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

MILL VALLEY FILM FESTIVAL

35th Annual Mill Valley Film Festival between October 4 and October 14. Here are the films that I'll be reviewing for bioethicsscreenreflections.com at MVFF 35.

October 4: Silver Linings Playbook

October 5: Argo

October 6: Flicker

October 7: Sessions

October 9: Rebel with a Cause, Whole Lotta Sole, Last Man on Earth

October 10: Happy Event, Tribute to Mira Nair & the Reluctant Fundamentalist
October 10: Rise of the Guardians ( will be covered by Fantasy BSR reviewers, Curd and Katie)

October 11: Lore, Not Fade Away

October 12: Rent a Cat, Like Someone in Love

October 13: It's a Disaster, Stand Up Guys

October 14: Life of Pi

THE WORDS: Creativity, Scientific Integrity & Cultural Evolution

THE WORDS is a film that brings a whole new meaning to the term character driven. Here, four different men play one principle character. He has different names, ages and stages of creative capacity portrayed by Bradley Cooper, Jeremy Irons, Ben Barnes and Denis Quaid. The character is in love with a story which has been translated into a literary work. There is an element of torment and ineptness in the love.  The moral muse of the male character is played by three women; Olivia Wiled, Zoe Saldana, and Nora Arnezeder. The capacity of this film to telescope one character and story into another is a marvelous Rubik's cube. Director Brian Klugman and co-writer Lee Sternthal should be well recognized for their facility in showing the multiple faces of this tale.  Each man in the film wants to own the story in question and does.

THE WORDS is important to bioethics because it illustrates that ownership of a narrative is complex; even more so when embroidered by its developmental consideration.  Literature, like science, resembles a value, like peace, more than property. Such values are owned by the collective not by the individual. We process all art through our own experience.  Isn't it what artists want us to do? What is really the harm of taking someone else's creative product as one's own?   Novels are usually solo creations. Other art forms, film, dance, drama and research are collaborative. How can they be considered to have only one author?  This delicate tangle of creative influences is often blown away by matters of law, abandoning obligations to understanding the moral significance of creative theft. Regulatory, societal devices co-modify creativity; confining it to the potential monitory product it yields.

A narrative has to be recorded in order to be owned under law, despite how its derived. The issue is chronology of registration as with patents, trademarks, publication copyright and other intellectual property registries. Theirs is also a question of order of authorship. Ownership in terms of moral authority to tell a story is more muddy. (See THE HELP on this blog.) In the eyes of the law, oral folk tales are not owned until published. Then they are owned by the publisher and editor. These stories exist for generations as the common property of the group of people who generate them, usually orally.  To paraphrase the late director of the game changing film BLUE, Krzysztof Kieślowski, the best of these narratives find resonance between people, breaking down isolation and becoming a part of culture. In this transcendence narratives can become universal.

There are only a few universal themes; love, birth, suffering, loss and death. Universal stories are common to all persons, if not to all living things. How a universal story differs in the telling is the key to intellectual property or legal ownership in literature. THE WORDS presents a new telling. The film is a constellation of stars without need for a sun. 

In contrast to literature, scientific integrity in research is dependent on reproducing the methods of other researchers to reach the same conclusion. Science is almost always collaborative. A hypothesis, ingeniously generated, is tested by attempts to disprove it. If the hypothesis cannot be disproved, that bit of information obtained is considered to be true. More experimental manipulation clarifies the amount of pressure a particular truth can withstand without becoming lost. The rules (laws and policies) defining research misconduct usually include: intentional fabrication, falsification, plagiarism  or other serious deviation from accepted practices of science in proposing, carrying out  or reporting results of research (Macrina, 1995). 

Bench researchers and other artist/craftsmen are both relatively low on the economic food chain. Their rewards for moral integrity are left largely unremunerated and errors in method swiftly found intolerable. Bad research results in dangerous medicines, medical implements, unsafe building structures and on and on. But the harm of plagiarism is broader than a mis-shaped commodity. Science is Art. Both are creative endeavors coming from a shared reservoir of human consciousness. Creativity is discouraged when it is not recognized. Plagiarism causes a creative post-traumatic stress syndrome, brilliantly depicted by Jeremy Irons in THE WORDS. Draining the creative reservoir limits creative growth and stifles prospects for cultural and intellectual evolution.  

