A LATE QUARTET: Bioethics and Grief

A Late Quartet had its USA premiere at the Mill Valley Film Festival. It is directed by Yaron Zilberman and co-written with Seth Grossman. Set for release on November 2, 2012, it will be a force to contend with. Generally, I try not to be effusive when writing about films. In this case, I have to admit, I can't help myself. Of all of the films I've seen at the 35th Mill Valley Film Festival; this is the only one that moved me uncontrollably to tears. The feeling evoked is most reminiscent of the intimacy one feels when caring for individuals and their families at critical points in their lives, particularly births and deaths.  A Late Quartet is a story of passion in the context of both.

This is a smart script.  The characters represent instruments in the Quartet; two violins, a viola and a cello, in reality and in the story line. The characters entrances into the composition are guided by sheet music, at once familiar and seen as though for the first time.  Christopher Walken, who I had seen the day before in a perfectly wonderful performance with Al Pacino in Stand Up Guys, surpasses even himself. In this film, the full range of his sensitivities and skill are apparent.  For me, he will never again be a convincing gangster or grifter. Philip Seymour Hoffman, who defies type casting, plays a surprisingly warm, vulnerable husband, father and second violin. Wallace Shawn, the founder of the Quartet, finds himself spiraling out of control because he falls prey to his own personality.

This is a big film for the two women who co-star in it.  In a season with only a handful of strong women's characters, Catherine Keener and Imogeen Poots both play sharp crisp roles. They well reflect both strength and the texture of women stretching the boundaries of love in a way that is uniquely specific to our gender. These are women’s roles bearing the strengths of this century.

How is this film significant in terms of bioethics? Bioethics is an organized way of thinking about conflicts between; what we know about medicine, what individuals want for themselves and what the collective thinks the other two are worth. There is medicine in the storyline, as well as grief, life threatening challenges and autonomous wishes and the need for transcendence. This work takes its lead from the String Quartet No.14 in C♯ minor, Op. 131, by Ludwig van Beethoven, an atypical seven movement quartet that is intrinsically connected to death.  On his death bed, Schumann requested to hear it.  The film, like the quartet, looks at loss from multiple angles; loss of life, love, health, passion and creativity. However, the story emerges from this abundance of loss with perseverance of passion. Fore-shadowing prepares the viewer for each characters arc. Set in warm rooms and a small concert stage, A Late Quartet is both ambitious and elegant in the style of a true New York movie and its classical music scene. 

A device of bioethics is the examination of the stages of grief to resolve associated conflicts in the process. The classical view of grief is the Kubler-Ross 5: denial, anger, depression, bargaining and acceptance. Instead, the James Hallenbeck 5 identifies tasks to be tackled during the developmental stage of life's end. People who are dying and those who love them need to say and hear: I'm sorry, I forgive you, thank you, I love you and, when it's time, goodbye.  The idea is that without focus on these processes, transcendence is not possible. Transcendence is the goal of dying and loss. In A Late Quartet, the Hollenbeck 5 form the opus. 

Finally, a variation of the Hettle Rule is attributed to cellist Pablo Casal; seek what works well instead of what does not, as a vehicle for healing. If there is one film to see this year, it is the visually smart, emotionally accessible, musically astounding, A Late Quartet.

A Late Quartet (35 mm) directed by Yaron Zilberman. USA.  2012
scheduled for release on November 2, 2012.


SILVER LININGS PLAYBOOK: Mental Illness Meets a New Genre

One of the two opening films, at the 35th Mill Valley Film Festival, was Silver Linings Playbook. Both the director/screenwriter, David O. Russell and lead actor, Bradley Cooper, were available for the post screening Q & A. Silver Linings Playbook is about people with manic depression, obsessive compulsive disorder, borderline personality disorder, situational depression and stigmatization.  The work is adapted from Matthew Quick's comic novel. The alternative publishing origins underpin the well sculpted traits of the film's characters. Did I mention it is a comedy? In fact, to be more specific, albeit a 21st century version, its genre is musical comedy. Think of Tracy and Hepburn doing Singing in the Rain. 

