A Waterstones Exclusive Q&A with Henry Marsh

There’s a good deal of humility in your new book, Admissions, (as there was in your last, Do No Harm) and an acute sense of the difficulty of what you call the ‘moral challenge’, the ‘balance between compassion and detachment’. Are we getting any better at training doctors to navigate the difficult path between the two?

Very hard to know but the shorter working week for junior doctors allows more women to train in what were traditionally male preserves (such as surgery) and that is probably a good thing. Without wanting to sound sexist the average woman, in my opinion, makes  a better doctor than the average man. They are less concerned, on average, with status and power and are better at talking to patients – but I might be wrong! In other respects the short working week is bad for training and continuity of care.

You include some fascinating snippets of information about your family history in Admissions, particularly your parents’ lives (I found myself wanting to read their story). It made me particularly aware of how much our individual expectations for our lives have altered. To what extent do you think there has been a change in emphasis in this country from wanting to live good lives, to expecting (perhaps even demanding) to live happy ones?

I can only speak for myself – trying to lead a good life is much more important than trying to be  “happy”, in terms of what you will eventually have to look back upon.  It is like the difference between tourism and travel. But there is plenty of evidence that what is important for human happiness, beyond a certain minimum level of income and material possession, is a secure family and  social life and a feeling of purpose and belonging in your community. Modern urban life and fragmented communities makes this more difficult to achieve and the emphasis instead drifts towards material acquisition and conspicuous consumption and social competition rather than social co-operation.

You’re a compelling storyteller and it made me wonder if that is what the surgeon has to do when assessing a case, decide the probability of which story the patient is in, one of survival and hope or one where the outcome is a tragedy – would you agree?

Ideally, yes. This is so-called “holistic” medicine but surgeons are not very good at doing it in my experience – they tend to see the patient as a machine with a broken part that needs fixing and we all naturally try to avoid painful conversations.

You comment that becoming a surgeon might be ‘a little self-indulgent. There might be more important ways of trying to make the world a better place… than being a surgeon.’ To what extent do you think that in seeking resolutely and at great expense to prolong life ever further we are at risk of prioritising the individual above the good of society and the world at large? 

Healthcare costs are running out of control – especially in the USA – because doctors and patients find it so hard to know when to stop. It is the medical equivalent of global warming. It is difficult not to fear that the human race is heading for a population crash. In healthcare this could take the form of greater and greater inequality in access to expensive treatment for cancer – a disease essentially of old age - and worse healthcare generally for people at the bottom of the social ladder as money gets diverted away from public health and primary healthcare.

I really enjoyed the chapter entitled ‘Making Things’, exploring your extensive work rebuilding your house and working with wood. To what extent do you think the satisfaction in this very different (and yet painstaking and complex) work is a corollary to your role as a surgeon, a different form of restoration where any faults lead to a ‘hope to do better’ without the corresponding ‘headstones in an inner cemetery?’

I have always had a compulsion to make things – whether it’s woodwork, building, writing or operating. I don’t really know where this comes from – doubtless it’s partly to draw attention to myself. It’s also to stave off boredom and depression but there’s a certain spiritual craving in it as well. To leave something worthwhile behind, and for my deep personal need to feel useful.  I feel very sorry for people who do not have the wish or ability to make things.

You write that ‘a doctor’s duty is to relieve suffering as well as to prolong life, although I suspect this fact is often forgotten in modern medicine’. What do you think drives us to prioritise saving the physical body (even at the risk of adding to what you call the ‘underworld of suffering’) above and beyond all other considerations?

Our deeply irrational fear of death, probably hard-wired by evolution into our brains.

You are open in advocating a greater personal choice over how and when we die. Would you agree that our approach to debating how we treat death and dying has not kept pace with the advances in medicine to keep us alive for longer? Why do you think the medical profession are so reluctant to debate the issue more vocally?

It is very difficult to tell somebody to go away and die. Hope is such a precious commodity and a very important part of how our brains work and motivate us. Doctors in many countries outside the UK do not seem to have the same problem with assisted dying as does the BMA and MPs in the UK. I’m not sure why – maybe English reserve and our  dislike of emotional confrontation and expression.

You write that ‘The faults of socialized health care are ultimately less than the extravagance, inequality; excessive treatment and dishonesty that so often come with competitive, private health care’. To what extent do you think the increasing connection between medicine and money is drawing healthcare away from its primary duty towards patients?

To a great extent, but money and medicine have always been close. Many medical decisions are not clear-cut – it is a question of balancing one probability (the risks and benefits of treatment) against another (the risk and benefits of no treatment or alternative treatment). Since these are probabilities the decision whether to recommend treatment or not is subject to many unconscious cognitive biases, and profit-seeking easily distorts clinical decision-making without necessarily being venal. Litigation and defensive medicine and increased costs also result if medicine is treated more and more as a business and little different from buying something in a shop.

You write about how patients with idiopathic conditions, particularly pain, often perceive the suggestion of a psychological cause to be dismissal of their symptoms. Do you perceive this as evidence of a prevalent stigma around psychological illness? How important is it to advancing understanding and treatment that we break down the divide between how we view our brains and our bodies?

Yes, there is still great stigma about psychological problems and it’s important to escape dualism. It is why I write about my own problems in the past. 

You are candid in your assessments of some of the increasing difficulties faced by the NHS for doctors and patients. If the NHS were your patient, what would be your prognosis for its future? 

It will steadily wither if there is not an open discussion about how to get people to pay more for healthcare. Spending on the NHS is a much more efficient, cheaper and equitable way of  providing healthcare than via profit-seeking private providers. The private healthcare system in the UK, anyway, is entirely parasitic on the NHS for the training of its staff and for bailing it out when things go wrong with patients. It is subsidized by the tax-payer and does not carry the true costs of what it does. It avoids treating expensive and complicated conditions. It is a myth that it is more “efficient” than state-funded healthcare There is an urgent need for an open public discussion ( maybe an old-fashioned Royal Commission) on how to educate  the public  about the true costs of healthcare and persuade the electorate to devote a larger proportion of their income to  healthcare.