THE WORDS (35 mm) directed by Brian Klugman (2012)  USA. CBS Films.  96 min.

For more understanding see: 

Macrin, Francis. Scientific Integrity: An introductory Text with Cases.  American Society of Microbiology. Washington, DC. 1995.  p 1-14

THE HELP (35 mm) directed by Tate Taylor. (2011) USA. Touchstone Pictures. 146 min.

http://www.musicolog.com/kieslowski_manycolours.asp

Tricolor: Blue. (35 mm) directed by Krzysztof Kieślowski (1993) France, Poland, Switzerland. Mirmax/MK2 Diffusion.

THE HELP: Racism v. Justice and the Right to Protest

-->The film, THE HELP is a historical fiction, close enough to the truth to raise moral concern.  It is mostly about the development of a book revealing the impact of racism on black and white families. The film is adapted from the Kathryn Stockett novel set in Jackson, Mississippi during the early 1960s. It's the rising phase of the civil rights movement. The story is viewed primarily through the eyes of women.  Central to THE HELP is unequal risk of harm to black women when compared with white women.

To the films credit, intentional or not, it also stimulates moral questions about the ethical conflicts inherent in the telling of other peoples' stories. Ethical concerns include adaptation from traditional oral storytelling, to novels, plays and films.  Necessarily, these adaptations raise worries about ownership of the intellectual property conveyed. In bioethics, we would consider these issues primary conflicts between the principles of autonomy (the right to do what is in one’s own best self-interest) and justice (the obligation to insure equal distribution of risks and benefits.   Finally, audiences believe in the accuracy of historical fiction. They are not dissuaded from this belief by the above the line statement, "based on..."   Those whose characters have been captured in fiction films are often angered by the ways in which they have been distorted by creative license.  Historically, artists have had the right to re-write history, even in ethically charged situations. 

THE HELP has an outstanding ensemble cast of both black and white women. In the film, Abline (Viola Davis) is a black woman who works as a domestic for a white family. She has done this kind of work since she herself was an adolescent.  The child in the family, a girl who is maybe three years old, is being emotionally and physically abused by her own mother. The mother of is viciously insecure. Abline cares for this child's health and dignity leaving her absent from the needs of her own family and community.  Abline's autonomy is thus compromised. In Abline's absence, her own son's life is brutally taken as a direct result of racism. Yet, Abline continues to maximize her humanity with regard to the child she cares for in the white family.  Davis eloquently, expresses the double bind black women, and others working as domestics, find themselves in.  Abline is forced to act against her self-interest, assuming a high risk while doing so.

A  Kennedy era white college graduate, Skeeter (Emma Stone) returns home to Memphis after having obtained a university education. Compared with her hometown peers, Skeeter is a feminist.  She struggles to want what her white southern culture demands for her, a man and a family. Those wants don't stick.  She really prefers a writing career. Skeeter's broader exposure leaves her questioning by the racism, sexism and classism of her childhood friends.  Like a good creative opportunist, in the film, she sees in Abline the story that can make her publishing mark; telling the story of black maids in their own words. This insight occurs in immediate context of the murder of Meager Evers, the African American, WWII Veteran and civil rights leader.

The character of the publisher (Mary Steamvirgin) insists that Skeeter not just edit but write part of the book. This is a small homage to the intellectual property conflict. The publisher's demand forces honesty about the strength of the bond between domestics and the children they care for. Skeeter's mother (Allison Janney) is dealing with cancer, imposing on her the end of life task of looking at her own inadequacies. Chief among these inadequacies is the moral cowardess she showed through vicious racism directed at the black woman who raised Skeeter (Cicely Tyson).  

