Renowned British physician Henry Marsh was one of the first neurosurgeons in England to perform certain brain surgeries using only local anesthesia. For over 30 years, he also made frequent trips to Ukraine, where he performed surgery and worked to reform and update the medical system.
As a surgeon, Marsh felt a certain level of detachment in hospitals — until he was diagnosed with advanced prostate cancer at age 70. Though he continued working after his diagnosis, it was sobering to interact with the hospital as both a doctor and a patient.
"I was much less self-assured now that I was a patient myself," he says. "I suddenly felt much less certain about how I'd been [as a doctor], how I'd handled patients, how I'd spoken to them."
In the memoir, And Finally, Marsh opens up about his experiences as a cancer patient — and reflects on why his diagnosis happened at such an advanced stage.
"I think many doctors live in this sort of limbo of 'us and them,' " he says. "Illness happens to patients, not to doctors. Anecdotally, I'm told that many doctors present with their cancers very late, as I did. ... I denied my symptoms for months, if not for years."
Marsh's cancer is in remission now, but there's a 75% chance that it will return in the next five years. It's an uncertainty that Marsh has learned to accept.
"For the last few weeks I've been in this wonderful Buddhist Zen-like state," he says. "At the moment, I'm really very, very happy to be alive. But that's really only possible because I've had a very complete life and I have a very close and loving family and those are the things that matter in life."
On seeing his own brain scan, and being shocked at its signs of age
It was the beginning of my having to accept I was getting old, accept I was becoming more like a patient than a doctor, that I wasn't immune to the decay and aging and illnesses I've been seeing in my patients for the previous 40 years. So it was actually terribly frightening looking at the scan, crossing a threshold, and I've never dared to look at it again. It was just too upsetting. In retrospect, it probably wasn't that big a deal. Probably, if I had seen that scan at work, I'd have said, "Well, that's a typical 70-year-old brain scan."
On continuing to work in the hospital after being diagnosed with cancer
As a doctor, you're not emotionally engaged in any way. You look at brain scans, you hear terrible, tragic stories and you feel nothing, really, on the whole, you're totally detached. But what I found was when I was at some teaching meetings and they would see scans of a man with prostate cancer which had spread to the spine and was causing paralysis, I'd feel a cold clutch of fear in my heart. ... I'd never felt anxious going into hospitals before, because I was detached. I was a doctor. Illness happens to patients, not to doctors.
On getting diagnosed at age 70, and feeling his life was complete
We all want to go on living. The wish to go on living is very, very deep. I have a loving family. I have four grandchildren who I dote on. I'm very busy. I'm still lecturing and teaching. I have a workshop. I'm making things all the time. There are lots of things I want to go on doing, so I'd like to have a future. But I felt very strongly as the diagnosis sunk in that I'd really been very lucky. I'd reached 70. I had a really exciting life. There are many things I was ashamed of and regretted, but I like the word "complete." Obviously, for my wife's sake, my family's sake they want me to live longer and I want to live longer. But purely for myself, I think how lucky I've been and how often approaching the end of your life can be difficult if there's lots of unresolved problems or difficult relationships which haven't been sorted out. So in that sense, I'm ready to die. Obviously, I don't want to, not yet, but I'm kind of reconciled to it.
On not fearing death, but fearing the suffering before death
I hate hospitals, always have. They're horrible places, though I spent most of my life working in them. It's not really death itself [I fear].
I know, as a doctor, that dying can be very unpleasant. I'm a fiercely independent person. I don't like being out of control. I don't like being dependent upon other people. I will not like being disabled and withering away with terminal illness. I might accept it, I don't know. You never know until it happens to you. And I know from both family and friends and patients, it's amazing what one can come to accept when you know your earlier self would throw up his or her hands in horror. So I don't know. But I would like the option of assisted dying if my end looks like it would be rather unpleasant.
On why he supports medically assisted death
Medical law in England [is that it] is murder to help somebody kill themselves. It's ridiculous, is the short answer. Suicide is not illegal, so you have to provide some pretty good reasons why it is illegal to help somebody do something which is not illegal and which is perfectly legal. And opinion polls in Britain always show a huge majority, 78%, want the law to be changed. But there's a very impassioned, dare I say it, fanatical group — mainly palliative care doctors — who are deeply opposed to it. And they've got the ear of members of parliament.
They argue that assisted dying will lead to coercion of what they call vulnerable people. You know, old, lonely people will be somehow bullied by greedy relatives or cruel doctors and nurses into asking for help in killing themselves. But there's no evidence this is happening in the many countries where assisted dying is possible, because you have lots of legal safeguards. It's not suicide on request. You can make the safeguards as strong as you like: You have to apply more than once in writing, with a delay. You have to be seen by independent doctors who will make sure you're not being coerced or you're not clinically depressed. So it's only a very small number of people who opt for it, but it does seem to work reasonably well without terrible problems in countries where it's legal. And there's no question of the fact, even despite good palliative care — although some palliative care doctors deny this — dying can be very unpleasant, both not so much physically as the loss of dignity and autonomy, which is the prospect that troubles me.
