Audio-Visual Media Reviews points. Further, while the series provides an overview of the issues, controversies and arguments in international research ethics, it is worth noting that it does not serve as a substitute for more in-depth training in research ethics, especially for those who are responsible for conducting research and interacting with research participants in low- and middle-income countries. Training in research methods, communication and research ethics are all imperative and interrelated on the operations side of research. Nonetheless, the series demonstrates a clear need for further development of international research regulations, policies, agendas, training programs and relationships.
JOSEPH ALI Berman Institute of Bioethics, Johns Hopkins University Baltimore, Maryland, USA.
The English Surgeon. Directed and Produced by Geoffrey Smith. 2008 Eyeline Films. 2009, PBS Distribution. Original Music by Nick Cave and Warren Ellis. Priced from US$24.95 & £14.95 (for home viewing) to US$295.00 & £100.00 (for institutional viewing). Henry Marsh, senior consultant neurosurgeon at St. George’s Hospital in London, first visited Kiev in 1992. Invited to travel to the Ukraine by an English businessman hoping to sell medical equipment there, during his stay Marsh visited a nearby hospital. There, he found a facility lacking adequate equipment and medical supplies, without a regular supply of electricity, and stinking of ammonia. Shocked by what he observed, Marsh asked how he could help. ‘You can do nothing’, he was told. Given the post-Soviet collapse of Ukraine’s public health infrastructure, local physicians said such efforts would be ‘a drop in the ocean’. The next day, Marsh encountered Igor Kurilets, a young physician who had taught himself English by listening to the BBC World Service. Kurilets, equally outraged by the state of health care in Kiev, was outspoken about the need to improve medical care and access to treatment. Since that first visit to Kiev, over an eighteen-year relationship Marsh has sent surgical instruments, hospital equipment and other medical supplies to Kurilets. Every year he visits Kurilets’ clinic, consults on cases, trains surgeons and helps treat Kurilets’ patients. At the time the documentary was filmed, Kurilets dreams of building his own hospital, but operates his clinic inside a private hospital run by the SBU, successor agency to the Ukrainian KGB. Many of the patients seen by Kurilets
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and Marsh are victims of delayed diagnoses and have advanced tumours. Marsh mentions that when he travels to the Ukraine he sees medical problems that ‘have not been seen in the West for 50 or 60 years.’ The English Surgeon is, in part, a story about two physicians’ efforts to provide desperately needed care in a setting where patients live in poverty. The health care ‘system’ in Kiev is poorly funded and hierarchical. Conflicts with other health care professionals make it difficult for Kurilets to keep his clinic functioning. Corruption is widespread and patients seeking treatment at local public hospitals are expected to make ‘under the table’ payments if they expect to receive prompt care. A practical man who enjoys working with his hands and appreciates the crafts of both carpentry and surgery, Marsh acknowledges that surgery is a ‘blood sport’. Marsh draws satisfaction from his work, but he also struggles with the consequences of his actions. Hospitals, Marsh mentions, are like prisons ‘where a small number of people are doing nasty things to a large number of people.’ The most thought-provoking scenes in The English Surgeon involve Marsh confronting the moral tensions involved in providing neurosurgical care and risking causing harm while trying to offer aid. Though the story might be engaging even with a central character confident of the virtue of his actions, what makes The English Surgeon particularly compelling is the modesty, thoughtfulness and, at times, agonized reflections of Marsh. The truly difficult challenge, Marsh argues, is not the act of surgery, but knowing when he should use his surgical skills and when he should instead ‘cross to the other side of the street’ and not subject patients to surgery. Pointing his fingers to both temples, Marsh describes the surgical procedures he offers as a form of Russian roulette for his patients. The risks that accompany providing surgery must be weighed against the risks of not offering surgical care. The case that most haunts Marsh involves a young child, Tanya, whom Marsh treated for what he describes as one of the largest brain tumours he has ever seen. Marsh first encountered Tanya and her mother in Kiev, and later flew them to London at his own expense. There, he performed two lengthy operations on Tanya before child and mother returned to Kiev. ‘Because of my two operations’, says Marsh, ‘she had a terrible last two years of her life.’ Reflecting upon her death, Marsh says that were he faced with the situation again he would know not to let emotion affect his clinical judgement. Yet, after making this claim, he mentions the pull to do something. While treating patients queuing in long lines in the dingy hospital’s hallway, Marsh struggles with the consequences of his visits to Kiev. He recognizes that he offers hope but he also knows that in many instances the hope patients have is unwarranted. He wonders whether
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by visiting the clinic he is cruelly creating false hope. When seeing patients at Kurilets’ clinic he encounters many patients with advanced tumours. Some patients he is able to help. In many instances he says there is nothing that can be done. Many patients, he mentions, would be ‘salvageable’ were he seeing them back in London. How much should be said to patients is a subject with which both Marsh and Kurilets struggle. Near the end of the film, Ulyana, a young woman with a terminal illness visits the clinic. She informs the doctors she has been told a tic bite might have resulted in encephalitis. Marsh tells Kurilets the young woman has an untreatable tumour and she will first go blind and then die. Kurilets stops translating from English to Ukrainian, stares at the floor, and says he does not know what to say to the woman. Neither doctor wants to lie to her, yet neither of them feels they should describe to her exactly what will happen. She leaves with instructions to return with her mother. The English Surgeon is a powerful and moving film. Marsh emerges as a thoughtful, decent, technically accomplished surgeon, trying to help patients who would not otherwise receive the care they need. Kurilets’ achievements are recognized, though as the title of the film indicates the focus falls on Marsh more than Kurilets
and his colleagues. In addition to describing the death of Tanya, the film dwells upon one patient, Marian, who remains awake throughout the operation as Marsh drills and cuts open the top of Marian’s skull and then removes a tumour from his brain. With the film’s focus on particular individuals, various ‘background’ themes do not receive much attention. Viewers learn little about the family lives of Marsh and Kurilets. The documentary offers limited insight into the broader social and political context of health care in the Ukraine. The film takes a ‘close up’ approach to its subjects and we get only glimpses of what a wide angle lens might capture of their lives and the broader social background against which events unfold. Despite this limitation, The English Surgeon, directed and produced by Geoffrey Smith, is a thoughtprovoking film and deserves a far wider audience than so many documentaries find.
LEIGH G. TURNER, PhD. Center for Bioethics and School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
© 2010 Blackwell Publishing Ltd.
