knowing when not to operate. Early in his career, driven by ambition and hubris, he attempted to completely remove a large tumor at the base of a patient's skull. Despite initially succeeding in removing most of it, he tore a small vessel and the patient never woke up. Years later, he would pass this man's room in a nursing home, seeing his curled-up form, and scarcely recognizing him. The experience taught him crucial lessons about the limits of surgical intervention and the dangers of overconfidence.

Chapter 3: Life and Death Decisions: The Weight of Surgical Responsibility

The burden of responsibility that neurosurgeons carry is unlike that of almost any other profession. They must make decisions that directly determine whether patients live or die, whether they emerge intact or devastated. This weight is something Marsh felt acutely throughout his career, particularly when facing cases that existed in the gray area between intervention and acceptance of mortality. Consider the case of a 32-year-old woman with an unruptured aneurysm discovered by chance. Marsh had to explain that without surgery, the aneurysm might eventually rupture and kill her, but the operation itself carried a 4-5% risk of death or disability. "What would you do if it was you?" she asked—a question that all patients should ask their doctors, but one most are reluctant to pose. Marsh honestly replied that he would not have the aneurysm treated, though he acknowledged the difficulty of living with such knowledge. The woman ultimately chose surgery, placing enormous trust in Marsh despite the risks he had outlined. Perhaps the most agonizing decisions involve patients with terminal conditions. Marsh recounts meeting a young man with recurrent brain cancer who was fully aware of his prognosis. "I know it can't be cured," the patient said bitterly, "but you'll take out as much as you can, won't you? This thing that is slowly doing me in." Marsh agreed to operate, though they both understood it would only buy time. On another occasion, Marsh visited a dying patient at another hospital who had been under his care for twelve years. Despite knowing the end was near, Marsh found himself unable to avoid the conversation: "I could operate again, but it would only get you an extra month or two at best... I have sometimes operated on people in your situation... I usually regretted it." These conversations reveal the profound ethical complexity of neurosurgery. Marsh must balance technical assessment with compassion, honesty with hope. He must resist the temptation to operate when it would only prolong suffering, yet recognize when intervention might genuinely improve quality of life. As he reflects, "With slowly progressive cancers it can be very difficult to know when to stop. The patients and their families become unrealistic and start to think that they can go on being treated forever, that the end will never come, that death can be forever postponed." The responsibility extends beyond the operating room to interactions with patients' families. After a catastrophic error during an operation on a patient with acromegaly, Marsh had to face the family's grief. The patient's wife fell to her knees, begging him to save her husband. Though they ultimately did not blame him—even asking him to remember their loved one in his prayers—Marsh carries these experiences with him: "I remember all my patients who die after operations. I wish I didn't."

Chapter 4: Learning from Failure: Humility in the Face of Complexity

A surgeon's journey is marked as much by failures as by successes, and it is perhaps in how they respond to failure that the true character of a surgeon is revealed. Throughout his career, Marsh experienced numerous devastating outcomes that forced him to confront his limitations and learn painful lessons about humility. One of his most profound failures involved a young Ukrainian girl named Tanya. At eleven years old, she had an enormous tumor at the base of her brain that had been deemed inoperable in both Moscow and Kiev. Rather than telling her mother to take her back home, Marsh arranged for Tanya to come to London for surgery. The first operation took ten hours with terrible blood loss, leaving half the tumor still in place. A second twelve-hour operation resulted in a severe stroke. After spending six months in the hospital, Tanya returned home more disabled than when she left. She died eighteen months later. Reflecting on this case, Marsh questions whether he should have intervened at all: "For the first few years after Tanya's death Katya would send me a Christmas card—coming all the way from Horodok it did not usually reach me until the end of January. I would put it up on my desk in my windowless office in the huge, factory-like hospital where I work. I would leave it there for a few weeks as a sad reminder of Tanya, of surgical ambition and of my failure." Another devastating error occurred when Marsh misdiagnosed a post-operative infection called a subdural empyema. He had never encountered such an infection before and found it impossible to believe that a seemingly successful operation could go so wrong. By the time he recognized the problem, the patient had been left almost completely paralyzed. Years later, during a legal conference about the case, Marsh admitted, "I'm just sorry to have wrecked the poor woman and to have cost you millions of pounds." These failures taught Marsh that neurosurgery demands not just technical skill but also moral courage—the courage to acknowledge mistakes, to face patients and families honestly, and sometimes to admit that nothing more can be done. He recalls how a colleague who operated on his son for a brain tumor once said, "Doctors, I tell my trainees with a laugh, can't suffer enough." Through his own experiences of failure, Marsh came to understand this paradoxical truth: that the suffering caused by mistakes, if faced with honesty and humility, can ultimately make one a better surgeon and a more compassionate human being. This humility extends to recognizing the limits of medical intervention. Marsh became increasingly conservative as he aged, meaning he advised surgery in fewer patients than when he was younger. This wasn't just because of greater experience, but because he became "more willing to accept that it can be better to let somebody die rather than to operate when there is only a very small chance of the person returning to an independent life."