On knowing when it was time to stop doing surgery
I stopped working full time and basically operating in England when I was 65, although I worked a lot in Kathmandu and Nepal and also, of course, in Ukraine. And what I always felt as a matter of principle, it's best to leave too early rather than too late. As in anything in life, whether it's a dinner party or your professional life itself, it's best to leave too early rather than too late. To be honest, I was getting increasingly frustrated at work. I mean, I'm a great believer in the British National Health Service, but it's become increasingly bureaucratic. And psychologically, I was becoming less and less suited to working in a very managerial bureaucratic environment. I'm a bit of a maverick loose cannon. Also, I felt it's time for the next generation to take over. And I had become reasonably good at the operations I did. I didn't think I was getting any better. And I had a very good trainee who could take over from me and had actually taken things forward, and particularly in the awake craniotomy practice, he's doing much better things than I could have done. So it felt like a good time to go in that regard.
What really surprises me now is I don't miss it at all. I was completely addicted to operating, like most surgeons. The more dangerous, the more difficult the operation, the more I wanted to do it, the whole risk and excitement thing. One of the most difficult parts of surgery is learning when not to operate. But much to my surprise, I don't miss it — and I don't quite understand that. But I'm very glad. In a funny sort of way, I feel like a more complete human being now that I'm no longer a surgeon. I no longer have a terrible split in my world view between me — and the medical system and my medical colleagues, that is — and patients. So I feel a more whole person.
Thea Chaloner and Joel Wolfram produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the web.
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. My guest, Henry Marsh, is a renowned British neurosurgeon who was awarded a CBE by the queen for services to medicine in the U.K. and Ukraine. For over 30 years, he's been making frequent trips to Ukraine, performing surgery, teaching and trying to reform and update the medical system. His work in Ukraine was the subject of an award-winning documentary called "The English Surgeon." In England, he was one of the first neurosurgeons to perform certain brain surgeries using only local anesthesia, enabling the patient to remain awake and provide feedback in real time about how the surgery was affecting the brain. Dr. Marsh's new memoir is about retiring from surgery and soon after becoming a patient himself, diagnosed with advanced prostate cancer. He shares his reflections on what it was like to walk into the hospital as a member of the, quote, "underclass of patients" and no longer a, quote, "self-important surgeon."
As a patient, he was sometimes haunted by the way he sometimes treated his own patients. His illness led to sobering thoughts about doctor-patient relationships, aging, death, medically assisted suicide and how to best live his remaining time. He's in remission now, but there's a 75% chance of the cancer returning in the next five years. His new memoir is called "And Finally: Matters Of Life And Death." It begins with the time, just 20 months before the cancer diagnosis, when he participated as one of the subjects in a study of brain scans of healthy people. He thought his brain scan would look pretty good. He was in despair when it showed his 70-year-old brain was relatively shrunken and withered.
Dr. Marsh, welcome back to FRESH AIR. I am so glad that you remain in remission.
HENRY MARSH: Well, thank you very much. It's very nice to talk to you again after a few years.
GROSS: You know, you write, rarely did I think about what it would be like when what I witnessed at work every day happened to me. Why didn't you think about that? I know every time I walk into a hospital to visit a friend or, you know, a loved one, I worry about them, and I worry what it will be like when I'm in the hospital 'cause it seems inevitable everyone's going to be hospitalized at some point. So why didn't you think about that?
MARSH: Because I think almost all doctors, you develop this pretty profound separation and detachment from patients. To a certain extent, you have to do that to do the work. If you got deeply emotionally involved with every patient, particularly if you do a very dangerous surgery, as I did, you wouldn't be able to do it. And also, you learn right from the get-go that the most frightening thing for a patient is a frightened doctor. And you often are anxious 'cause that's the nature of the work. And you therefore have to pretend and deceive to a certain extent to radiate confidence and certainty when, actually, inwardly you don't feel that. And of course, the best way of deceiving other people is to deceive yourself. So I think many doctors live in this sort of limbo of the us and them. The illness happens to patients, not to doctors. Anecdotally, I'm told that many doctors present their cancers very late, as I did, and I denied - at a very deep, unconscious level, I denied my symptoms for months, if not for years.
GROSS: Why did you deny them? I mean, you had problematic symptoms, like increased urgency and frequency of urination, difficult flow. But so many older men have that 'cause their prostate gets enlarged.
MARSH: Yes. You ought to get it investigated to exclude cancer. And a combination of fear and reluctance to sort of cross over to the other side of the road and become a patient myself, men turn a blind eye to it. And, I mean, a lot of people do that with all sorts of things. You know, it's a sort of - in medical language, it's called hysterical dissociation or cognitive dissonance. You know it's a serious problem, but part of you dismisses it.
GROSS: You had to break the news to many patients that they had tumors or cancers of some sort. How did the doctors break the news to you that you had advanced prostate cancer?
MARSH: Well, it was over the phone by a colleague of mine who I know quite well. And he just said, your PSA is 130. I'm referring you to an oncologist.
GROSS: So if you're in the 130s in your PSA, what's considered normal?
MARSH: Oh, less than one (laughter). And most men with cancer will have one of 20 or 30, something like that. So mine is sky high. And then I saw an oncologist. But I was very struck - as I say in the book, I felt completely tongue-tied, and partly 'cause I was terribly reluctant to sort of throw my weight around and say, they must have known who I was. You know, I'm a very famous surgeon; I'm a well-known writer. So instead, I went to the other extreme of really saying very little. I wasn't sort of blurting out, like, you know, more or less, how long have I got? And of course, he doesn't know. No doctor knows. It's all about probabilities. So most of the information I learned for myself by Googling it, as we all do, which, of course, is a very frightening experience.
