Admissions: Life as a brain surgeon

Chapter 1.

Vlad the Impaler 弗拉德三世 弗拉德三世·德拉库拉·采佩什（1431年11月或12月－1476年12月）。 (罗马尼亚) 瓦拉几亚大公.“采佩什”在罗马尼亚语中的意思是「穿刺」，这是由于他酷爱以穿刺刑折磨人，故被称作穿刺者弗拉德。他也是著名的吸血鬼傳說「德古拉伯爵」的原型。

Joe Bloggs /dʒəʊ ˈblɒɡz/ noun a name for a hypothetical average man.
"what goes on in the pits is a million miles away from what happens when Joe Bloggs puts his car in for a service"

Chapter 2. London

Robin Dunbar. 罗宾·I·M·邓巴（英語：Robin Ian MacDonald Dunbar，1947年6月28日－）
是一位英国人类学家和演化心理學家[1][2]，专攻灵长类的行为，知名于提出了邓巴数[3]。

邓巴数（英語：Dunbar's number），也稱150定律，指能與某個人維持緊密人際關係的人數上限，通常人們認為是150。这里的人际关系是指某个人知道其他人是谁并且了解那些人之间的关系。支持者认为超过这个人数上限的团队，需要更加严格的规则，法律以及强制性规范来维持稳定性和凝聚力。鄧巴數並沒有精確的數值，它處於100到230之間，而通常人們使用150。邓巴数首先是英国的人类学家罗宾·邓巴於1990年代提出，是新皮质的大小决定的，并因此成为了一个团队规模的限制。新皮质处理能力决定了能与某个人维持紧密人际关系的人数上限。在這樣的團體中，每個人都認識彼此且知道彼此的關係。此外，这个数量包括熟悉的老同学和老同事，也就是說實際的親密的朋友數量會更少，直至接近個位數。

Chapter 6.

Namaste: 那摩斯戴（梵語：नमस्ते，羅馬化：namaste；或Namaskar、Namaskaram），又譯作南無斯特，是印度人常用的问候语，梵语原义为“向你鞠躬致意”。在向别人说这问候语时，通常还会将雙手合攏置于胸前，并微微点头。这一动作被称为合十手印（Añjali Mudrā或Pranamasana）。在不说话时也可以做此动作，表示相同的含义。

But I also thought of the research into bonobos (previously known as pygmy chimpanzees), our closest evolutionary relatives, which shows that they have compassion and kindness, a sense of fairness and console each other over pain – at least for their own group. They have not been told to do this by priests or philosophers or teachers, it is part of their genetic nature, and it is reasonable to conclude that the same applies to us.

Battle Abbey

Chapter 9

Endowment effect 禀赋效应或厌恶剥夺(英語：Endowment effect)，形容当一个人拥有某项物品或资产的时候，他对该物品或资产的价值评估要大于没有拥有这项物品或资产的时候。可稱紅豆效應

这一现象常常用于行为經濟学的分析中，并与损失厌恶的理论相联系。由于禀赋效应，人们在决策过程中，往往会产生偏见，导致对于规避风险的考虑远远大于对于追逐利益的考虑，因此人们在出卖物品或资产时，往往索价要比其本身更高的价值。

I had noticed that the sickest patients on the ITU, the ones expected to die or become brain-dead, had often disappeared by the next morning. I was reluctant to ask what had happened, and it was some time before I learnt that usually the families would take the patients home, hand-bagging (手工按压呼吸气管气袋) them if necessary, so that they could die with some dignity within the family home, with their loved ones around them, rather than in the cruel impersonality of the hospital. It struck me as a very humane solution to the problem, although sadly unimaginable back home.

Chapter 11 Memory

My mother’s sister was an enthusiastic supporter of Hitler and the Nazis, and her brother joined the Luftwaffe, although from a love of flying and not from any political conviction. I do not know how my mother knew that Hitler’s regime was evil. It is only since her death, by reading about Germany at that time (in translation, given my shameful lack of German) that I have come to understand just how remarkable was her defection. Her decision to leave Germany – a country with the deepest respect for authority and on the br nk of war – would have been seen by many as treason. It seems obvious and easy in retrospect, but how I wish she was still here so that I could talk to her about this.

作者的母亲（德国人）因为反对纳粹，在二战爆发前夕毅然离开了自己的祖国，在当时这种行为可能被很多人指责为叛国。然而历史将会证明，在一个独裁政权国家，不爱国是最大的正义。

FRCS examination: Fellowship of the Royal Colleges of Surgeon, a professional qualification to practise as a senior surgeon in Ireland or the United Kingdom.

