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Million Dollar Baby (2004) and Palliative Care

José Elías García Sánchez, Enrique García Sánchez and María Lucila Merino Marcos1

Departamento de Medicina Preventiva, Salud Pública y Microbiología Médica. Facultad de Medicina. Universidad de Salamanca (Spain). 1Departamento de Pediatría del Hospital Universitario de Salamanca (Spain).

Correspondence: José Elías García Sánchez. Facultad de Medicina. Alfonso X El Sabio s/n. 37007 Salamanca (Spain).

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Received 10 December 2006; accepted 20 December 2006


Summary

The worst misfortune that can befall an old, tormented and fearful boxing trainer is that the pupil he is training and of whom he is very fond should have a lesion as serious as a quadriplegia. This is the crux of the plot in Million Dollar Baby. A person who suffers a quadriplegia sees how most of her physical and sensorial abilities disappear and habitually suffers psychological disturbances requiring palliative medical care. Relatives are subjected to great stress and suffering. All these aspects are reflected, in general accurately, in the film.

Keywords: Quadriplegia, Palliative Care, Euthanasia, F.X. Toole, Cinematographic Adaptation.


Technical details

Title: Million Dollar Baby

Country: USA

Year: 2004

Director: Clint Eastwood

Music: Clint Eastwood. David Potaux-Razel (song Solferino)

Screenwriter: F.X. Toole (book). Paul Haggis.

Cast: Clint Eastwood, Hilary Swank, Morgan Freeman, Anthony Mackie, Jay Baruchel, Mike Colter, Lucia Rijker, Brian O'Byrne, Margo Martindale, Riki Lindhome, Michael Pena, Benito Martinez, Bruce MacVittie, David Powledge and Joe D'Angerio.

Color: Color

Runtime: 132 minutes

Genre: Drama

Production Companies: Warner Bros. Pictures, Lakeshore Entertainment, Malpaso Productions, Albert S. Ruddy Productions and Epsilon Motion Pictures.

Synopsis: An old, fearful and tormented boxing trainer reluctantly agrees to train a young woman. When things are going well, in a match for the world championship his pupil receives a foul blow that causes her a quadriplegia. His fears are realised and his tormented life reaches its height.

Awards and nominations: Oscar (2004) to Best Motion Picture of the Year, Best Director (Clint Eastwood), Best Leading Actress (Hilary Swank) and Best Supporting Actor (Morgan Freeman). Nominated for Best Leading Actor, (Clint Eastwood), Best Achievement in Editing and Best Adapted Screenplay.

The Film

This film is based on some boxing stories included in the book Rope Burns: Stories from the Corner, by F.X. Toole (literary pseudonym of the boxing trainer Jerry Boyd), among them the homonym Million $$$ Baby1. The script came from the pen of Paul Haggis.

Within the framework of a boxing film, female boxing, Clint Eastwood presents, in his work with most awards, the story of two lonely people marked by their past, whose lives cross thanks precisely to this sport. One of them is Frankie Dunn, the male lead, played by Clint Eastwood himself. Frankie is an old boxing trainer and manager, who has an ancient gymnasium for this sport in Los Angeles. The other is Maggie Fitzgerald, the female lead, played by the Oscar-winning Hilary Swank, a waitress who wants to be a boxer. From the point of view of plot, the meeting of these two is the trigger for the action and its dénouement, although Frankie’s importance in the plot is greater since the story revolves around this time of his life. Another three characters have a significant impact on the development of the plot, one present, Eddie “Scrap-Iron” Dupris, the main secondary character, an old boxer who takes care of cleaning Frankie’s gym –he even lives there. He is played by Morgan Freeman (figure 1). The other two are only mentioned, Frankie’s daughter and Maggie’s father.

As has been said, the framework of the film is boxing, and the action begins with a fight, but the word “framework” has been chosen deliberately, since this is not a classic boxing film in the Hollywood style, such as Martin Scorsese’s Raging Bull (1980) or the Rocky saga by John G. Avildsen and Sylvester Stallone. Really boxing could have been replaced by another human activity and moreover it is neither the driving force of the action nor its ultimate objective.