Chapter 5: The Patient's Experience: Fear, Hope and Trust

The world of neurosurgery looks dramatically different from the patient's perspective. While surgeons may see a challenging operation or an interesting pathology, patients face the terrifying prospect of having their most essential organ—the one that houses their very sense of self—cut open and manipulated. Throughout his career, Marsh developed a deep appreciation for this perspective, particularly after becoming a patient himself. When a patient is diagnosed with a brain tumor or aneurysm, they enter what Marsh describes as "a strange world one enters when you fear for your child's life—the outside world, the real world, becomes a ghost world, and the people in it remote and indistinct. The only reality is intense fear, a fear driven by helpless, overwhelming love." This was Marsh's experience when his three-month-old son William was diagnosed with hydrocephalus and a brain tumor. Though the operation was successful and William survived, the experience gave Marsh invaluable insight into the terror patients and their families endure. Later in his career, Marsh himself became a patient after suffering a retinal detachment. Despite his medical knowledge, he found himself experiencing the same anxiety as his patients: "I lay that night in my dark bedroom, my wife Kate beside me as anxious as I was, opening and closing my eye, checking if I could see, wondering if the eye might go blind." After surgery, he reflected, "I had always dreaded becoming a patient yet when, at the age of fifty-six, I eventually did I found it remarkably easy. This was, quite simply, because I realized how lucky I was compared to my own patients—what could be worse than having a brain tumor?" Trust forms the foundation of the surgeon-patient relationship, yet it exists in tension with honest disclosure of risks. Marsh describes the phenomenon of "informed consent" as far more complex in reality than in principle: "Patients are both terrified and ignorant. How are they to know whether the surgeon is competent or not? They will try to overcome their fear by investing the surgeon with superhuman abilities." This dynamic creates a profound responsibility for the surgeon to be honest about risks while not destroying all hope. Perhaps most poignant are the cases where patients place their complete trust in Marsh despite devastating odds. A man with terminal brain cancer tells him, "I trust you," even as they both know the operation can only buy time, not cure. A woman who underwent successful surgery for trigeminal neuralgia returns to his clinic transformed—her face once contorted with pain now radiantly beautiful—and kisses him goodbye, saying, "I hope I never see you again." These moments of connection remind Marsh of the privilege and responsibility of being entrusted with patients' lives.

Chapter 6: Medical Ethics and Healthcare Systems: Navigating Bureaucracy

Behind the drama of individual operations lies a complex system of healthcare delivery that shapes how neurosurgery is practiced. Throughout his career, Marsh witnessed dramatic changes in the National Health Service (NHS) and frequently found himself at odds with the bureaucratic structures that increasingly dominated medical practice. The contrast between public and private healthcare systems is a recurring theme in Marsh's experience. When treating a patient with trigeminal neuralgia in Ukraine, he found himself operating in conditions that would be unthinkable in Britain—using second-hand equipment that he had driven out himself from London, in a hospital with unreliable electricity. Yet despite these limitations, the operation was successful, and the patient appeared on national TV news the next day to say she was pain-free for the first time in many years. Back in Britain, Marsh frequently battled against NHS bureaucracy. He recounts attending a mandatory training session called "MAST Catchup Seminar" where he was instructed about empathy and self-control by "a young man with a background in catering." The irony was not lost on him: "How strange it is, I thought as I listened to him talking, that after thirty years of struggling with death, disaster and countless crises and catastrophes... I should now be listening to a young man with a background in catering telling me that I should develop empathy, keep focused and stay calm." Bed shortages were a constant challenge, forcing difficult decisions about which patients to operate on. Marsh describes the painful ritual of having to apologize to patients whose operations were canceled at the last minute because no post-operative bed was available. The fragmentation of care due to shorter working hours for junior doctors also troubled him: "Shifts have been tried elsewhere and are universally unpopular. It destroys any continuity of care. The doctors will be changing over two or three times every day. The juniors on at night will rarely know any of the patients, nor will the patients know them." Perhaps most challenging was navigating the ethical complexities of resource allocation. As a member of the National Institute of Clinical Excellence (NICE) Technology Appraisal Committee, Marsh participated in decisions about which drugs should be available on the NHS. During one meeting considering an expensive cancer drug, he witnessed the emotional testimony of patients and wrestled with difficult questions: "Surely the real utility of the drug is to give dying patients hope? The hope that they might be statistical outliers and live longer than average? How do you measure the utility of hope?" Despite his frustrations with bureaucracy, Marsh maintained his focus on patient care. When a dying alcoholic patient begged for a cigarette after being told he had only months to live, Marsh arranged for nurses to bend the strict no-smoking rules. This small act of compassion illustrates his belief that humanity must sometimes transcend rigid systems and rules.