PVs [vaginal examinations]。分娩时的一种常见的妇科检查，医生或助产妇将手指伸入孕妇阴道内以感知宫颈(cervix)扩张程度。

Chapter 12 Ukraine

SBU: The Security Service of Ukraine (Ukrainian: Служба безпеки України, romanized: Sluzhba bezpeky Ukrainy) or SBU (Ukrainian: СБУ). 烏克蘭國家安全局

Chapter 13

I spoke of how difficult it is for doctors to be honest. We learn this as soon as we put on our white coats after qualifying. Once we are responsible for patients, even at the lowest level of the medical hierarchy, we must start to dissemble. There is nothing more frightening for a patient than a doctor, especially a young one, who is lacking in confidence. Furthermore, patients want hope, as well as treatment

So we quickly learn to deceive, to pretend to a greater level of competence and knowledge than we know to be the case, and try to shield our patients a little from the frightening reality they often face. And the best way of deceiving others, of course, is to deceive yourself. You will not then give yourself away with all the subtle signs which we are so good at identifying when people lie to us. So self-deception, I told the Ukrainians, is an important and necessary clinical skill we must all acquire at an early stage in our careers. But as we get older, and become genuinely experienced and competent, it is something we must start to unlearn. Senior doctors, just like senior politicians, can easily become corrupted by the power they hold and by the lack of people around them who will speak truth to power. And yet we continue to make mistakes throughout our careers, and we always learn more from failure than from success. Success teaches us nothing, and easily makes us complacent. But we will only learn from our mistakes if we admit to them – at least to ourselves, if not to our colleagues and patients. And to admit to our mistakes we must fight against the self-deception that was so necessary and important at the beginning of our careers.

Chapter 14. neither the sun nor death // Talking about death and euthanasia

There is no evidence that the moral fabric of these societies that permit euthanasia is being damaged by the availability of this form of euthanasia, or that elderly parents are being bullied into suicide by greedy children. But even if that occasionally happens, might it not be a price worth paying to allow a far greater number of other people a choice in how they die?

neither the sun nor death can be looked at steadily, and I do not know what I will feel as I enter old age, if I start to become dependent. What will I decide if I begin to lose my eyesight, or the use of my hands?

Scientific medicine has achieved wonderful things, but has also presented us with a dilemma which our ancestors never had to face. Most of us in the modern world live into old age, when cancer and dementia become increasingly common. These are now usually diagnosed when we are still relatively well and of sound mind – we can predict what will happen to us, although not the exact timing. The problem is that we are condemned by our evolutionary history to fear death. In the remote past our ancestors – perhaps even the simplest life forms with some kind of brain – did not survive into frail old age, and extra years of healthy life were precious if the species was to survive

Life, by its very nature, is reluctant to end. It is as though we are hardwired for hope, to always feel that we have a future. The most convincing explanation for the rise of brains in evolution is that brains permit movement. To move, we must predict what lies ahead of us. Our brains are devices – for want of a better word – for predicting the future. They make a model of the world and of our body, and this enables us to navigate the world outside. Perception is expectation. When we see, or feel, or taste or hear, our brains, it is thought, only use the information from our eyes, mouth, skin and ears for comparison with the model it has already made of the world outside when we were young. If, when walking down a staircase, there is one more or one less step than we expect, we are momentarily thrown off balance. The famous sea squirt, beloved of popular neuroscience lectures, in its larval stage is motile and has a primitive nervous system (called a notochord) so it can navigate the sea – at least, its own very small corner of it. In its adult stage it fastens limpet-like to a rock and feeds passively, simply depending on the influx of seawater through its tubes. It then reabsorbs its nervous system – it is no longer needed since the creature no longer needs to move. My wife Kate put this into verse.

I wish I were a sea squirt,
If life became a strain,
I’d veg out on the nearest rock
And reabsorb my brain.