Another thing is the strong personality of the characters, mainly because of their past, as is quite frequent in Eastwood’s films. Frankie Dunn is tormented in the family, professional and religious spheres. For years his daughter, apparently his only child, has not wanted to have anything to do with him; every week he sends her a letter which systematically is returned unopened. He is the one to blame for this lack of a relationship, the causes of which are not mentioned. He is also marked on the professional level; he knows a lot about boxing but fears the consequences so much that he puts as many obstacles as he can in the way of his trainees for holding fights that may involve danger even if they are of sporting and economic interest. They always need two or three more fights; he would rather be short of money than put them at risk, his rule is always protect yourself. He is a practising Catholic of Irish origin; he can read Gaelic, reads Yeats, has been going to mass almost every day at the same church for 23 years (figure 2), but he has doubts about the dogmas of Catholicism, such as the Holy Trinity or the Immaculate Conception, doubts which he poses, with a smile, to the priest at the church he goes to and whom he exasperates, although they both really know that his true moral and religious problem is his daughter. The consequences deriving from his relationship with Maggie will be for him the final touch that closes this stage of his tormented life. Clint Eastwood’s lean, hard, bitter, aging and not very expressive face and his acting skills suit the character to a tee. As regards Maggie Fitzgerald, her personality is marked by her family, by the father she adored and lost and whom she misses terribly, by her obese, selfish mother, who lives on welfare and is a disaster, the same as her sister and her brother, who is in prison when the action starts. Dissatisfied with her economic and family situation, she left the misery of her home in Missouri and went to Los Angeles where she now works as a waitress in order to survive and be able to achieve her dream –to be a professional boxer. She saves up every last cent, even eats the remains of food left by the customers so as not to spend money and thus be able to finance her training. She goes to Frankie for him to coach her and make her a boxer. Right from the start she has full confidence in him. Although she had taken part in some middle-distance fights the truth is that, as is seen in the gym, her technique leaves a lot to be desired. The choice of Hilary Swank to play the lead is another of the film’s successes, since she gave the character incredible tenderness, simplicity, ingenuousness, sweetness and love. Her talents as an actress were already more than well-known and she prepared herself suitably for the character.

The narrative form chosen is the staging of the content of the letter that Eddie writes to Frankie’s daughter to tell her about this episode in her father’s life and so that she will know what he was really like. At the end of the film, the voice-over heard throughout makes it clear that the viewer has been seeing the staging of the letter as the sender was writing it. Despite the fact that this device is not new in the cinema, its inclusion in this film was a good decision.

The first part of the film presents the main character, and those in his surroundings, particularly Eddie “Scrap-Iron” Dupris, and Maggie. Between Eddie and Frankie there is something more than a worker-employer relationship; there is friendship and the boss takes an interest in his employee’s needs, even down to the fact that he should have socks without holes in them. Maggie appears as soon as the film begins, at the end of the fight that opens the action, which she went to through a tunnel going into the area. Afterwards, she gets in touch with Frankie, asks him to coach her, to be her manager and make her a good boxer. She is seeking a better future. In a chauvinist attitude Frankie rejects her; he tells her that he doesn’t coach girls, to find someone else, and even tells her that she is not the right age for this sport. Despite this, Maggie perseveres, goes to the gym and begins to train on her own (figure 3). Later Frankie will accept her presence because Eddie tells him that she has paid six months and her economic situation is not very good, as several details in the film show.

The second part begins when Maggie, thanks to Eddie’s cunning and her constancy and effort, manages to get Frankie to coach her and later to even become her manager. Throughout this phase the film continues to go more deeply into the characters and shows the growing affection that arises between the protagonists. Frankie begins to call her mo cuishle (my darling, my blood); he has found a daughter, and Maggie feels true devotion for him; she has found a father. The relationship between them is mutually beneficial not only on the personal level but also on the economic level (Frankie changes his car and Maggie buys a house for her mother). After a relatively short preparation, Frankie manage to get Maggie to win several fights and become known, her triumphs come so quickly that Frankie has to buy opponents for her and in the end, against his own rules, agrees that she compete for the WBA welter-weight world title in Las Vegas against the champion, an East German called Billie “The Blue Bear” (Lucia Rijker), a real “non-observer” of the Marquis of Queensberry’s rules. At the end of the third round Maggie, forgetting Frankie’s maxim to protect herself at all times, receives from behind a side blow to the face as she is going to her corner. She falls and hits her neck on the edge of the stool that has just been taken out and is still on its side. In an incredible sequence the spectators see and perceive that she has broken her neck, later they will know that Maggie has fractured C1 and C2 with complete severing of the spinal cord (figure 4). The tormented trainer comes up against what he has always feared, a terrible consequence of boxing, his trainee’s quadriplegia.

The last part shows the medical, personal, family and ethical consequences of quadriplegia. The medical consequences entail the setting in motion of immediate and palliative care. The personal ones reflect how Frankie will do anything for Maggie, how affection and love grows and grows between the two of them, attaining unbelievable heights; they have both found substitutes for their dearest ones. His feeling of guilt for having trained Maggie and for allowing the fight affects him and at first he tries to project it onto Eddie. Maggie personally assumes the fact and despite everything thinks that she has achieved all she desired thanks to boxing. The family consequences affect Maggie. Her mother, brother and sister, after enjoying themselves in the amusement parks in Los Angeles for a week, go to visit her and all they are interested in is getting her belongings. The sequence is very well achieved by the protagonist. Finally there are some consequences with an ethical impact, Maggie’s attempts at suicide and the “euthanasia” carried out by Frankie at her request. This last event, with Frankie’s disappearance, brings Eddie’s letter and the action to an end.

The film not only belongs to auteur cinema but also to highly personal cinema. Why? Because the importance of Clint Eastwood in its making is enormous, owing not only to his production company, Malpaso Productions, but also to the fact that he himself directed it and took the lead, and, if this were not enough, the simple but effective sound track is his and his daughter Morgan appears in a significant scene.

