Marsh recounts the story of Darren, whom he operated on for a medulloblastoma at age 12. After the tumor removal, Darren required a shunt for hydrocephalus, which blocked several times over the years. Despite these complications, he did well and went on to study accounting at university.

Eight years later, an unusually late recurrence, Darren’s tumor returned while Marsh was on sick leave. The night before a scheduled operation, Darren suffered a catastrophic hemorrhage into the tumor. He was placed on a ventilator but was “brain dead.” The ventilator was switched off days later.

Darren’s mother, convinced surgical delay had caused his death, requested a meeting. In Marsh’s office, she tearfully recounted her son’s last plea for help. After she repeatedly went over the events, Marsh, in desperation, shouted that he had not been there and could not help. She angrily reported that ITU staff had said that keeping her “brain-dead” son on the ventilator was upsetting for them. She rushed out.

Marsh followed her to the car park, apologized, and said he had no loyalty to the hospital. As they walked back, he passed a sign about withholding treatment from abusive patients and reflected on mutual distrust between the hospital and patients. The mother left without another word.

A registrar revealed that Darren’s mother had refused to allow the ventilator to be turned off, causing difficulties with the nursing staff. Marsh remembered his own anger when his son William nearly died due to what he had felt was a doctor’s carelessness. He also recalled a young girl with long red hair who bled to death on the operating table; afterward, her grieving mother had held and consoled him.

Marsh reflects that while doctors need accountability, patients and families can sometimes offer the gift of forgiveness. He notes that Darren’s mother did not pursue a formal complaint, but he feared she would be haunted forever if she could not forgive.

Marsh reflects on becoming a consultant in 1987 and the sudden weight of responsibility for trainees’ mistakes. He recalls one of his first cases: a pleasant Italian man with acromegaly who came to the clinic with his emotional wife and three daughters. They expressed great confidence in him.

The pituitary surgery went well. However, three days later, as he was about to be discharged, Marsh found the patient aphasic with a paralyzed right arm after suffering a major stroke. A scan confirmed the stroke had somehow been caused by the operation. The patient could no longer use or understand language.

Marsh recalled other patients he had left in this condition, including two who suffered strokes during surgery and looked at him with terrible “dumb” anger and fear. The Italian man seemed merely puzzled. Marsh had many emotional conversations with the family. After the patient remained stable for 48 hours, Marsh assured them he would not die, although he doubted the man’s speech would return.

At one in the morning, the patient deteriorated. Marsh’s registrar called to report that his pupils had blown and he would die. Though Marsh initially said he would not come in, he drove to the hospital. He found the family, including a three-year-old granddaughter, crying in the corridor. He gathered them and explained the inevitability of death. The wife fell to her knees, begging him to save her husband. After half an hour, the family accepted that death was better than living without language. The daughters said they did not blame Marsh. The granddaughter, Maria, kissed him good night. As he left, the wife asked him to remember her husband in his prayers.

Marsh was relieved the man had died rather than survived severely disabled. Though he felt technically innocent, he sat in his car in the rain outside his house for a long time before going to bed.

Marsh operated on a young man for a recurrent glioma that he had first removed five years earlier. The operation was performed with the patient awake under local anesthetic so Marsh could monitor motor function. The patient talked happily with the anesthetist, Judith, throughout the procedure. The operation went well. After supervising his registrar through two spinal cases, Marsh traveled to London for a legal conference.

The conference concerned a case from three years earlier when Marsh had failed to diagnose a postoperative streptococcal infection—a subdural empyema—leaving a female patient almost completely paralyzed for life. He met a neurosurgeon colleague advising his Defence Union. Marsh explained he had made the disastrous misdiagnosis over the phone on a Sunday while busy and distracted, having never encountered such an infection before.

They met with two Defence Union solicitors and a young Queen’s Council (QC). The QC gently stated the case was indefensible. Marsh immediately agreed. After his colleague left the room, the QC confirmed they had no case. Marsh said he was reconciled to this and was sorry to have devastated the woman and cost them millions.