Gotta talk about the performances on this one. Pat Jr. (Bradley Cooper) gives one of the most convincing ranges of a person with mental illness that I have ever seen and as a clinician of thirty years, I've seen a lot. Robert De Niro (Pat Sr.) follows closely in Cooper's wake. Jennifer Lawrence, pops out of her role as Mystique/Raven (X-Men) seamlessly into the just this side of psychotic -perfect match for Pat Jr. They make what could have been a small domestic comedy a full contender.  

There are eight major characters and three of them are people of color: Chris Tucker, John Ortiz and Anupam Kher.  These roles brilliantly link the mentally ill to other disparities in health and their risks.  Anupam Kher's role raises great questions about reverse transference, where the therapist sees himself in his sports loving client. Kher as a psychiatrist may step over some traditional boundaries and Pat Jr. joins him.   One might argue that Russell was following the lead of the source material on the ethnic distribution, however many writers and directors don't.   Russell says that he followed the talent in his casting choices. I give him credit for even more than that in this many ways progressive film.

By subtly magnifying simple behaviors in the main characters, viewers begin to realize that mental illness is just one extreme of the human range of function for family, friends and neighbors. With conservative estimates being that 22 million Americans are affected by mental illness annually, the refreshing view of this film is not "the mentally ill are among us," but instead, "the mentally ill are us."  There is only one person in the film who you can't diagnose and it's because she is a device. She has virtually no spoken lines and shows up only as a Mrs. Colombo or Maris Crane cameo.
Bioethicists have been closely linked to providing guidelines protecting persons with mental illness who may also have poor decision making capacity.  Without decisional capacity, there can be no informed consent. However, assessing decisional capacity may be difficult for those who do not often use stringent organized tools for doing so. Worsening matters; the higher the risk the more stringent the informed consent should be.  For instance, in placebo trials, people have to understand that they may or may not get an effective drug as a placebo in the control or experimental arm of a study.  This understanding can occur but not likely in a five minute informed consent procedure provided for most subjects or patients. 
The task of the clinician and research team is to determine whether the potential subject has a level of health literacy to understand complex concepts. Every day practice improves decisional capacity. Even the prescribing of an aspirin should have an attendant disclosure for the drug and assessment of decisional capacity and remedy for its absence. The patient gets practice with the small things but so does the clinician. When the big things, like cancer, pop up at least everyone knows the playing field of informed consent, mental ill or not. 
Sometimes, there is a question when mental illness is decompensated simultaneous with high risk problems but intermediate urgency calling for a rapid decision. (It's an easy call if there is a life threatening emergency - error on the side of life and sort it out later; unless an advance directive prohibits such action.)  State by state in the USA, there are protections and rules in place which generally take matters out of the hands of clinicians, as well as the person who is mentally ill.   Generally, these rules are a part of the probate court system in the form of conservator, temporary or permanent, or other proxy for making decisions.  
As is the case with the main character of Silver Linings Playbook, Pat Jr., there is an historical precedent for stigmatizing mental illness as causing higher levels of violent crimes than the general public. In reality, evidence supports that people with mental illness are involved in violent crimes for the same reasons as those without mental illness; in the same proportions, but not caused by the mental illness itself. The case of jealous rage would be a good example. 
Silver Linings Play Book, beyond the serious aspects around mental illness, supports the ever resilient premise the art of love prevails over all adversaries. This love is romantic love, family love and community love. Smultz? Yes, but did I mention, it's a musical comedy? 
Silver Linings Playbook. (35mm) directed by David O. Russell. USA. The Weinstein Company. 2012
(At the time of this publishing this film's scheduled release USA release date is November 21, 2012.)
For information About Stigmatization in Mental Illness see:
Chambless, Dianne. Beware the Dodo Bird: The Dangers of Over generalization. Clinical Psychology: Science and Practice Volume 9, Issue 1, Article first published online: 11 MAY 2006
For information about informed consent, capacity and health disparity see:  
Williams, September.  Pain Disparity: Assessment and Traditional Medicine in THE AMERICAN ACADEMY OF PAIN MEDICINE Textbook on Patient Management. 2012. Deer, T.R.; Leong, M.S.; Buvanendran, A.; Gordin, V.; Kim, P.S.; Panchal, S.J.; Ray, A.L. (Eds.) Springer SBN 978-1-4614-1559-6
Due: November 30, 2012