Chapter 7: Ukraine and Beyond: Surgery in Challenging Environments

Henry Marsh's professional journey extended far beyond the confines of his London hospital, taking him to some of the most challenging medical environments in the world. His work in Ukraine, which began in 1992 shortly after the collapse of the Soviet Union, revealed both the stark inequalities in global healthcare and the universal aspects of surgical practice. Marsh's first visit to Kiev was almost accidental—an English businessman looking to sell medical equipment had contacted his hospital seeking neurosurgeons to accompany him. Upon arrival, Marsh was shocked by the conditions he encountered. The Neurosurgical Research Institute was a huge building with endless dark corridors, decorated with propaganda from the Soviet era but feeling tired and faded. When he asked to see the operating theaters, he was told they were "being redecorated." The Emergency Hospital he visited was even worse—operating theaters were dark and cavernous, with battered instruments "that looked as though they came from a scrapyard." Amid this bleak landscape, Marsh met Igor Kurilets, a young neurosurgeon who stood out for his honesty about the dire state of Ukrainian healthcare. Unlike his colleagues who maintained the fiction that Ukrainian neurosurgery was world-class, Igor admitted, "Everything terrible here!" Their meeting began a partnership that would span decades, with Marsh returning regularly to Ukraine to perform operations, teach surgical techniques, and bring equipment. The contrast between surgical practice in Ukraine and London highlighted both the technical and ethical challenges of neurosurgery. In 1995, Marsh found himself operating on a woman with trigeminal neuralgia, using second-hand equipment, with television cameras filming for the national news. "I was 2,000 miles from home, operating without any official permission—probably illegally—doing a dangerous operation on a woman's brain never done in the country before," he recalls. Despite these challenges, the operation was successful. Over time, Marsh's Ukrainian work evolved from mere technical assistance to profound cultural exchange. He brought patients like Ludmilla, who had a dangerous brain tumor deemed inoperable in Ukraine, to London for treatment. He drove second-hand medical equipment across Europe, wrote articles for Ukrainian newspapers, and trained Ukrainian doctors in London. His commitment to the country and its people transcended professional obligation, becoming a deeply personal mission. This international perspective gave Marsh insights into how neurosurgery is practiced across different cultural and economic contexts. In America, he observed a more "can-do" attitude but also noted that "we have a commercial health-care system and nobody can afford to admit to making mistakes." In Ukraine, he witnessed how politics and patronage shaped medical practice, with Igor facing official denunciations and threatening phone calls for daring to declare Ukrainian neurosurgery backward. Yet despite these differences, Marsh recognized universal truths about neurosurgery: "Our vulnerability and fear of death when we are patients know no national boundaries, and the need for honesty and kindness from doctors—and the difficulty at times in giving these—is equally universal."

Summary

Henry Marsh's journey through neurosurgery reveals a profound paradox at the heart of medicine: the constant tension between technical mastery and human fallibility. Throughout his career, Marsh operated at the limits of what is surgically possible, saving countless lives through his skill while also witnessing—and sometimes causing—devastating outcomes that changed his understanding of success and failure. His evolution from an ambitious young surgeon seeking technical perfection to a reflective practitioner who recognized when not to operate represents a universal path toward wisdom in the face of human mortality. The ultimate value of Marsh's experience lies not in his technical achievements but in his hard-won humility. "You can't stay pleased with yourself for long in neurosurgery," as one of his colleagues observed. "There's always another disaster waiting round the corner." This perspective offers a powerful lesson for anyone in a position of authority or expertise: acknowledging our limitations and mistakes, however painful, allows us to approach our work with greater compassion and wisdom. For those who will never hold a scalpel, Marsh's journey demonstrates how confronting the fragility of human life—whether as surgeon, patient, or loved one—can deepen our appreciation for each day we have and each connection we make with others in our shared vulnerability.

About Author

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Henry Marsh

Henry Marsh read Politics, Philosophy and Economics at Oxford University before studying medicine at the Royal Free Hospital in London. He became a Fellow of the Royal College of Surgeons in 1984 and was appointed Consultant Neurosurgeon at Atkinson Morley's/St George's Hospital in London in 1987, where he still works full time. He has been the subject of two major documentary films, YOUR LIFE IN THEIR HANDS, which won the ROYAL TELEVISION SOCIETY GOLD MEDAL, and THE ENGLISH SURGEON, featuring his work in the Ukraine, which won an EMMY award. He was made a CBE in 2010. He is married to the anthropologist and writer Kate Fox.His latest book is And Finally, coming after Admissions and Do No Harm.

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