THE HELP is a film tied to Steven Spielberg's DreamWorks Studio. There is a long drama between the film industry and the struggle around racism. In 2000, Spielberg refused to receive the "D.W. Griffith Lifetime Achievement Award" of the Director's Guild of America unless the name was changed. Once having leveraged change of the award's name to the "DGA Life Time Achievement Award", he spoke of the elephant in the room during his acceptance speech.  Paraphrasing, he believed "You can honor the evolution of film grammar, without honoring the name of a known racist.”   We don't always get genius in the package we want, but we don't have to be happy about that fact. The history of the struggle against racism has been a series of small changes with occasional big peaks. Having a filmmaker of Mr. Spielberg's heft stand against racism is significant in an industry that has so much power.  He also mentioned “that yet to occur moment when an African American director first wins the DGA Lifetime Achievement Award.” What a tragedy it would be if that director was forced to reject the honor - because it was named after a racist.

How is THE HELP relevant to the applied bioethics called clinical medical ethics? Justice is the most complex of the three ethical principles which influence ethical medical care.   Beneficence and autonomy are thought to be the other most relevant principles. Justice, though we know it when we see it, seeing it is rare.  We speak more of injustice. Injustice is defined as: designation of risk and benefits to specific persons in a way that causes them disproportionate harm.  Racism is a typical manifestation of injustice. Injustice almost always exists on a geopolitical historical scale. This scale is hard to manage in a clinical setting but we see its repercussions daily; post-traumatic stress, loss of self-worth, depression and diseases of health disparities. Among these diseases are: tuberculosis, cancer, diabetes, cardiovascular disease, HIV/AIDS, and substance abuse.  Injustice blocks learning, motivation and frequently causes death at the hands of self or others. The fundamental transhumanistic/public health principle underpinning clinical medicine is the obligation to use science to strive for better and longer life.  If injustice impedes meeting this obligation, it is logical that justice could reverse the harm. Hence, clinical medical ethicists find injustice so difficult to manage; we are dragged into the fight for justice.

Viola Davis' portrayal of Abline's grief from the death of her son, takes a bite out of the American public's heart, like none since Cicely Tyson's son was taken from her in ROOTS (1977).  I saw THE HELP at a small neighborhood theater in a mostly Asian community of San Francisco.  A blockbuster movie was opening on the screen in the empty adjacent theater.   On that Saturday night, there was a music festival in Golden Gate Park a few blocks away, drawing thousands. Yet, THE HELP had a fairly full, predominantly neighborhood Asian audience. The mostly Latina domestic hotel workers on strike downtown, demonstrated outside of a major Cineplex where THE HELP was screening. Their placards truthfully stated, "We are the Help!"  People identify with the characters in this film across racial and ethnic lines. Many viewers are connected by class or family history.

While Viola Davis' Abline is unrelenting, direct, unapologetic, controlled and rational, Octavia Spencer's portrayal of Minny provides brilliant comic and common sense relief.  In Spencer's hands, Minny is reminiscent of Hattie McDaniel in GONE WITH THE WIND (Flemming, 1939); speaking lines McDaniel could only have wished to speak. Those who argue that racism in America has been done to death on film should note this fact: in February 2012, Black history Month, Minny or Mammy remains the preferred African American woman big screen portrayal compared with the rarer, Abline roles. 

There have been more strides in small screen narratives toward expanding the types of roles for African Americans and other peoples of color. The film, DANCING IN SEPTEMBER (Rock-Blithewood, 2000) promotes this phenomenon. Films other than THE HELP, like LA MISMA LUNA/UNDER THE SAME MOON (Riggen, 2007), have improved understanding of racism, sexism and classism directed at women. The unconscionable cost of making and distributing good film continues to preclude some of the most socially relevant creative works from being viewed cross racially. This is unfortunate as film has quickly, and more broadly, influenced change in the moral spectrum than any other art form. For now, those who struggle for justice are thankful enough for THE HELP.


THE HELP (35mm) directed by Tate Taylor. (2011) USA. Touchstone Pictures. 146 min.

Roots (miniseries) produced by Stan Margulies. (1977) USA. ABC. 8 episodes / 720 min.

