Book Review: ‘And Finally,’ by Henry Marsh

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Nonfiction

Henry Marsh's "And Finally" tests the limits — and comforts — of knowledge.

By Kieran Setiya

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AND FINALLY: Matters of Life and Death, by Henry Marsh

It was said by the Roman philosopher Cicero that to philosophize is to learn how to die. He was echoed by the 16th-century essayist Michel de Montaigne, sometimes in earnest, at other times in jest. "If you don't know how to die, don't worry," Montaigne playfully concluded. "Nature will tell you what to do on the spot, fully and adequately."

We don't need to learn the biological mechanics of dying in order to die. But it may help to know them in facing death. If the philosophers haven't figured out how to do that — at least not to everyone's satisfaction — might a physician have more luck? Henry Marsh is an author and retired doctor, in whom, said The Economist, "neuroscience has found its Boswell." In his most recent book, the physician becomes a patient, confronting a diagnosis that will probably end his life.

Many years ago, Marsh read philosophy at Oxford University, but he left for the more practical world of medicine after a year. He finds himself returning in this book to philosophical questions about consciousness and fear of death, though he does so through narrative, not argument, his skills honed by years of storytelling as a clinician recounting case histories. Marsh knows how to set a scene, how to create suspense and how to surprise the reader.

Case in point: He opens with a bait-and-switch. "It seemed a bit of a joke at the time," he writes, "that I should have my own brain scanned." We know he's about to be seriously ill and we assume that the scan will reveal a tumor; poetic injustice. In fact, what the scan reveals is the ordinary attrition of aging, a brain diminished by the years. The real diagnosis comes later: advanced prostate cancer, its detection delayed by the misguided fortitude of a doctor who assumes that only patients get sick. (About a friend's calm response to news of an untreatable tumor, Marsh observes: "It was difficult to know whether this came from stoicism or frontal brain damage.")

Not that the scan isn't frightening; Marsh feels fear as well as wonder at the image of his slowly withering brain, comparing his experience to a vision of the night sky — an allusion to the philosopher Immanuel Kant. "Two things fill the mind with ever new and increasing admiration and awe," Kant declaims in one of Marsh's epigraphs, "the starry heavens above me and the moral law within me."

I suppose the cerebrum is a suitably neuroscientific substitute for the voice of conscience. Marsh finds it "very hard to comprehend that ‘I’ am the 86 billion nerve cells of my brain," its wiring longer "than the distance from the earth to the moon." At one point he suggests, in passing, that "the real world is just a pattern of electrochemical impulses." At moments like these, I wish he’d stuck with philosophy a little longer. We are not brains, but embodied beings — as philosophers have been arguing for at least a century — and the Cartesian "veil of ideas" that traps us in our minds is not helpfully replaced with a veil of neurons.

But these are minor elements of the book. For the most part, Marsh does not pretend to answer metaphysical questions about the mind, or even assume that they can be answered by the likes of us: "You can't cut butter with a knife made of butter," quips a neuroscientist friend. Instead, we reach for metaphors. Before the mind was a computer, it was a telephone exchange, and before that a steam engine, though Freud's psychoanalytic theory "made the id and ego sound like the components of a flushing toilet."

Marsh is often funny, sometimes at his own expense. Dismissing Freud on dream interpretation and complaining that other people's are "quite remarkably boring," he finds himself narrating a long nightmare about his wife. The fairy stories he tells his granddaughters have allegorical elements, like an "orphaned unicorn who develops the dreaded Droopy Horn Disease." Like many others, Marsh was treated for prostate cancer by "chemical castration," depriving cancerous cells of androgen, with side effects of breast development, impotence and muscle loss.

His account of the subsequent radiotherapy celebrates the technology, which is almost lyrically described; not so much the medical practitioners. It "was only when I was diagnosed with cancer myself," he writes, "that I could see just how great is the distance that separates patients from doctors, and how little doctors understand about what their patients are going through." Not that he's judgmental. Marsh acknowledges his own failures of compassion as a surgeon and the detachment needed to function as a doctor from day to day. His advice to clinicians is pragmatic: "You should always be seated when talking to patients, and never appear to be in a hurry."

What lessons does he have for the rest of us, as we learn how to die? In part, a measured argument for assisted suicide, which has not so far led to the abuses conjectured by its critics. In part, an argument against the immoderate wish to live forever. Seventy years should be enough — death is different when it comes to someone young — and we have to make room on the planet for other people. "I have had my time in the sun," Marsh writes, "now it is the turn of the next generation."

I’m not sure he does better than philosophy when it comes to facing death, but I don't think Marsh does worse. There's no false comfort here. Instead, there's prose that breaks in gentle waves, its undercurrents deep, the surface of an ocean vast enough to put our lives in moral perspective. The narrative takes detours through DIY and dollhouses, hospital décor and Himalayan hikes. Marsh is seated, storytelling, and he is in no hurry.

Kieran Setiya teaches philosophy at M.I.T. and is the author of "Life Is Hard: How Philosophy Can Help Us Find Our Way."

AND FINALLY: Matters of Life and Death | By Henry Marsh | 227 pp. | St. Martin's Press | $27.99

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