GROSS: You write that you gave your doctors mixed messages. You told them you want to know the truth, but you also want to be given hope.
MARSH: Yes, I think so. I think I was very confused. I mean, I had two surprises when I was diagnosed with cancer. I wasn't particularly surprised at what it was like to be a patient. I'd been a patient before. My wife is an anthropologist and has Crohn's disease and has often been in hospital. She's a trained observer of people. And, you know, she made it clear to me - which I hadn't really appreciated until I met her. We've been together 24 years. You know, the last thing you get in hospital is peace, rest or quiet. And there are many similarities between being in a hospital and being in prison. And the other point was my son, when he was 3 months old, 40 years ago, almost died from a brain tumor. He was saved by a wonderful surgeon. So I had some personal experience.
But what did surprise me was, firstly, the fact that I was shocked (laughter) that I had cancer, which is ridiculous. You know, I'd been dealing with patients with cancer all my life. And secondly, when I went through a very difficult period for the first few weeks, when I didn't know if I had widespread disease or not, and I suddenly found I was remembering all sorts of patients I'd completely forgotten. It was as though all my patients had came back as ghosts. They weren't exactly accusatory, but I suddenly felt much less certain about how I'd been, how I'd handled patients, how I'd spoken to them. I hope I wasn't too bad. But I was much less self-assured when I was a patient myself.
GROSS: You spent time after you were diagnosed going to neurosurgery meetings, as opposed to consult. And you write that you were divided between being a doctor and being a patient. Can you describe both points of view at those meetings that you were experiencing in your mind?
MARSH: Well, when you - when you're - as a doctor, you're not emotionally engaged in any way. You look at brain scans. You hear terrible, tragic stories, and it doesn't actually - you feel nothing, really, on the whole. You're totally detached. But what I found was - and I was at some teaching meetings, and they would see scans of a man with prostate cancer which had spread to the spine and was causing paralysis, you know, I'd feel a sort of cold clutch of fear at my heart, rather like you saying when you go into a hospital, you - it fills you with anxiety. You know, I'd never felt anxious going into hospitals before because I was detached. I was a doctor. Illness happens to patients, not to doctors. And I would sort of - emotionally, I'd learned otherwise.
GROSS: So you were diagnosed at the age of 70, and you felt your life was kind of complete. Does that mean you were willing to have it end?
MARSH: In a sense, yes. I mean, we all want to go on living. You know, the wish to go on living is very, very deep. I have a loving family. I have four grandchildren I dote on. I'm very busy. I'm still lecturing and teaching. I have a workshop. I'm making things all the time. So there are lots of things that I wanted to go on doing. So I'd like to have a future. But I felt very strongly as the diagnosis sunk in that I'd really been very lucky, you know? I had reached 70. I had a really exciting life. There are many things I was slightly ashamed of and regretted, but I really - the word complete. I like the word complete. Obviously, for my wife's sake, for my family's sake, they want me to live longer. And I want to live longer. But purely for myself, I think how lucky I've been and how often approaching the end of your life can be difficult if there's sort of lots of unresolved problems or difficult relationships which haven't been sorted out. So in that sense, I'm ready to die. Obviously, I don't want to, not yet, but I'm kind of reconciled to it.
GROSS: Let me reintroduce you here. If you're just joining us, my guest is retired British neurosurgeon Henry Marsh. His new memoir is called "And Finally: Matters Of Life And Death." We'll be right back after a short break. This is FRESH AIR.
(SOUNDBITE OF GILAD HEKSELMAN'S "DO RE MI FA SOL")
GROSS: This is FRESH AIR. Let's get back to my interview with British neurosurgeon Henry Marsh. His new memoir, "And Finally: Matters Of Life And Death," is about the experience of being the patient, not the surgeon, after he was diagnosed with advanced prostate cancer.
After the diagnosis, you experienced wave after wave of anxiety and despair.
MARSH: In the initial stages, yes.
GROSS: Yeah. And there was a period where you wanted to just get it over with and die because you were afraid of dying (laughter).
MARSH: Yes, which is just ridiculous.
GROSS: Yeah. But was it fear of dying or fear of suffering before dying?
MARSH: It was fear of suffering before dying, and of, you know, lingering on, being in a hospital bed. And I hate hospitals, always have done. I think they're horrible places, even though I spent most of my life working in them. No, it's really - death itself holds no fears for me at all, as far as - I love the famous 18th century philosopher David Hume, who on his deathbed was asked, aren't you terribly worried about what will happen after death? And he said, no, I'm no more worried about not existing after death than I'm worried about not existing before I was born. And that is my view about death. I don't believe in an afterlife. But I know, as a doctor, that dying can be very unpleasant.
I'm a fiercely independent person. I hate - I don't like being out of control. I don't like being dependent upon other people. I will not like, you know, being disabled and withering away with terminal illness. I might accept it, you know? I don't know. You never know until it happens to you. And I know from both family and friends and patients it's amazing what one can come to accept when, you know, your earlier self would throw up his or her hands in horror. So I don't know. But I would like the option of assisted dying if my end looks like it would be rather unpleasant.
GROSS: Well, you actually have, basically, a suicide go bag with medication in it.
MARSH: Yes, I do. I do, yes.
GROSS: Can I ask what's in that bag, what the medication is?