GONE WITH THE WIND (35 mm) directed by Victor Flemming and others (1939) USA. MGM/Warner Bros. 238 min.

DANCING IN SEPTEMBER (35 mm) directed by Reggie Rock Bythewood (2000) USA. HBO. 106 min.

  LA MISMA LUNA/UNDER THE SAME MOON (35 mm) directed by Patricia Riggen. (2007) USA. Fox Searchlight Pictures/The Weinstein Company. 106 min.

MY WEEK WITH MARILYN: Commodification, Frailty and Injustice

In an exchange of a few weeks ago about a recently dead star, I made the comment that I stand by: "If you consider a person a God, when they fall to the ground they are a Monster." People, in general should just be people; just equal.  To be considered more or less than a person is an injustice.  Marilyn Monroe was a woman who was frequently treated more or less than a person and so unjustly.   In her youth as a foster child, she was less. In her stardom, she was more. Approaching her death she was less again. 

My week with Marilyn (Michelle Williams) is based on two books by Colin Clark. It is adapted for the screen by writer Adrian Hodges and director Simon Curtis. The film shows Marilyn as frail and dependent.   It is under these circumstances that she spent time with Colin Clark (a young gofer for Sir Lawrence Olivier during the period when movie The Prince and the Showgirl was being made.
Smart people do not tolerate injustice well, when trapped they will chew off their paw to get out of a trap.  History is replete with examples, among them Marilyn Monroe. Until fame changes, its price won't. Fame is unsustainable because, in the language of Bioethics, the people who make fame use people as a commodity.  This commodity model is a slave model. When one slave dies the fame industry buys another.
Norma Jean Baker was 36 years old when she died.  Any college student with interest in child and family psychology could understand how Norma Jean Baker came to be found dead in August 1962 from probable suicide.  She was set up for the fall through rejections and abuses during her early years, followed by rejections and abuses during her years of fame. 
The Norma Jean Baker well depicted in the My Week With Marilyn was frail, vulnerable and misunderstood by all but a "lackey."  There is also an homage to Marilyn Monroe in The Help (Taylor, 2011). In this film it was also "the help"   that understood and protected her.  In both films she was married to a man she loved, but feared would not love her if he knew her truths. In both films she was pregnant but unable to be a viable mother. In both films she turned to working class people for support; her acting coach, production assistant, body guard, maid.  The outcome in The Help homage to Marilyn Monroe would have been so much more a better fate than the one actual befalling the real woman. Accuracy in historical biographies often takes a backseat to narrative, but these threads of Marilyn's reality stream through all her biographical leads.
Marilyn Monroe, though often reflected as dependent and frail, lived a dichotomous life. She supported and identified with working class and poor people. She was allied to significant forces in the left political and art movement; Arthur Miller, the Actors Studio as cases in point.  She openly supported   banning nuclear bombs, racial equality, human and civil rights. Her personal sexuality was in the feminist vein.  Further, she abhorred the HUAAC, just as openly as she embraced her causes. As a star, her job was to be a sexual commodity, yet as factory worker her photos are thought to have been a part Rosie the Riveters' evolution.  In her personal life, her fertility was at odds with her sexuality and her love relationships tenuous.  This woman's life was a perpetual double bind of competing interest.
Bioethical Conflict is considered irresolvable. If resolvable, it likely was not a real conflict.  Norma Jean Baker was caught in a real ethical conflict. Like many famous people, she died without resolution: Wealth and Fame, allowed her to do good. Fleeing Wealth and Fame would doom her to the poverty of self and finances from which she came.  My Week With Marilyn  is a road map to and for the fallen star.
My Week With Marilyn. (35 mm) directed by Simon Curtis. USA. The Weinstein Company. 2011. (101 min)

The Help (35 mm) directed by Tate Taylor. USA. Touchstone Pictures. 2011. (146 min)

The Prince and the Showgirl (35 mm) directed by Lawrence Olivier.  USA.
Warner Bros. 1957 (115 min)