GUESTWORDS: A Dangerous Film

   The very French movie called “Amour” has created a tsunami of universal acclaim: a beautiful, but tragic, love story of a lifelong romantic couple, now elderly, made even more real by the actors, themselves an aging movie hero and heroine. However, there may be a tragic misunderstanding involved in this universal appeal. The movie seems to tap into a perverse, pervasive, and profound misunderstanding of how we die of chronic, debilitating diseases, and of the critical role of doctors and medical knowledge at the end of life. Unfortunately, what may be satisfying as a work of art is so terribly dangerous and misleading as a guide to how to deal with the realities and necessities of terminal illness at home that I feel clarification is required.

    There may be problems of cultural ambiguity when this movie is viewed through the seasoned eyes of an American doctor (me). The magnificent acting and controlled direction make the audience think it is watching an astonishingly real story of soul mates dealing lovingly with death. Instead, we see a painful example of unnecessary pain and suffering caused by human ignorance, social neglect, and unintended dangers threatening two people so devoted to each other that they close themselves off to the rest of the world.

    Tolstoy, in his religiously fanatical final year, dealt harshly with devoted married love because he felt all humans should help others as much as possible, something that such intimate love prevented. The two characters in “Amour” are certainly shut off from the world. Consequently, the caregiver spouse ends up murdering the dying spouse, and the director wants and hopes to have the audience believe the murder is a generous act of caring love.

    My 55 years as a practicing doctor and clinical professor of medicine dealing closely and thoroughly with patients’ death and dying at home have taught me that much is left out in this film. She is dying slowly, agonizingly, relentlessly from multi-infarct dementia (mini strokes that gradually cause loss of brain tissue). The process is far enough along to cause loss of appetite. So she refuses to eat or even drink. Doctors know this happens because the disease deactivates some genes and activates others, causing complete anorexia, which becomes part of dying. Such dying patients differ from other humans and do not suffer when food and water are withdrawn.

    What does this caregiver do? He feels he must force her to eat. Why? To keep her alive? He knows her situation is hopeless. Yet her continuing refusal to eat builds up after weeks a sense of helplessness, frustration, and exhaustion, causing him to slap her sharply across her shriveled face. This aggression mortifies him, and he begs forgiveness, which he will not feel when daily accrued aggression leads to murder by suffocation.

    What does he say to her before his mortifying slap? “If you persist, I’ll call Bertier [the family doctor] and he’ll put you in hospital. They can force-feed you there. Is that what you want?” Where do such inappropriate ideas come from? This couple are not French peasantry, but well-educated musicians. What’s missing in the script is any conversation between the doctor and the struggling couple, or, if the patient is not competent, with the caregiver alone, perhaps including the daughter.

    Their doctor comes every two weeks and has been observing the helpless deterioration. He would have to be an idiot, and French doctors are not idiots, not to see what is happening to the patient and the caregiver. The script contains no dialogue regarding home management of how to deal practically with death and dying. Even the younger generation, their daughter, does not appear to have been involved. The director and screenwriter, Michael Haneke, has left all this out without explaining why. The audience is left to feel that doctors and medicine are one hideous beast best left outside the door.

    There are really two disease stories here. The dying wife and the overcommitted, caring, grieving husband, who has a relatively new but increasingly well-understood clinical condition we doctors call “caregiver syndrome” in its most severe form. Virtually all his time is devoted to backbreaking, intimate, emotionally humiliating (for both) care.

     Apparently the doctor never discusses this problem. But the audience glimpses it indirectly in two scenes — one with the daughter, who was critical of her father in some ambiguous way, and one with a fired nurse. He answers his daughter angrily, shouting, “Do you want to pack her off to a care home?” — as though that were the only alternative to his caregiving. Then he digs in with, “Do you want to have Mom live with you?” Not, “How about helping me with her care two or three times a week for a few hours to give me a break?” Her inability to answer makes her look bad and blameful to the audience, and what can be missed is the fact of just how overwhelmed he is. He must do everything and only his way.

    This rigidity comes out when he fires the nurse, whom he accuses of incompetence. (Or is it just her refusing to do it his way?) The previously competent nurse’s claim of injustice suggests the possibility of some compulsive irrationality of his, such as we saw with the forced feeding.

    So, suffering from anger and frustration, he murders his wife on an apparently sudden impulse by suffocation, a lousy way to die when conscious and struggling, which you see her doing for an inaccurately short period of time. Mr. Haneke wants us to think this was an act of mercy to end suffering. Whose? The husband’s or his wife’s? He talks it over with no one, not even himself. Don’t he, his doctor, his daughter, his nurses know that if he didn’t feed her for six or seven days she probably would have died peacefully?

    Another big problem the movie ignores is that once the human animal has killed, murdered, that soul is changed forever. Perhaps that is why everything that follows is a blur: Dialogue would be difficult. What you get is him on the phone about a pigeon getting in the apartment and a ridiculous scene with a blanket. It shows him smothering the pigeon much as he did his wife, yet he says on the phone he saved it.

    We see him silently cutting flower heads to make a pretty scene around her corpse. Who is the director kidding? Death is never pretty and any attempt to make this death pretty with daisies is outrageous, ignominious, and shameful. The death was neither certified by her doctor nor reported. Where does he go? What does he do? Tell the daughter? Look in the mirror? Laws were broken. Does Mr. Haneke want to solve all these complex story problems by simply implying a suicide? Was this a murder-suicide to begin with? If so, suicide frees the husband from human judgment.

    I want to be sure the reader does not take my comments to be a criticism of French medicine. That is not the point. The point is, a caregiver ignorant of recent medical knowledge concerning treatment of death and dying can cause great harm. Lack of conversation and communication between patient and an informed doctor, caregiver and doctor, caregiver and patient, to the fullest extent possible, leads to messy, avoidable tragedy.

    Love is not the only thing needed in terminal care. Common sense, knowledge, and dialogue can be more important.

    Jay I. Meltzer, M.D., is emeritus clinical professor of medicine at Columbia University College of Physicians and Surgeons. A contributor to The Star for 30 years, he lives in Manhattan and Water Mill.

     “Amour” is nominated for Oscars for best picture, best director, and best original screenplay at the Academy Awards ceremony Sunday night.