DO NO HARM

That brain surgery is fraught with disaster and complications should come as no surprise. However, we rarely hear about that side of this field. That is, until the wonderful confessional book Do No Harm by the British neurosurgeon Henry Marsh pictured above.

Marsh's book recounts his experiences operating on brains and spinal cords for over forty years in England and elsewhere. Unlike most medical books that focus on the heroic, this book also highlights how harrowing the experience of brain surgery can be to both the patient and the surgeon.

Mistakes in medicine are inevitable. Yet, there is no organ less forgiving of mistakes than the brain. Certainly, there are portions of the brain that when traumatized do not lead to permanent damage. Then, there is the rest - what Marsh calls "eloquent brain" - that whose damage leads to significant disability. Unfortunately, very terrible diseases often lurk in or near eloquent brain - tumors, aneurysms, strokes. While the latter is the domain of the neurologist, the former two are the domains - and perhaps cemeteries - of brain surgeons.

How does one venture into these territories day in and day out? It takes more than hubris. It takes courage and the conviction that the benefits of intervention outweigh the risks. Marsh acknowledges that it is heroic to take on challenging cases that others might pass on. However, he clearly reminds the reader that thoughtfulness and cautiousness must also be considered if we are to truly operate under the principle of "first, do not harm" -  a first principle of Medicine that is laid out in the Hippocratic Oath that all doctors take at some point in his/her training.

I often think of this Oath and this principle of avoiding interventions when harming the patient seems much more certain that helping him. Oncology is not brain surgery, but certain parts of the body, like the nerves or bone marrow, do not forgive or forget the poisons to which they are exposed. Because of this, I do have an abiding belief that it is much worse to harm a patient with an intervention than to withhold a toxic, unsafe therapy that has the potential to improve longevity by a few months.

My patients often disagree with this approach. This is because, although there are risks with dangerous treatments like chemotherapy, the risk of a poor outcome without no treatment is a certainty.

It is within this context that life and death medial decisions are made every day. Marsh reminds the practitioner and patient alike of the gravity of Medicine and our choices. Let us remember his words when making these shared decision, and let us first do no harm!