Dignity Matters

REVIEW:

"The English Patient" (1996)

by Anthony Minghella

Reviewed by: Prof Willem Landman
Rating: ★★★★★

It is exactly 30 years since the release of the film The English Patient, a grand epic with the vast, sweeping north African landscape as backdrop, set in Egypt, but shot in the Tunisian desert at the same location as Star Wars. The vast, uncluttered expanse of the desert evokes the same sense of space and proportion as the Russian steppes in Doctor Zhivago (filmed in Spain and Finland).

The film is based on an eponymous novel by Michael Ondaatje, published in 1992. It was translated into 38 languages, shared the Booker prize in 1992, and won the Golden Man Booker 50 prize having competed against the best Booker winners of the preceding 50 years, with a finalist for each decade.

In 1997, the film won nine Academy Awards (Oscars), including best picture (Saul Zaentz), best director (Anthony Minghella), best supporting actress (Juliette Binoche) and best cinematography (John Seale).

The English Patient is indeed a milestone in the art of filmmaking.

Like the book, it is complex, with the Second World War as looming context, and five key characters. It is filled with intrigue, adventure and passion.

After a summary account of key moments in the complex plot, I propose an assessment of the closing scene of the film, an instance of medical assistance in dying (MAiD). Interestingly, discussions seldom reference this emotionally loaded climax of the film.

The film moves back and forth between two timeframes, the “present” and the “past”.

The “present”

The “present” plays off in the bomb-damaged, abandoned Church of San Girolamo in Fiesole, a town on a hill overlooking Florence, in Italy, in October 1944, towards the end of the Italian campaign in which the Allied forces were driving the Nazis northward through Italy.

With her field hospital relocating, Hana, a Canadian Army nurse (Juliette Binoche), offered to remain behind in the abandoned monastery church to care for an unknown, severely burned man, named “the English patient” (Ralph Fiennes) on account of his accent (later to be identified as a Hungarian, Count Ladislaus de Almásy). He was too badly injured to be relocated and not expected to survive much longer. He is bandaged and unrecognisably disfigured, suffers from amnesia, and does not remember his own name.

Almásy’s only possession is the ancient Greek historian Herodotus’s The Histories, with personal paper fragments and letters tucked inside. Hana reads Herodotus to him and administers morphine to ease his intense pain. Sedated, the English patient’s memory gradually returns and the “past” of the movie is revealed.

Also arriving at the monastery in the “present” are two characters who add to the complex tapestry of the film.

There is the enigmatic Caravaggio (Willem Dafoe), an Italian Canadian working for British intelligence, a friend of Hana’s father. He is at once colourful and somewhat menacing. His hands are bandaged because his thumbs were severed by the Nazis and he shows an interest in Hana’s morphine. Sinisterly, he claims he knows who the English patient is and that he cooperated with the Nazis. He tells Hana that her patient in fact remembers everything.

Also arriving at the church-hospital is the handsome, cheerful Indian Sikh officer Kirpal (Kip) Singh (Naveen Andrews) who volunteered with the British military for sapper bomb disposal under Lord Suffolk. Hana and Kip develop feelings for each other and begin a relationship.

An iconic, truly magical, scene is when Kip hoists Hana up by means of a rope attached to a pulley so she could have a close-up look at the paintings high up on the walls of the church, by flickering light and with dancing shadows on the walls.

Kip withdraws emotionally when Lord Suffolk and his sapper team, with whom he experiences a sense of belonging, are killed while attempting to dismantle a new type of bomb set up under a bridge by the retreating Nazis.

The “past”

From the vantage point of the “present”, the abandoned church serving as a hospital, the English patient (Almásy), sedated by morphine, begins to reveal his past.

Before the war, Almásy was a cartographer who divided his time between a desert camp and Cairo. To draw his maps, he piloted his own plane over the majestic desert landscape.

An Englishwoman, Katharine Clifton (Kristin Scott Thomas), and her husband, Geoffrey Clifton (Colin Firth), accompany Almásy’s desert exploration team. Almásy falls in love with Katharine, mesmerised by her voice as she reads Herodotus’s remarkable story of King Candaules of Lydia aloud by campfire.

When the war breaks out, the Cliftons abandon Almásy’s desert camp. In Cairo, Almásy and Katharine begin an intense affair. But Katharine cuts it short, saying that Geoffrey, whom she had recently married after their studies at the University of Oxford, would go mad if he were to find out.

Geoffrey discovers his wife’s affair with Almásy after she had already ended it. She is wracked with guilt. In an act of jealousy, Geoffrey pilots a plane, with Katharine on board, and deliberately crashes it into Almásy’s camp killing himself instantly, while Almásy survives and Katharine is seriously injured. She admits to Almásy that she always loved him.