MARSH: It's opiates, which I obtained entirely legally. And I'm not going to say how. But my worry is they might not work, or I might vomit them up, which is why in the book I say I have spoken to a medical friend. And he has promised to provide backup if necessary. Obviously, both of us very much hope it won't be necessary.
GROSS: Would that be legal, if your doctor friend helped you?
MARSH: No. It would be totally illegal. That would be classed as murder.
GROSS: Yeah. What is the law in England about medical - yeah.
MARSH: The law in England is it is murder to help somebody kill themselves.
GROSS: What are your thoughts about that?
MARSH: Oh, it's ridiculous (laughter) is the short answer. Suicide is not illegal. So you have to provide some pretty good reasons why it is illegal to help somebody do something which is not illegal, you know, which is perfectly legal. And opinion polls in Britain only show a huge majority, 70, 80%, want the law to be changed. But there's a very impassioned, dare I say, fanatical group, mainly of palliative care doctors, who are deeply opposed to it. And they've got the ear of members of parliament.
They argue that assisted dying will lead to coercion. Or what they call vulnerable people, you know, old, lonely people, will be sort of somehow bullied by greedy relatives or cruel doctors and nurses to asking for help in killing themselves. But there's no evidence this is happening in the many countries where assisted dying is possible because you have lots of legal safeguards. It's not suicide on request. You have to make - you know, you can make the safeguards as strong as you like. But you have to apply more than once in writing with a delay. You have to be seen by independent doctors who will make sure you're not being coerced or you're not clinically depressed.
So it's only a very small number of people who opt for it. But it does seem to work reasonably well without terrible problems in countries where it's legal. And there's no question of the fact, even despite good palliative care - although, some palliative care doctors deny this - dying can be very unpleasant both - not so much physically. It's the loss of dignity and autonomy, which is the prospect that troubles me.
GROSS: Through your concerns about getting older and the possibility of dying sooner than you'd like because of the prostate cancer, you had no wish to be young again. Why not?
MARSH: Now I don't. I was such a complete twit, a prune, whatever...
MARSH: ...Whatever the American word would be. I was totally out of control. I didn't understand my emotions. I'm a very emotional person. And I think many people, as we get older, we learn a lot. We calm down a bit. And I'm really - I've been on hormone therapy, which is chemical castration by another name. It's bearable but unpleasant. I've now stopped it. I may have to go back on it (laughter). I don't want to. But what I hadn't realized, really - I mean, depression and fatigue are common side effects. But you kind of get used to it. I wasn't used to the fatigue and the muscle weakness. You lose muscle when you haven't got testosterone. But I was actually pretty fed up. And I thought that was just because I was unhappy about having cancer.
But there's been this huge change in my mood since, I assume, my testosterone levels are on the way up. And I never thought - I'm basically a very anxious, driven person, was always trying to achieve, worrying about the future. And for the last few weeks, I've been in this wonderful, Buddhist, Zen-like state. I know I've got this PSA test in three weeks' time, which may very well be bad news, but I don't mind. I think, well, that's three weeks away. You know, the future doesn't exist yet. And this is not denial. This is just, to my complete surprise, learning to live in the present and make the most of it. So at the moment, I'm really very, very happy to be alive. But that's really only possible because I've had a very complete life and I have a very close and loving family. And those are the things that matter in life.
GROSS: But it sounds like you're also attributing that, in part, to your raising testosterone levels 'cause you're no longer on the thing that blocks testosterone.
MARSH: And it's one of the things I discuss in the book is this mystery of mind and matter. I mean, I, like anybody - almost anybody who understands a bit of neuroscience - I think our brains are physical systems obeying the laws of physics. So, you know, how much of my mood is somehow learning and experience and wisdom, how much better hormones? There's no way of telling. And ultimately, thought and feeling and your mood are all chemical - electrochemical processes, as well. And we just didn't understand any of this. And I find that immensely fascinating.
GROSS: Has the treatment of blocking your testosterone and then stopping that treatment and allowing your testosterone to return, has that made you think a lot about gender and the biology of gender?
MARSH: Not really, no. I mean, you lose all libido, all interest in sex. You become impotent. Your genitalia shrink a bit. You put on weight. I acquired a little eunuch's paunch, which I didn't like at all. Didn't like looking at myself in the mirror. But no - but again, I'm now - I'm going to be 73 in a few weeks' time. You know, sex is not a very important part of my life now and I don't miss it. In some ways, if my - I think my libido might be returning a bit, I don't really want it, you know? I want my muscle strength back. And I'm doing - I'm running a lot more now and I'm getting fitter. But, you know, sex, that's in the past now, as far as I'm concerned.
GROSS: When you were diagnosed with cancer, you had this period of, like, really, like, wanting to die and get it over with. You realized that was because you were afraid of dying and you realized that's ridiculous. And then - but still, you had a lot of anxiety and fear, although now it sounds like you're pretty much trying to live in the present and...
MARSH: I'm succeeding.
GROSS: ...Succeeding. Yeah.
MARSH: I'm succeeding. I don't know for how long, but the present's enough.
GROSS: I want to compare that to the experience of profound depression that you experienced in college. You ended up dropping out of college. There was a period when you were in a mental health institution to deal with the depression. Did you have thoughts - 'cause I know now you strongly believe in medically assisted hastening of death. How close did you come to trying to end your life?
