THE DESCENDANTS meets DARK VICTORY: Medical Ethics and Sudden Death

Bette Davis' character Judith Trahern, in the film Dark Victory (Goulding, 1939) was ahead of the times in her resistance to the medicalization of her death. She showed the autonomy only allowed a spoiled willful young heiress. The Descendants (Payne, 2011) is a film taking the dialog about the end of life to another level.  We now know that Kubler Ross' five stages of dying are also the stages of grief.  As with Citizen Ruth, a film about a glue sniffing pregnant woman, director Alexander Payne again demonstrates deft handling of complex bioethical issues in the Descendants.   The Descendants is a progressive sequel to Dark Victory. A Husband and Father (George Clooney) is heir to virgin Hawaiian land. He is obligated to do what is best for it and for his tragically terminally injured wife.  He takes his obligations seriously but with emotion not previously shown in men. Clooney's performance demonstrates, in contrast to Bette Davis', the profound inelegance of dealing with conflict within families at ethically charged transitions.  Dark Victory and The Descendants each provide a snap shot of knowledge about these transitions as understood in their eras.   

The Descendants is about a Father and his two children dealing with a tragic accident which rips the mother from the family. The film is unique because the star (the character who undergoes the most change) has no lines. She is pictured water skiing for a few seconds, establishing that she is vibrant, athletic and sensual. She spends the majority of the movie comatose in a hospital bed until finally removed from medical supports.  However, her arch controls the other members of the classic upper class American Family.  The first born child, in late adolescence, is not ready for the world and wallows in self-indulgences bordering rack and ruin.  

The second child, at ten, is a trooper and may be the only adult pictured in most of the film.   The father of the family is left to the task of enacting his wife's advance directive.  As instructed by the family physician, he gathers friends to say goodbye to his wife. He is detoured by figuring out with whom his wife was having an affair. The latter project brings him closer to his eldest daughter at a point where the issues of anger are shared between them. The affair becomes a transition object acceptable to direct their rage. Parent and child then proceed together down the path to acceptance of the mother's death.   

What else is different about the Descendants? Instead of being a maudlin hand wringer, The Descendants is a comedy - in the same vein that Citizen Ruth was a comedy.  It is also cross cultural (Hawaiian) and evokes a responsibility to conserve memories of families and the environment. Finally, the Descendants deals with sudden death. Deaths are sudden only because in current medicine, some people who appear fatally injured do occasionally survive. These occasions lead to an expectation of survival, and when it does not occur the death becomes "sudden."  Historically, all death was sudden except that from old age.   

Clinical medical ethics, an applied arm of bioethics, often deals with issues associated with the edges of life; birth, illnesses that leave people lingering between life and death, individualism vs. community, and end of life transitions.   Some deaths are known to increase the risk of complex grief; sudden, violent, mass death or those involving children or young people.  Complex grief looks clinically like a post traumatic syndrome because. The Descendants brings an understanding of complex grief in the setting of traumatic sudden death in the presence of the modern tool of autonomy, the advance directive.  The screen writers move Clooney's character through the process of grief, in the best ways to prevent prolonged grief - they demonstrate beneficence or what we know ought to be done in such situations.   

This process of grieving begins from the moment that a life threatening illness is apparent.  Family and friends of those dying from chronic illness or injuries have time to grieve.  In sudden death scenarios, the psyche of loved ones does not have advance warning which allows them to organize the task of their grief.  Complicated Grief manifest itself as emotional illness, substance abuse, increased stress resulting in cardiovascular disease, insomnia and so on. Many hospital settings provide services to improve end of life and palliative care (to make peace with death and pain). However, we know that complex grief is only apparent greater than six months out from the primary event. Frequently, the need to track complex grief symptoms is buried by the curative model of care instead of being exposed by the palliative model.  

The Descendants is a good example of how bioethics astute medical teams deal with the risk for complex grief. In the film, a doctor gently notifies the husband of his wife's brain dead state.  The Husband responds, "But, she is going to be okay, right?"  This is a frequent denial response in such situations. The doctor realizes that the husband can't hear what has been said.  With a grief counselor at his side, the physician simply repeats the facts and leaves the father to begin to absorb the reality. However, the grief counselor stays to support the father. The primary care doctor, with the long view of the family, is clear and decisive about the mother's condition and her advance directives. He charges the husband with tasks which will move the grief process along; gathering friends and family who need to say goodbye. Further, without clubbing the viewer over the head, a memorial is created through preservation of virgin lands commemorating the life force of the now broken family.   

The Descendants is one of a few movies about death and dying demonstrating doctors taking a back seat. It is accurate in its demonstration of best practice in end of life care. The health care team sets in motion circumstances that foster  the family dealing with their own grief. 

Dark Victory (35 mm) directed by Edmund Goulding. 1939. USA. Warner Bros. 104 min.   

Citizen Ruth (35 mm) directed by Alexander Payne. 1996. USA. Miramax. 103 min.   

The Descendants (35 mm) Alexander Payne. 2011. USA.  Fox Searchlight Pictures. 115 min.   

Also Read:   

Kauai, H. (2010) The Descendants. Random House. New York. 283 pp.  

Ramsey, P. (1980) Ethics at the edges of life.   Yale University Press. New Haven. 370 pp.   

Housley, J.  Beutler, L.  ( 2007) Treating Victims of Mass Disaster and Terrorism. Hogrefe & Huber Publishers. Cambridge. 72 pp.   

Pfeiffer M.  and Quadrelli, S. 2011)  Paternalism and beneficence: Dark Victory  in  The Picture of Health.  eds. Colt, H. , Quadrelli, S. and Friedman, L. Oxford University Press. New York.  p. 56- 60.   

Quill, E. et al (2010) .  Grief and Bereavement in  Primer of Palliative Care 5th edition.  American Academy of Hospice and Palliative Medicine. AAHPM. Glenview.   p. 160-163.