Almásy carries Katharine to the nearby Cave of Swimmers for shelter. He promises to return with help and embarks on a long and arduous journey.

He reaches the British-controlled town of El Tag. The British do not believe his story and refuse to mount a rescue mission. Tragically, had he identified the injured Katharine by her real name, and not as his wife, which he did in the hope of receiving urgent help for her, she might have been saved because her name was well known to the British through her husband’s work for them making detailed aerial maps of North Africa.

In the years that follow, Almásy cooperates with German forces in North Africa. This enables him to return to the desert. He retrieves a colleague’s plane buried in the sand, flies back to the Cave of Swimmers, where Katharine’s body has been lying for several years. He wraps her remains in a cloth and attempts to fly her out of the desert. The plane suffers a mechanical failure and catches fire. Almásy is on fire but escapes the flaming inferno by parachute. He suffers from severe burns, leaving him unrecognisable, and is found and rescued by Bedouin tribesmen.

A merciful end

Back to the “present”. The critically burned Almásy, the English patient, suffering from failing organs, distraught and in severe pain, decides that he is ready to die. He signals this to his devoted nurse, Hana, by deliberately pushing several vials of morphine toward her. He says that he has “had enough”. Hana is deeply emotional but understands his desire for a merciful death. She grants his wish by administering a lethal dose of morphine into his IV drip.

As Almásy drifts into permanent sleep, Hana reads aloud the final, heartbreaking letter written by his late lover, Katharine, which she wrote while dying alone in the Cave of Swimmers.

Says AI: “This scene serves as one of the emotional peaks of the film, framing the act not as a crime, but as a final, compassionate gesture of mercy and love between the caregiver and her patient.”

Legalising merciful death

Interestingly, reviews of the film tend not to pick up on this theme of medical assistance in dying (MAiD). Considering contemporary debates about the ethics of both MAiD itself and of legalising MAiD, the following aspects of the final scene of the movie are worth noting:

• The English patient was injured, not suffering from an illness, although his organs were beginning to fail because of his injuries;

• It is hard to tell whether he was in a terminal state, often defined as likely to die within six months; burn patients now have a better recovery rate than in the 1940s, so he could have been in a terminal state;

• He was irremediably injured, irreversibly incapable of ever again leading a life that even approximates normal human enjoyment;

• His suffering was because of physical pain as well as resultant mental distress;

• We do not have any reason to believe that he was not mentally competent to decide about his continued life and to request MAiD;

• His request was voluntary, with no-one coercing or pressuring him into his decision, although the war and limited medical care obviously narrowed his options;

• Hana was in the employ of a field hospital with medication provided by the hospital, so it was a case of medical assistance in dying; and

• MAiD was administered by the caregiver, not self-administered; the English patient was likely incapable of self-administering due to his injuries.

Would the English patient have been eligible for MAiD as envisioned for South Africa by DignitySA’s constitutional challenge? I believe so.

The English patient was likely mentally competent, had severe injuries making any semblance of a normal life impossible, without ever higher dosages of morphine his suffering was unbearable and intractable, and his request was the outcome of a free choice.

With responsible institutional safeguards in place and observed, assistance like Hana’s would not only be ethically justified (as a matter of right and compassion) but also legal in a South Africa shaped by the normative standards – values, principles and rights – of its Constitution.

Palliative care is always non-negotiable in a MAiD setting. And with the extreme suffering caused by burn wounds palliative care and its limits require increased scrutiny.

Instances of nurses identifying with the suffering of their patients, even to the point of causing their death to end their suffering, are regularly reported worldwide in the media and lead to criminal prosecutions, like our own Smorenburg (1992) High Court case.

These instances involve non-voluntary MAiD where nurses act on what they believe is in patients’ best interest and without patients’ consent. This was not the case with Hana’s deed of compassion since Almásy himself judged his own life no longer worth living and consented to receiving a lethal dosage of morphine.

DignitySA’s court challenge involves voluntary MAiD only.

In conclusion

The English Patient is one of those timeless films that do not show their age despite radical developments in acting style and photographic technology. Hence it can be revisited, like works of classical literature, or groundbreaking movies, such as Ben Hur, The Shawshank Redemption, 2001: A Space Odyssey, or Schindler’s List. It is a story of love, betrayal and perhaps even redemption. Its stunning cinematography beautifully captures the majestic north African desert landscape.

Above all, it is a story of identification and solidarity with another, of caring and compassion for the sufferer, to the point of heeding the ultimate request despite the personal emotional cost involved for the helper.

