And Finally: Matters of Life and Death by Henry Marsh

(St. Martin’s)

Review by Walter Cummins

The “finally” in Henry Marsh’s title refers to the clear signal that death awaits him. After seventy years of avoiding admission of that inevitability, he is confronted by a diagnosis of advanced prostate cancer. Despite decades as a prominent British neurological surgeon and successful author of books on medicine, suddenly he is no longer in charge, just another patient in an open-back hospital gown undergoing test after test in a dramatic role reversal.

The book is much more than a contemplation of his own dying—something he wants very much to avoid—but also an occasion to consider the life he has led, his own limitations, the limitations of human understanding, and—perhaps most significantly—what really matters in the time we have as human beings.

I have no idea if Marsh was typical of physicians in avoiding the confrontation with their own vulnerabilities, but shortly before reading the Marsh book, I learned of the death of a college friend years older than Marsh’s seventy. He had been a significant cardiologist, teaching in a leading medical school. Yet when he suffered a major heart attack, he did not the follow the care advice he must have given hundreds of patients. His wife was frustrated with him, at wit’s end. My guess is, unlike Marsh, that he—used to being tops in his class—was incapable of accepting his new reality as a patient.

Marsh accepted reality even though he wasn’t comfortable with it. However, as a writer he is used to reflecting on the human condition, and before the cancer diagnosis he was aware of his increasing limitations. And Finally, in its opening pages, reveals how Marsh overcame his reluctance to undergo a scan of his own brain and was shocked by what he saw: “My seventy-year-old brain was shrunken and withered, a worn and sad version of what it once must have been. … Not to put too fine a point to it, my brain is starting to rot. I am starting to rot. It is the writing on the wall, a deadline.”

Limitations to his physical dexterity, hands affected by carpal tunnel, had already led him to turn over performing surgery to younger physicians while still teaching and diagnosing, still volunteering to give instruction in Ukraine and Nepal, upset when the Covid epidemic made travel to those countries impossible. He wanted to serve others. He wanted to matter.

Faced with his own cancer, Marsh can’t avoid contemplating his own dying and what will matter in his remaining years, which is a concern for anyone who cannot avoid awareness that their time is limited. As a physician who has devoted a career to life and death consideration of others, he in his new status as patient endures another humbling realization: “… being a patient is an essentially disempowering and humiliating experience”:

After I had been diagnosed with advanced prostate cancer and become a patient myself, I was surprised to keep on remembering more and more patients whom I had completely forgotten – some were cases going back more than thirty years. Now that I was so anxious and unhappy, feeling abandoned, I realised how anxious and unhappy so many of my patients must have been, and yet how I had chosen to turn a blind eye to this. My former patients became reproachful ghosts who came to punish me. They were everywhere, lurking behind everyday thoughts and sights and sounds. I thought of how I would be a much better doctor if I could start all over again.

Not only do many physicians fail to understand what their patients are experiencing, there is so much about human existence that physicians—like all of us—do not know about the functioning of our brains and, ultimately, what are lives are all about. “As it is, we understand remarkably little about how our brains work.” But that’s only one part of it.

The universe we exist in is an even greater mystery. Marsh refers to the evolutionary biologist J. B. S. Haldane, who observed, “it’s not just that the universe might be stranger than we think, but that it might be stranger than we can think.”

Although Marsh at the end of the book knows his prostate cancer is in temporary abeyance, he also knows that his death is inevitable. How does he fill the time? He enjoys building things, larger structures that require timber and miniature doll houses for his granddaughters. And he creates fairytales that amuse those children, dedicated to being a much more involved grandfather than he was a father consumed by the importance of his surgical career.

More than just a diversion, such tales help us cope with situations that might overwhelm us: “We live in a model of the world, a story of sorts. The intense feeling of plot and narrative in our dreams, although it may well be meaningless, suggests that making sense of the world by telling stories is a critical part of being human.”

While Marsh is greatly disturbed by the legacy of climate change and the destruction humans have brought to the planet in the quest for progress, most personally the future his granddaughters will face, he offers some comfort: “If there is anything good about our intelligence, it is that it gives us the ability to love and respect all forms of life, and not just our own.”