MARSH: Quite close. Quite - I sort of - I won't go into details, but I came quite close to it. I don't think I actually would have done. It was a sort of cry for help, which I blocked off and ran away rather than seek help. I sort of rushed off and abandoned my degree at Oxford University. But when I came back after a year, then I did seek help. And it was extreme - I saw a psychiatrist, was admitted briefly. And it made me a profound believer in the helpfulness of psychiatry and the fact we all - not many people don't have mental health problems at some point in their life. And as with all problems in life, they're best admitted to and approached and not blocked off and hidden. And a large part of my medical lecturing now to medical students and young doctors is about how to cope with mistakes, how to cope with things going badly, how to be a good colleague, you know, which is really terribly important, both for patient outcomes and for your own sanity.
GROSS: Did your experiences with suicidal thinking affect at all your thoughts about medically assisted hastening of death?
MARSH: No, no, it - I know it's a debate, particularly going on in Canada. In Holland and Belgium, you can have assisted suicide on the grounds of a purely psychiatric diagnosis. I think the arguments are quite strong. But practically speaking, I would not want to see legislation in England which permitted assisted dying for a purely psychiatric diagnosis 'cause I think it's too complicated, it's too fraught. Even though, that having been said, given the mind-matter problem, the dividing line between psychiatric illness and physical illness is very difficult, just like the dividing line between my low testosterone and, you know, acquiring a Zen, Buddhist wisdom about living in the present.
GROSS: Well, let me reintroduce you again. If you're just joining us, my guest is Dr. Henry Marsh. His new memoir is called "And Finally: Matters Of Life And Death." And it's about the change in his life when he went from neurosurgeon to patient after being diagnosed with advanced prostate cancer. We'll be right back after a short break. I'm Terry Gross, and this is FRESH AIR.
(SOUNDBITE OF STEFON HARRIS AND BLACKOUT'S "UNTIL")
GROSS: This is FRESH AIR. I am Terry Gross. Let's get back to my interview with retired British neurosurgeon Henry Marsh. His new memoir, "And Finally: Matters Of Life And Death," is about the experience of being the patient, not the surgeon, after he was diagnosed with advanced prostate cancer. He shares his reflections on doctor-patient relationships, aging, death, medically assisted dying, and how to best live his remaining time. He admits that in retrospect, he regrets how he treated some of his patients. For over 30 years, he's made many trips to Ukraine - performing surgery, teaching and trying to help reform and update the medical system. His work in Ukraine was the subject of the Emmy Award-winning documentary "The English Surgeon."
So I want to ask you about your work in Ukraine. You started doing it shortly after the collapse of the Soviet Union. Why did you want to do medical work in Ukraine?
MARSH: Well, I went to - I was taken out to Kyiv by an English businessman who was trying to sell medical equipment in the newly independent Ukraine. And there was a big, famous neurosurgical hospital in Kiev (ph), as it was called then. And he thought if he got an English neurosurgeon to give some lectures, it would kind of create goodwill.
It so happened I - when I was at Oxford University, before I had read - studied medicine, I had studied politics and economics and philosophy. And I had specialized in Soviet politics 'cause I was very interested in totalitarian politics probably because my mother was German and a political refugee from Nazi Germany. She had to leave in a rush 'cause the Gestapo, the secret police, were after her. So I was kind of - would have been a criminologist, if I hadn't had my sort of nervous breakdown halfway through my Oxford degree and decided I'd become a doctor, though I did then complete my Oxford degree. And I was totally horrified by the medical conditions I found in Ukraine.
First of all, they were 50 years out of date anyway. Secondly, because of the economic disruption with the fall, or disintegration, of the Soviet economy, the hospitals were in a ghastly state. And I met a very dynamic, young neurosurgeon. And to cut a long story short, he got permission to come and work with me in London. He did for three months. He studied incredibly hard. And after that, I said to him, well, look, you know, I'm willing to come out to Ukraine once or twice a year and bring secondhand modern operating equipment. They didn't have any microscopes or anything like that. And so we started working together.
It was exciting. It was medically challenging, very difficult. I wouldn't say it was easy. But it was also - I just knew instinctively that Ukraine was an incredibly important country because it's a borderland. It's a junction of Western European liberalism and freedom and sort of Russian Eastern dictatorship, which goes back via Lenin and Stalin to Genghis Khan, the mazars (ph). And the war now is incredibly important. It's not just about Ukraine. It's about having a rules-based world order. It's about freedom and democracy. And it's just so important.
GROSS: Let's talk about your work in Ukraine and how that's been changed by the war. First of all, where in Ukraine have you been working? And how dangerous is it there? Because it seems like all of Ukraine is in danger right now.
MARSH: I've been a couple of times to - both to Lviv and Kyiv, once in the summer when there were no missile attacks, a second time in October. I arrived in the railway station in Kyiv exactly the same time as some Russian missiles, which is the first time I'd been under fire. But actually, in the major cities in the center of the country and the West, you know, the risk of being killed by these missile strikes statistically is very, very small. It's quite different if you're in the East at the front line, which I haven't been to and don't intend to go.
Neurosurgery is a very small part of battlefield surgery. I am not a war surgeon. I've been continuing to help colleagues with basically elective, routine neurosurgery. Because I'd been going to Ukraine for so long, I'm actually very well-known in Ukraine and a bit of a sort of minor public figure. So my sort of moral support for the country is quite, is - I think they like and the fact that I'm unusual and have been going there for 30 years and my - I have many friends there. And they were terribly happy when I came to visit them.
