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VIEWS & REVIEWS: Eelco F.M. Wijdicks and Coen A. Wijdicks The portrayal of coma in contemporary motion pictures Neurology 2006; 66: 1300-1303 [Abstract] [Full text] [PDF]

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The portrayal of coma in contemporary motion pictures

Joseph J. Fins, M.D.   (13 June 2006)

The portrayal of coma in contemporary motion pictures

Dhaval P Shukla   (13 June 2006)

Reply to Fins and Shukla

Eelco F.M. Wijdicks, Coen A. Wijdicks   (13 June 2006)

The portrayal of coma in contemporary motion pictures 13 June 2006
Joseph J. Fins, M.D., Division of Medical Ethics Weill Cornell Medical College 525 E. 68th St., New York, NY 10021 Send Correspondence to journal: Re: The portrayal of coma in contemporary motion pictures jjfins{at}med.cornell.edu Joseph J. Fins, M.D.	Although Wijdicks and Wijdicks note clinical inaccuracies in the portrayal of coma in film, they do not comment upon the more significant discordance between the cinematic depiction of disorders of consciousness and actual public perceptions. [1] Despite the therapeutic nihilism and societal neglect of this population, and their association with the right-to-die movement from Quinlan to Schiavo, [2] such patients are popular in film, and as the authors note, often in scripts with happy endings. [1] It is against this broader irony that the genre's "accuracy" needs to be considered. Cinematic "distortion" can also be understood as a compensatory artistic device that counters societal perceptions about brain injury which themselves may be inaccurate. From this broader cultural context, poetic license on the part of a filmmaker could be construed as a corrective. Nowhere is this seen more powerfully than in Pedro Almodovar's Academy award winning film "Talk to Her." [3] While Wijdicks and Wijdicks rightly point to the improbability of a late and nearly unscathed recovery from prolonged unconsciousness, Almodovar's depiction of a young ballerina's recovery from the vegetative state is metaphorically powerful. Moreover, it anticipates the emerging diagnostic and prognostic significance of distinguishing the vegetative state from the recently described minimally conscious state. Patients who are minimally conscious may make gains that allow for the recovery of functional communication and some degree of reintegration with their families despite overwhelming levels of disability, [4] generating complex ethical questions about what constitutes an acceptable clinical outcome. [5] Almodovar helps foster such considerations by depicting both types of patients, though the degree of recovery enjoyed by the ballerina is fanciful. Although my assertion that Almodovar's work anticipated important nosological advances in neurology is speculative -- to be sure the ballerina's outcome is mere fantasy, there can be little doubt about the accuracy of his portrayal of the personal and social isolation of severe brain injury. This is best conveyed in the Spanish title of the film, "Habla" or alternately "Hable con Ella" best translated as "Talk with Her". The Spanish preposition "con", or with, conveys reciprocity of communication and with that, community and the social context of the self. The power of film to inspire and instruct may be lost when the critic's gaze is directed too literally at manifest medical content. A broader cultural lens is required to consider neuropalliative goals of care. [5] References 1. Wijdicks EFM and Wijdicks CA. The portrayal of coma in contemporary motion pictures. Neurology 2006;66:1300-1303. 2. Fins JJ. Constructing an ethical stereotaxy for severe brain injury: Balancing risks, benefits and access. Nature Reviews Neuroscience 2003;4: 323-327. 3. Fins JJ and Plum F. Neurological diagnosis is more than a state of mind: Diagnostic clarity and impaired consciousness. Archives of Neurology 2004; 61:1354-1355. 4. Lammi MH, Smith VH, Tate RL and Taylor CM. The minimally conscious state and recovery potential: a follow-up study 2 to 5 years after traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2005;86: 746-54. 5. Fins JJ. Clinical Pragmatism and the care of brain injured patients: Towards a palliative neuroethics for disorders of consciousness. Progress in Brain Research 2005;150:565-82. Disclosure: The author reports no conflicts of interest.
The portrayal of coma in contemporary motion pictures 13 June 2006