Walking across Waterloo Bridge in freezing rain with his colleague, Marsh described the agony of facing a patient whom he had destroyed and admitted that the professional shame hurt most. He revealed that he had told the family to sue him and admitted he had made a terrible mistake, while remaining on friendly terms with them. His colleague remarked that there was always “another disaster waiting round the corner” in neurosurgery (191).

That evening, Marsh visited the young man he had operated on that morning. Sitting up in bed, the patient thanked him with intense gratitude. Marsh quietly told him to rest and left. He notes that he had learned two years later that the settlement was for £6,000,000.

On a spring Saturday, Marsh visited his mother in a 10th-floor hospital room overlooking Parliament. Her breast cancer from 20 years earlier had metastasized to her liver. She complained that overworked staff had left her bed unmade for two days and kept her without food while she awaited an unnecessary ultrasound. Marsh was on call for the weekend, dealing with bed shortages. He unsuccessfully tried to persuade an elderly man to go home, as he was well enough to be discharged. Consequently, he had to cancel another woman’s operation. Afterward, the ward sister forced Marsh to apologize to the elderly man who accused him of being rude.

While Marsh was in Glasgow, his mother was diagnosed with untreatable cancer and sent home to die. He returned to find her more jaundiced and frail. His father, beginning to suffer from dementia, looked on vaguely as Marsh cried. His mother said she did not want to leave them but believed death was not the end.

Marsh and his sister, a nurse, cared for their mother at home as she deteriorated rapidly over the next fortnight. They carried her upstairs each evening until she became too weak and decided to remain in the bedroom she had shared with their father for 40 years. A few days before her death, the extended family, including Marsh’s new partner, Kate, whom he had recently met, gathered for an impromptu wake while she was still alive upstairs.

Marsh describes his mother’s death as perfect: at home, lucid, pain-free, and surrounded by love. He details the physical decline of dying—the flesh shriveling, the face becoming unrecognizable, worn down to the skull’s anonymous outlines. On the morning she died, she was too weak to speak but nodded and shook her head in response. His sister called at midday to say their mother had died peacefully.

Marsh reflects on “the binding problem” in neuroscience (197)—how the physical matter of the brain remarkably creates consciousness. He does not share his mother’s belief in an afterlife. He recalls her saying she had lived a wonderful life and that everything that needed to be said had been said.

Marsh reflects on the neuroscientific view that consciousness depends entirely on the physical brain. An eminent neurologist asked him to examine a former patient in a “persistent vegetative state” (201). Marsh had operated on the woman a year earlier for a life-threatening hemorrhage from an arteriovenous malformation, which saved her life but left her in a coma. Weeks later, he had performed a shunt for hydrocephalus at her local hospital. The shunt had made no difference to her condition.

Marsh agreed to visit the patient at the long-term nursing home where she now lived. After his clinic, he drove to the neurologist’s home, and they traveled together to the nursing home—a former country house run by Catholic nuns. The nuns’ faith contributed to their provision of a caring home for patients with severe brain damage.

A sister led Marsh up a grand staircase. In the corridor, he was dismayed to see enameled plaques bearing the names of at least five former patients. He recounts his mentor’s remark that “great surgeons” tended to have poor memories, allowing them to forget and move on from their surgical failures. On one of the doors, Marsh recognized the name of a man he had operated on years ago in an 18-hour operation, tearing the basilar artery at two in the morning and leaving him in a permanent coma. Looking at the man’s “grey, curled-up body” in the bed (205), he realized he would not have recognized him.

Marsh examined the patient, a former journalist. She lay mute and immobile with rigid limbs and open, expressionless eyes. Photographs on the walls showed her before the hemorrhage, full of life. He quickly confirmed her shunt was working. A nurse interpreted bleeps from a Morse-code buzzer supposedly operated by the patient’s finger, relaying the patient’s questions and thanks.

In the corridor, the patient’s mother spoke desperately with Marsh, expressing doubt that her daughter had truly authored the communications transcribed by the nurses. Marsh reflects on the mother’s nightmare of uncertainty—her daughter both alive and dead. He was left to wonder about the unanswerable questions of whether the patient was truly conscious and whether the nurses were inventing the messages.