The problem now is my wife was horrified when the Russian missiles were landing. And I - you know, I can't really justify at the moment inflicting all the anxiety on her of my returning although I think the risk of my coming to harm is extremely small. So I didn't quite know what will happen. I'm setting up a charity at the moment to support palliative care in Ukraine, which is very lacking.
GROSS: Do you think in weighing the risks of returning to Ukraine, the times that you actually went there during the war, that knowing that you had prostate cancer and that your time might perhaps be limited, that you were more willing to take those risks?
MARSH: I think a little bit, yes. Or at least I'd had a lot of time thinking - I'd spent a lot of time thinking about death and dying. And, yeah, I thought it's not - no big deal. You know, it's not - it's more important to get on with things. So it probably had some influence on it. On the other hand, I hadn't been under fire before, and I think as do certain people, like war correspondents and war doctors - and I know a few - is something slightly addictive and attractive about it. And it made me realize - you know, certainly for myself and, I think, many surgeons, maybe especially neurosurgeons - I don't know - we actually find risk attractive. OK, it's a risk to the patient, but it's still sort of risky. What I didn't realize when I went into neurosurgery - there were risk for me (laughter) in becoming a neurosurgeon.
GROSS: Are you talking about the risks of actually harming a patient in the process of performing surgery?
MARSH: Well, that will happen. And you will have periods of deep, deep guilt and shame and regret. And I start my first book, "Do No Harm," with a wonderful quote by the French surgeon Rene Leriche, who wrote that all doctors, all surgeons, carry inside themselves a cemetery. And it's a place to which they must go from time to time and think about the - when things went badly. And I, like many surgeons I know - senior surgeons or retired surgeons - I don't remember my successes. I remember my failures very clearly. And under the stimulus of having cancer myself, I remembered a whole lot more. And those days, memories, they're with me now even though I stopped working, doing clinical work in England, two or three years ago.
GROSS: You've treated soldiers, I believe. And, you know, as part of your work in Ukraine, you treated people who had been soldiers in Crimea, which Russia annexed, you know, a few years ago.
MARSH: I saw some, yes.
GROSS: And one story you tell in the book, you're talking to a soldier and you're asking about post-traumatic stress disorder. And he's insisting he doesn't have it and that the Ukrainian soldiers don't have it because they're tough and they believe in their mission. What did you make of that?
MARSH: Well, I think it's wishful thinking. I think soldiers, you know, and normal young men - they end up seeing terrible things and doing terrible things. We know from research that if soldiers are well-led and don't have previous mental health issues, they're less likely to develop post-traumatic stress disorder. But there's going to be an epidemic of it in Ukraine. And in fact, my - all my medical friends say it's already a problem. I'm just reading that New York Times bestseller by the Dutch American psychiatrist der Kolk called "The Body Keeps the Score," which is all about post-traumatic stress disorder - it's absolutely fascinating and it's tragic. I mean, it's terrible. War is awful. And what is happening both to the young Russian soldiers and the young Ukrainian soldiers who are killing and being killed and suffering terribly and inflicting terrible suffering, basically, for the sake of old men - old men in Russia. I mean, it's grotesque.
GROSS: Well, let me reintroduce you here. If you're just joining us, my guest is neurosurgeon Dr. Henry Marsh. His new memoir is called "And Finally: Matters Of Life And Death." We'll be right back. This is FRESH AIR.
(SOUNDBITE OF MOACIR SANTOS' "EXCERPT NO. 1")
GROSS: This is FRESH AIR. Let's get back to my interview with retired British neurosurgeon Henry Marsh. His new memoir "And Finally: Matters Of Life And Death" is about the experience of being the patient, not the surgeon, after he was diagnosed with advanced prostate cancer.
You've given up performing neurosurgery. How did you know it was time to stop?
MARSH: Well, I'd always assumed I go on - I stopped working full-time and basically operating in England when I was 65, although I continued to operate - you know, I worked a lot in Kathmandu and Nepal and also, of course, in Ukraine. What I always felt, as a matter of principle, it's best to leave too early rather than too late, as with anything in life, whether it's a dinner party or your professional life itself. It's best to leave too early rather than too late.
I was getting - well, to be honest, I was getting increasingly frustrated at work. I mean, I'm a great believer in the British National Health Service, but it's very - it's become increasingly bureaucratic. And psychologically, I was becoming less and less suited to working in a very managerial bureaucratic environment. I'm a bit of a maverick, loose cannon. And also, I felt it's time for the next generation to take over. I had become reasonably good at the operations I did. I didn't think I was getting any better, and I had some very good - a very good trainee who could take over from me and had actually taken things forward in the - particularly in the awake craniotomy practice. He's doing much better things than I could have done. So it felt a good time to go in that regard.
What really surprises me now is I don't miss it at all. I was completely addicted to operating, like most surgeons. You know, the more dangerous, the more difficult the operation, the more I wanted to do it - the whole risk and excitement thing. In fact, an important part of a surgery is learning - one of the most difficult parts of surgery is learning when not to operate. But much to my surprise, I don't miss it and I don't quite understand that. But I'm very glad. In a funny sort of way, I feel a more complete human being now that I'm no longer a surgeon.
GROSS: What do you mean?
MARSH: And I no longer have this terrible split in my world view between me and the medical system and - my medical colleagues, that is - and patients. So I feel a more whole person.