Script by Michael Ondaatje and Anthony Minghella
Based on Michael Ondaatje’s novel The English Patient
Directed by Anthony Minghella
With Ralph Fiennes as Count Ladislaus de Almásy; Juliette Binoche as Hana; Willem Dafoe as Caravaggio; Naveen Andrews as Kirpal (Kip) Singh; Kristin Scott Thomas as Katharine Clifton; and Colin Firth as Geoffrey Clifton
1996
162 minutes
Awarded nine Oscars

This review was provided by Prof Willem Landman. Willem is DignitySA's Chair and Co-founder, and holds degrees in philosophy, political philosophy, theology and law from the Universities of Stellenbosch, Oxford (as a Rhodes Scholar) and Unisa. He has chaired philosophy departments in South Africa and held a chair in Medical Humanities in the United States. He is the founding CEO of the Ethics Institute of South Africa and a co-founder of the international journal Developing World Bioethics.

REVIEW:

"Before Forever After: When Conversations About Living Meet Questions About Dying"

by Helena Dolny

Reviewed by: Vicki Read
Rating: ★★★★

Before Forever After is difficult to review because it makes you think about things that most of us would rather not think about at all.

Death. Dying. And what happens before we get there.

Helena Dolny’s Before Forever After gives us a collection of real experiences and difficult conversations and, in doing so, asks us to consider something much more personal: what do we actually want for ourselves at the end of our lives?

That sounds like a simple question. It isn’t.

As I read, I found myself stopping to think about my own wishes, the things I would want my loved ones to know, and the decisions I would want to have made while I was still able to make them. It made me realise how much of end-of-life planning isn’t really about dying at all. It is about making sure that the people we leave behind aren’t left trying to guess what we would have wanted.

And for me, that was one of the most valuable things about this book.

It doesn’t present death as something belonging only in hospitals or hospices. It brings it into our ordinary lives, our families, our relationships, our homes and our conversations. There are practical questions, emotional questions and deeply personal ones. Some are uncomfortable and some are surprisingly freeing.

I have always found it strange that we can talk quite openly about birth, relationships, illness, money and even our plans for retirement, yet the subject of death can bring a conversation to an abrupt halt.

Perhaps we are afraid that talking about death somehow makes it more real, but I’m now learning that talking about death can actually make us more present in our lives.

It can make us think about what matters. It can encourage us to put our affairs in order, to have difficult conversations while we still can, to tell people what we want, and perhaps just as importantly, to listen to what the people we love want.

As I have started exploring the world of death and dying more deeply, including my own interest in becoming a death doula, I have realised that I am not particularly interested in death as an abstract concept. I am interested in what happens to us as human beings when we know that our time is limited, and how we can help one another navigate that time with as much honesty, dignity and compassion as possible.

I don’t think I am any less afraid of death because of this exploration. Rather, I am becoming more comfortable with the idea that death is something I can acknowledge without allowing it to overshadow life.

There is something oddly comforting about being able to say, “Yes, this is going to happen to me one day.”

And then ask, “So what do I want to do with the time I have before it does?”

That is what stayed with me after reading Before Forever After.

It reminded me that dignity at the end of life doesn’t begin in our final days. Perhaps it begins much earlier, with knowing ourselves, expressing our wishes, having the conversations we have been avoiding, and giving the people we love the gift of not having to make every decision for us.

I also came away thinking that preparing for death is not a morbid exercise. There is something profoundly loving about it.

We prepare not only for ourselves, but for the people who will one day have to carry on without us.

Before Forever After won’t give you all the answers. I don’t think it is meant to. What it does is encourage you to start asking the questions.

And perhaps that is the point.

Perhaps the greatest gift this book gave me was the reminder that we don’t have to wait until someone is dying to begin talking about death. We can have those conversations while we are well, while we are together, and while there is still time to listen to one another.

And perhaps that is where dignity begins.

Vicki Read is a DignitySA Ambassador based in White River, Mpumalanga. In her application to become an Ambassador she wrote, “I have spent much of my working life organising, coordinating, communicating and making sure things happen properly. For years, I viewed those skills as merely administrative. Yet now I see that those same abilities could be used to bring order and comfort to families during one of the hardest periods of their lives…. At its heart, I believe (that being an Ambassador for DignitySA) is about setting yourself aside long enough to accompany another person through one of the most important moments of their life. I know it's a cliché, but I want to make a difference in someone's life that is meaningful, while also contributing to something on a larger scale. For me, that means being part of the work to challenge the current constitutional and judicial position around dignity, choice and end-of-life care in South Africa.”