Dhaval P Shukla, Clinical Fellow Department of Neurosurgery, Fujita Helath University, Toyoake 470-1192, Aichi, Japan. Send Correspondence to journal: Re: The portrayal of coma in contemporary motion pictures neurodhaval{at}rediffmail.com Dhaval P Shukla	I read with great interest the article by Wijdicks and Wijdicks regarding portrayal of coma in movies. [1] Hollywood is renowned for making the best films which involve research and investigation of specific technical aspects. However, the purpose of making movies is to entertain so it is not surprising that details of specific medical conditions are overlooked. Most Indian films are full of drama and medical details are not considered by directors or film critics. In 2003, the comedy "Munnabhai MBBS"--a satire on medical education and training--was released. [1,2] The lead actor, Sanjay Dutt, won the Indian Film Fare Award which is the equivalent of the American Academy Award. The plot begins when a gangster named Munnabhai enters medical college and believes that everyone can be treated by hugging (sign of compassion) or joking (idea of laughter is the best medicine); two important aspects which are often neglected in otherwise serious medical education. The film portrays a patient in persistent vegetative stage (PVS) for 12 years. He is accurately depicted as an untidy man with an overgrown beard and a pathetic vacant look; not as a “sleeping beauty”. He has been so neglected that the doctors do not remember his name and he is reduced to an interesting "case". He is deemed as a bed occupying patient and senior staff comment to medical students that such a patient is a burden on the health care sector and question the need to keep such person alive. On hearing this, Munnabhai arranges a special bed for the neglected patient and starts a rehabilitation program for him including interaction and taking him outside hospital in a wheel chair. This results in gradual return of arousal, initially by a meaningless blinking of eyes followed by meaningful blinking and then wheelchair ambulation with return of speech. I believe that in this background of full of drama and comedy, the portrayal of the patient in PVS and the attitude of doctors toward him was accurate. References 1. Dixit H. Munnabhai MBBS.Kathmandu Univ Med J (KUMJ) 2003;14:233. 2. Pai S. Munnabhai MBBS. BMJ 2004;328:841. Disclosure: The author reports no conflicts of interest.
Reply to Fins and Shukla 13 June 2006
Eelco F.M. Wijdicks, Mayo Clinic 200 First Street SW, Rochester, MN 55905, Coen A. Wijdicks Send Correspondence to journal: Re: Reply to Fins and Shukla Wijde{at}mayo.edu Eelco F.M. Wijdicks, et al.	During our study we were unable to interview screenwriters, although repeated attempts were made. Fins speculates that cinematic distortion may have been used deliberately to show another perspective or to inspire. This is an interesting take on the screenwriter’s frame of mind. It may be true in artistic films, but we think coma is just another device to tell stories in movies such as thrillers or comedies. We do agree that Almodovar’s film “Habla con Ella” correctly displays the friend’s agony over his loved one in a vegetative state. However we were troubled by the pleasant facial expression (a touch of a smile) and excellent outcome in one of the two actresses. After awakening, she is seen walking minimally supported by a cane. Doubt about the diagnosis was never suggested by the attending physician, only to believe in recovery despite medically impossible. However, our critique of these 30 movies is only part of our results. We were most troubled by the potential influence it may have on viewers. We believe our study showed that even an educated audience in surprisingly large numbers unlikely will make that intellectual leap and see movies in a “broad cultural perspective” or see the full recovery of the vegetative state as “metaphorically powerful”. Shukla mentions an interesting, not widely distributed, movie from Bollywood. Reading Shukla’s description of this comedy, we are concerned by the depiction of a neglected patient in a vegetative state for 12 years, but emergence of communication after the introduction of a rehabilitation program. Not only is this inaccurate, but what is the message that the screenwriter wants to convey here? Disclosure: The authors report no conflicts of interest.