GROSS: You pioneered in England a kind of brain surgery with the patient awake on only a local anesthetic. What is the explanation for doing it that way?
MARSH: True brain tumors - by which I mean to say tumors that arise within the brain itself - true brain tumors look like the brain. They're in the brain itself. There's no clear margin as to where the brain stops and the tumor starts. And usually, in fact, the tumor infiltrates the brain 'cause the brain tissue is soft. It doesn't put up a resistance to the cells of a tumor. So you have a margin at the edge of a tumor where your brain - could be functioning brain, working brain, with tumor cells in it. Now, 30 years ago, we were just starting to get more and more brain scanners with the new technology, basically an MRI - 40 years ago. And we started seeing brain tumors in the early stages when they'd - they'd announce their presence. Maybe it was something like an epileptic fit. And historically, the view was taken, well, we know some of these patients who've had a fit will come back with a big symptomatic brain tumor years later. But they're well at the moment. It's too dangerous to operate. You have to tell the patient there is a brain tumor there and we can't do anything about it, which is pretty devastating.
And I thought, well, if you actually had the patient awake, particularly when you're operating near the speech area, you know, there's a better chance you can remove more of a tumor because you wait - if a patient's asleep on a general anesthetic, you can't test what's happening. That was being done in America by a guy called George Ojemann in Seattle and Mitch Berger. They were doing it mainly for epilepsy, but some tumors. I picked up the technique from them. And in England and Europe, it was kind of controversial at the time, but now it is the standard way of operating on this particular subgroup of tumors. And it's extraordinary. I once had a patient I was operating at the back of the brain on the left in the visual area. So I had him looking at things on the right side 'cause the left side of the brain looks at things on the right side of the world. But also, he could see his own brain on the computer monitor, which was showing what I was doing down my microscope. So you had the visual area of the brain looking at itself, and you feel there should be the metaphysical equivalent of acoustic feedback. You know, there should be a...
GROSS: Yes, exactly.
MARSH: ...Metaphysical explosion in the operating...
GROSS: Exactly, exactly.
MARSH: ...Center. But there's not. And the patient just said, it's crazy. And it is crazy. It is extraordinary.
GROSS: How do you test the patient, test whether you were invading a part of the brain that would end with some kind of, you know, brain injury?
MARSH: With a little electrical probe, and you stun the brain for a few seconds. So you have them talking, and then you stun little bits of brain. And if you stop them talking, it means you're over the speech area. It's - more or less, that's it. That's how you do it. An exploratory probe that stuns but doesn't actually damage the brain.
GROSS: So before you cut, you test that part.
MARSH: If you stimulate that part of the brain and it interferes with speech, you know you mustn't operate on that part.
GROSS: Right. So is this the kind of surgery you only perform when the surgery affects speech?
MARSH: Well, you can do it for movement as well, but there are more modern ways of electrically monitoring movement without having patient - the patient awake. So it's primarily now used for speech. When I started doing it 30 years ago, it was for movement as well and, to a lesser extent, for vision.
GROSS: The other thing that's really crazy is that it apparently doesn't hurt 'cause the brain doesn't...
MARSH: It doesn't - no, it doesn't hurt.
GROSS: ...Have nerve cells. And - I mean, yeah, it doesn't have pain receptors.
MARSH: Yeah. If you got pain in your little finger, it is an illusion that the pain is in the little finger. It's not. The pain is in a model of your little finger - a model of your body in your brain. So it's very strange. So the pain - the given pain is created in the brain. The pain has no pain receptors. You'd have to have another brain, you know, with a model of the first brain feeling the pain. So it's completely painless to operate on the brain.
GROSS: Yeah, because the brain translates things into pain. So if there was pain in the brain, it would take another brain to translate that.
MARSH: Yes. Exactly, exactly.
GROSS: It's like multi-universes or something (laughter). I don't know...
MARSH: It is. It is. And it's quite difficult, thinking it through. It's quite complicated.
GROSS: How did you explain it to the first person you did this - you performed this procedure on in England, where it was a basically unknown procedure?
MARSH: That patient is still alive and well, actually, 30 - more than 35 years later - no, just 35 years later. I just explained the anatomy and how we wanted them not to do any harm and things like that. And she said, go for it. And has been very well ever since.
GROSS: Well, let's take another break here, and then we'll talk some more. If you're just joining us, my guest is retired British neurosurgeon Henry Marsh. His new memoir is called "And Finally: Matters Of Life And Death." We'll be right back. This is FRESH AIR.
(SOUNDBITE OF DANIEL FREEDMAN'S "LOVE TAKES TIME")
GROSS: This is FRESH AIR. Let's get back to my interview with retired British neurosurgeon Henry Marsh. His new memoir, "And Finally: Matters Of Life And Death," is about the experience of being the patient, not the surgeon, after he was diagnosed with advanced prostate cancer.
About 20 months before your cancer diagnosis, you got a brain scan, participating in a study of the brain scans of normal people, you know, people who didn't have, you know, dementia or any - or a brain tumor or anything like that. So you're a neurosurgeon. You looked at your own brain scan afterwards. Compare what you were expecting to see to what you actually saw when you read your own scan.
MARSH: I was horrified (laughter). I thought somehow, naively, it would show my brain was unmarked by age, but in fact, it was - showed marked age-related changes. It had shrunk quite a lot. There was evidence of what's called white matter hyperintensities, a blood vessel - miniature strokes in parts in the white matter, the bits that connect the brain together. And although I felt mentally absolutely fine. And as far as I could tell, I was still fairly smart. So it was a huge shock. This is before I was diagnosed with cancer, as you said.
