Do No Harm: Stories of Life, Death and Brain Surgery by Henry Marsh Read Free Book Online

‘And now this.’
    ‘I’m almost certain it’s benign,’ I told him. Many brain tumours are malignant and incurable and I often have to overcome my instinct, when talking to patients with brain tumours, to try to comfort and reassure them – I have sometimes failed to do this and have bitterly regretted being too optimistic before an operation. I told him that if I thought it was benign it almost certainly was. I then delivered my standard speech about the risks of the operation and how they had to be justified by the risks of doing nothing. I said that he would die within a matter of months if he did not have the tumour removed.
    ‘Informed consent’ sounds so easy in principle – the surgeon explains the balance of risks and benefits, and the calm and rational patient decides what he or she wants – just like going to the supermarket and choosing from the vast array of toothbrushes on offer. The reality is very different. 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.
    I told him that there was a one or two per cent risk of his dying or having a stroke if the operation went badly. In truth, I did not know the exact figure as I have only operated on a few tumours like his – ones as large as his are very rare – but I dislike terrorizing patients when I know that they have to have an operation. What was certain was that the risk of the operation was many times smaller than the risk of not operating. All that really matters is that I am as sure as I can be that the decision to operate is correct and that no other surgeon can do the operation any better than I can. This is not as much of a problem for me now that I have been operating on brain tumours for many years, but it can be a moral dilemma for a younger surgeon. If they do not take on difficult cases, how will they ever get any better? But what if they have a colleague who is more experienced?
    If patients were thinking rationally they would ask their surgeon how many operations he or she has performed of the sort for which their consent is being sought, but in my experience this scarcely ever happens. It is frightening to think that your surgeon might not be up to scratch and it is much easier just to trust him. As patients we are deeply reluctant to offend a surgeon who is about to operate on us. When I underwent surgery myself, I found that I was in awe of the colleagues who had to treat me though I knew that they, in turn, were frightened of me as all the usual defences of professional detachment collapse when treating a colleague. It is not surprising that all surgeons hate operating on surgeons.
    My patient listened in silence as I told him that if I operated upon one hundred people like him, one or two of them would die or be left hopelessly disabled.
    He nodded and said what almost everybody says to me in reply to this: ‘Well, all operations have risks.’
    Would he have chosen not to have the operation if I had said that the risk was five per cent, or fifteen per cent, or fifty per cent? Would he have chosen to find another surgeon who quoted lower risks? Would he have chosen differently if I had not made any jokes, or had not smiled?
    I asked him if he had any questions but he shook his head. Taking the pen I offered him he signed the long and complicated form, printed on yellow paper and several pages in length, with a special section on the legal disposal of body parts. He did not read it – I have yet to find anybody who does. I told him that he would be admitted for surgery the following Monday.
     
    ‘Sent for the patient?’ I asked as I entered the operating theatre on Monday morning.
    ‘No,’ said U-Nok the ODA (the member of the theatre team who assists the anaesthetist). ‘No blood.’
    ‘But the patient has been in the building for two days already,’ I said.
    U-Nok, a delightful