23 Nov, 12 | by BMJ
A striking aspect of clinician involvement in bioethics is the therapeutic focus they bring to the table. Time and again, when non clinician ethicists present dilemmas, the doctors propose fresh diagnostic and therapeutic options, from therapist inputs to treatment choices. These release a creativity that liberates problems from artificially dichotomous and often more emotionally charged solutions that non clinicians tend to see. In general, the angles proposed tend to have strong elements of comfort and palliative care as well as of health gain.
This approach may not be as well articulated in ethical textbooks, but represent an ethics of care, competence (both technical and ethical), and communication (1) that has been elegantly summed up by Atul Gawande in the three principles underpinning Better, his book on improving healthcare: diligence, doing the right thing, and evoking human ingenuity.
This constructive and humane perspective is a useful lens through which to interpret medical issues in popular culture, and in particular the unhappy marriage of despair and lack of appropriate support and advice when faced with severe disability and illness.
For physicians experienced in rehabilitation, for example, the euthanasia of the quadriplegic woman boxer by her coach at the ending of the film Million Dollar Baby arose at the end of an extraordinary catalogue of missed therapeutic opportunities. Her pressure sores, as well as an infected leg which led to amputation, were indicators of sub-standard care by modern standards, she clearly had a severe untreated depression and unresolved family strife, and no effort was made to provide a more domestic and personalized environment in her “care” facility.
Similar thoughts struck me as I left a silent and subdued cinema at the end of Amour, the latest and much fêted movie from Michael Haneke, the Austrian director. Given the bleak style and subject matter of his previous films—self-mutilation (The Piano Teacher), family suicide (The Seventh Continent) and sadistic serial murders (Funny Games)—this film is notable in the first instance for its portrayal of warm and loving relationship between an ageing couple, both retired music teachers.
The formidable duo of actors at the heart of the narrative, Jean-Louis Trintignant (Georges) and Emmanuelle Riva (Anne), are both in their eighties in real life as well as on screen. Our first encounter is at a concert by one of their pupils, followed by their return home on public transport.
The first portent that the tenor of their comfortable life is to be disrupted is signaled by damage to the lock on their apartment from an attempted burglary. When soon after this Anne has a complex partial seizure at breakfast, presumably vascular in origin, Georges is puzzled but we sense a foreboding, and sure enough an encroaching darkness is looming.
Investigation reveals a carotid stenosis, but she suffers from a significant perioperative stroke after endarterectomy and returns home with a dense right hemiparesis. Georges is shown caring for her with love and affection, navigating with a kind resignation the peevishness and irritability that she expresses over her changed circumstances. His gloomy assessment to his daughter—”It will go steadily downhill for a while: and then it will be over”—raises question marks over what sort advice and support he has been given at discharge from the hospital.
A further stroke leads to marked aphasia and vascular dementia, and we embark on a pathway where Georges’ loving attention is punctuated by carer stress (leading at one point to him slapping Anne), elder abuse by a paid carer, and an eventual dénouement of euthanasia and suicide.
What struck me most, however, was his isolation from support and comfort from both professionals and family. The French were early pioneers of home care, with a fairly extensive package of support available to older people.
Yet we see Georges struggling largely on his own, using his own resources to pay for care support, for example, paying €800 when firing the care attendant/nurse who was rough with Anne, and making no call on adult protective services. A part of this is may be the irony well recognized in geriatric medicine that the income and social milieu of comfortable middle class may distance them from the public services, usually those best placed to respond to complex needs.
The relationship with his only child is strained and distant, although the director grants us subtle insights that the close cocoon of her parents’ love for each other may have also have had exclusionary aspects.
In the final scene, Anne signals distress through the repeated cry of “Mal,” a word that signals not only pain but also other layers of suffering. Could she be suffering from a pulmonary embolus, or the mundane but unexpressed pain of leg cramp or even constipation? Without support or guidance, the end-game plays out, and I felt not only their pain, but intense frustration at what might have been, and sadness that the final events might be construed as noble or beautiful in this context.
However, there are many deeply telling insights in this film, and in particular the portrayal of love and adaptation with serious illness and ageing. The interior and quite static style seems to echo another classic cinematic take on ageing, Tokyo Story, with the sobriety and lack of background music bringing to mind the harrowing Death of Mr Lazarescu.
What little music there is—Schubert and Beethoven played in concert or on CD—is beautiful but nearly always abruptly terminated, a marker of beauty stopped short by other circumstances, a further masterly metaphor from a cinéaste at the height of his powers.
1. Russell C, O’Neill D. Developing an ethics of competence, care, and communication. Ir Med J. 2009;102:69-70.
Desmond O’Neill is a consultant physician in geriatric and stroke medicine in Dublin, and director of the National Programme Office for Traffic Medicine in the RCPI: the views stated are personal.