And I had wanted to write another book, but I'm going to do it from a slightly different angle by starting with my own brain scan. But it kind of, you know, it was the biter bit. And it was the beginning of my having to accept I was getting old, accept I was becoming more like a patient than a doctor, that I wasn't immune to the decay and aging and illnesses I'd been seeing in my patients for the previous 40 years. So it was actually terribly frightening, looking at the scan. You know, I was crossing a threshold, and I've never dared to look at it again 'cause it was too upsetting. In retrospect, it probably wasn't that big a deal. It probably - if I had seen that scan at work, I'd have said, well, that's a typical 70-year-old brain scan. But that was me, you know? And it was the beginning of the process, which then became much more violent when I was diagnosed with cancer.
GROSS: Once you saw the brain scan and saw, like, the degeneration that was taking place, did you feel different about your own mental performance?
MARSH: No, not really. I mean, it came (ph) a little bit more with my memory not as good as it was, but that's all normal as we get old. You know, I forget names. I don't think I'm dementing yet. But as many people my age, I'm very frightened about dementia. My father died from Alzheimer's at the age of 96. So many of my friends have had elderly parents who demented. It's terrible and tragic to see people withering away. And I dread that happening to me. In my more sardonic moments, I say I regard my prostate cancer as vaccination against Alzheimer's.
GROSS: Oh, because you'll die too soon (laughter).
MARSH: Yeah, that's the plan.
GROSS: Die before the Alzheimer's sets in.
MARSH: Yes, yes.
GROSS: Is your fear of dementia and watching your father deal with dementia, is that one of the reasons why you have a kit with medicine that could allow you to hasten your own death?
MARSH: Yes, it is. But assisted dying doesn't solve the dementia problem because you have to have mental capacity. In jurisdictions where assisted dying is allowed, you have to undergo - determine your mental capacity (ph). It may be in the early stages of a disease you can. But the idea of an assisted dying will somehow be used to kill off swarms of demented old people is just not true. It's not possible. It won't happen.
GROSS: Do you think that you would want to hasten your death in the early stages of Alzheimer's?
MARSH: Yes. If I'd been certainly diagnosed with it, yes. Yeah. But having said that, actually happens, I don't know. But the man I am at the moment, if I knew I was definitely dementing, I would not want to inflict that on my family.
GROSS: You know, you've talked about becoming more Zen at this stage in your life and living in the moment and not trying to worry about the future.
MARSH: Yeah, it's wonderful. I don't know how long it will last.
GROSS: Yeah, well, you say in your book, why think about the future? Because, you know, at a certain age, the future, especially if you have, you know, cancer, that the future, you know, isn't going to be...
MARSH: It's not going to be good.
GROSS: Yeah, it's going to be decline, even if not in the near future, in the distant future. So why dwell on that? So you've probably thought a lot about how you want to spend your remaining time. What are your thoughts about that? How are you thinking differently about your life now?
MARSH: I want to see as much as I can of my children and grandchildren. I am not going to write any more books for adults. But there's one chapter, a slightly a wacky chapter, in my new book where I discuss the fairy stories I tell my granddaughters on FaceTime during the pandemic, when I couldn't see them, this invented, magical world I created. And I wonder - I'm starting to write those up and not really with a view to publication but just as a sort of family heirloom. And lots of people are encouraging me to do that, and I try to do the illustrations myself as well. Like, I'm a sort of cartoon artist of sorts. So that's a nice thing to do. I've got a workshop. I'm always making things. I've just finished - I spent two years making a very grand, complicated doll's house for my third granddaughter. And my - I'm very happily married to my wife, Kate, who lives in Oxford. I divide my time between Oxford and London. So I've got plenty of things to do. And I'm physically well at the moment. I keep fit. I run and exercise and things like that. So at the moment, I feel I'm very lucky.
GROSS: Dr. Marsh, thank you again for coming back to our show. And I want to wish you continued remission and good health.
MARSH: Thank you very much.
GROSS: Henry Marsh's new memoir is called "And Finally: Matters Of Life And Death." Tomorrow on FRESH AIR, our guest will be Lizzy Caplan, one of the stars of "Fleishman Is In Trouble," a series about marriage, parenthood and middle age. She's also known for her roles in "Mean Girls," "Party Down," "Freaks And Geeks" and "Cloverfield." She was nominated for an Emmy for her performance in the series "Masters Of Sex." I hope you'll join us.
(SOUNDBITE OF JESSICA WILLIAMS' "MONK'S HAT")
GROSS: FRESH AIR's executive producer is Danny Miller. Our technical director and engineer is Audrey Bentham. Our interviews and reviews are produced and edited by Amy Salit, Phyllis Myers, Sam Briger, Lauren Krenzel, Heidi Saman, Therese Madden, Ann Marie Baldonado, Thea Chaloner, Seth Kelley, Susan Nyakundi and Joel Wolfram. Our digital media producer is Molly Seavy-Nesper. Roberta Shorrock directs the show. My thanks to Dave Davies for doing such great interviews while I was on vacation last week. I'm Terry Gross.
(SOUNDBITE OF JESSICA WILLIAMS' "MONK'S HAT") Transcript provided by NPR, Copyright NPR.