We have to choose between probabilities, not certainties, and that is difficult. How probable is it that we will gain how many extra years of life, and what might the quality of those years be, if we submit ourselves to the pain and unpleasantness of treatment? And what is the probability that the treatment will cause severe side effects that outweigh any possible benefits? When we are young it is usually easy to decide – but when we are old, and reaching the end of our likely lifespan? We can choose, at least in theory, but our inbuilt optimism and love of life, our fear of death and the difficulty we have in looking at it steadily, make this very difficult. We inevitably hope that we will be one of the lucky ones, one of the long-term survivors, at the good and not the bad tail-end of the statisticians’ normal distribution. And yet it has been estimated that in the developed world, 75 per cent of our lifetime medical costs are incurred in the last six months of our lives. This is the price of hope, hope which, by the laws of probability, is so often unrealistic. And thus we often end up inflicting both great suffering on ourselves and unsustainable expense on society.

In every country, health-care costs are spiralling out of control. Unlike our ancestors, who had no choice in these matters, we can – at least in principle – decide when our lives should end. We do not have to undergo treatment to postpone fatal diseases in old age. But if we decide to let nature take its course, and refuse treatment for a fatal disease such as cancer, most of us are still faced with the prospect of dying miserably, as in only a few countries is euthanasia – a good death – allowed. So, if euthanasia is not
permitted, we are faced with the choice of dying miserably now, or postponing it for a few months or longer, to die miserably at a later date. Not surprisingly, most of us choose the latter option and undergo treatment, however unpleasant it might be.

Our fear of death is deeply ingrained. It has been said that our knowledge of our mortality is what distinguishes us from other animals, and is the motive force behind almost all human action and achievement. It is true that elephants can mourn their dead and console each other, but there is no way of knowing whether this means that, in some way, they know that they themselves will die.

But I do not believe in an afterlife. I am a neurosurgeon. I know that everything I am, everything I think and feel, consciously or unconsciously, is the electrochemical activity of my billions of brain cells, joined together with a near-infinite number of synapses (or however many of them are left as I get older). When my brain dies, ‘I’ will die. ‘I’ am a transient electrochemical dance, made of myriad bits of information; and information, as the physicists tell us, is physical. What those myriad pieces of information, disassembled, will recombine to form after my death, there is no way of knowing. I had
once hoped it would be oak leaves and wood. Perhaps now it will be walnut and apple in the cottage garden, if my children choose to scatter my ashes there. So there is no rational reason to fear death. How can you be afraid of nothing? But of course I am still frightened by the prospect. I also greatly resent the fact that I will never know what happened – to my family, my friends, to the human race. But my instinctive fear of death now takes the form of fear of dying, of the indignity of being a helpless patient at the mercy of impersonal doctors and nurses, working shifts in a factory-like hospital, who scarcely know me. Or, even worse, of dying incontinent and demented in a nursing home

I doubt if she would have wanted to bring her life to a quick end with a suitable pill if she had been given the choice. She strongly disapproved of suicide. But for myself, I see little merit or virtue in the physical indignity which so often accompanies our last few days or weeks of life, however good the hospice care which a minority of us might be lucky enough to receive. Perhaps I am unrealistic and romantic to hope that in future the law in England will change – that I might be able to die in my own bed, with my family beside me, as my mother did, but quickly and peacefully, truly falling asleep, as the tombstone euphemisms put it, rather than incontinent and gasping with the death rattle – at first demonstrating the O-sign, as doctors call it, of the mouth open but with the tongue not visible, to be followed by the Q-sign, which heralds death, with the furred and dried tongue hanging out.

For those who believe in an afterlife, must we suffer as we lie dying, if we are to earn our place in heaven? Must the soul undergo a painful birth if it is to survive the body’s death, and then ascend to heaven? Is it yet more magic and bargaining – if we suffer now, we will not suffer in the future? We will not go to hell or linger as unhappy ghosts? Is it cheating, to have a quick and easy death? But I do not believe in an afterlife – my concern is simply to achieve a good death. When the time comes, I want to get it over with. I do not want it to be some prolonged and unpleasant experience, presided over by terminal-care professionals, who derive their own sense of meaning and purpose from my suffering. The only meaning of death is how I live my life now and what I will have to look back upon as I lie dying. If euthanasia is legalized, this question of how we can have a good death, for those of us who want it, with pointless suffering avoided, can be openly discussed, and we can make our own choice, rather than have it imposed upon us. But too often we prefer to avoid these questions, as I did with the poor man at the beginning of my surgical career. It’s as though it is better to die miserably than to admit to the inevitability of death and look it in the face.

Afterword

(About the author)
HENRY MARSH...He was made a CBE in 2010

CBE - Commander of the Most Excellent Order of the British Empire / 司令勋章
参加 Order of the British Empire (大英帝國勳章)