The Oscars received, corresponding to films released in 2004, without doubt reflect the quality. These were for the best motion picture, best director (Clint Eastwood), best leading actress (Hilary Swank) and best supporting actor (Morgan Freeman). Clint Eastwood had already received an Oscar as best director in 1992 for Unforgiven and Hilary Swank in 1999 as best leading actress for Kimberly Pierce’s Boys Don’t Cry. The film also had three nominations, for the best leading actor (Clint Eastwood), best adapted screenplay (Paul Haggis) and best achievement in editing (Joel Cox). Despite all that has been said, it is fair to point out that the film was undoubtedly released in order to be able to opt for that year’s Oscars. It came out in a limited way on 15 December 2004, and its full release occurred in the United States on 28 February 2005.

This sad film is, inevitably, very “Eastwoodian” and the characteristic narrative rhythm of this director and his fatalism can be perceived throughout it. It belongs to a type of cinema of high sensitivity and there is a sequence that is pure cinematographic poetry, when after visiting her mother to give her a house, Maggie goes back to Los Angeles with Frankie and they stop to fill up at a petrol station. There she looks and sees a girl with a dog, the girl is Morgan, Clint’s daughter (figure 5); then she tells Frankie how her father, already very ill, killed his dog, which had its hindquarters paralysed, so that it would not suffer. She will use this argument later to ask him to take her life.

The passage from Yeats that Frankie reads to Maggie and which mentions Innisfree is undoubtedly a tribute to John Ford and The Quiet Man (1952).


Medical Aspects of the Film

Taking into account the impact that traumatic lesions have on the development of the film, the presence of doctors and other health staff is scarce; it exists but these professionals are almost always in the shadows, they are not in the limelight and so it is not possible to make an analysis of this group, as either good or bad. Actually, what really matters to the director is Maggie’s injury and its outcome. It is taken for granted that as boxing is a violent sport a doctor always has to be present at the fights and so it is. We see them assess the haemorrhages and examine Maggie when she suffers her cervical lesion. After this they go into action, but rather as incidental background than anything else. The most striking presence of a doctor is in the scene where a doctor told her that he might have to amputate one of her legs.

As in any film that prides itself on being a boxing film, bruises, contusions, fractures and haemorrhages are the order of the day. Boxing is a hard, brutal sport, both from the human and medical point of view. It causes suffering, gives rise to frequent injuries, many of which are serious and even fatal, and long-term after-effects. Thus it is mentioned that in his 109th fight Eddie lost the sight in one eye; in several stills it can be seen that he has a cataract, obviously traumatic. One of the opponents that Maggie knocked out suffered concussion and perforation of an eardrum. Frankie is an expert in controlling haemorrhages and in knowing the different external coagulants and their application, as is revealed on more than one occasion (figure 6). He is also a master in the manual setting of nasal fractures in the ring; obviously his technique is not accompanied by the use of any type of anaesthetic. These aspects, like the visits to hospital emergency services, can be considered as adornments that help with the atmosphere of a film in which there is a lot of boxing in the structure and plot. Although Maggie’s injury is the consequence of the combination of different unfortunate events, and it is clear that it was the result of an unsporting attitude of her rival, it is a feasible fact in real life. Despite this, there are dialogues which aim at exalting this harsh sport.

Immersed in the characterization of the film, and with a certain role in the narration is Danger, a supporting character played by Jay Baruchel (figure 7). Danger is a person with a mental disability who travelled from Texas to Los Angeles with his mother’s boyfriend and was then abandoned by him there. After he ends up in Frankie’s gym the film shows the two attitudes that people have to those with this type of disability: acceptance and integration, as Frankie and Eddie show, or mockery and ridicule, which is what is shown by many of the boxers who come to the gym. Other medical aspects mentioned are the fact that Maggie was born with a low weight, 1 kilo 40 grams, her father died of a non-specified disease which incapacitated him and that her mother suffers from morbid obesity.

In both the plot and its medical analysis Maggie’s quadriplegia is the most significant aspect.


Quadriplegia, Palliative Care and Euthanasia

Maggie’s quadriplegia, as has been said repeatedly, is a lesion of traumatic origin. What made the traumatism so violent? First, the impelling force, the blow from her opponent, made her fall to the mat, then, the weight of her body was added to this force and finally and definitively she hit her neck on a raised, narrow surface, the edge of the stool in her corner which had just been put in and which Frankie did not have time to withdraw. Thus momentum, body weight and a raised blunt instrument are combined. The sequence is impressive. The director manages to get the spectator to realise that Maggie has broken her neck. After the accident she remains lying on the mat, nobody moves her, as is logical; the doctor is called, he examines her pupillary reflexes and it is commented that she is breathing (figure 4). Later it is said that she has fractured C1 and C2. Was the spinal lesion caused by the fall or when she was moved? On the mat she was breathing spontaneously and subsequently she needed a respirator.

Quadriplegia is a brutally disabling process; sometimes the patient can only move the muscles of the face, and it determines the setting in motion of measures tending to achieve, first, survival and then the best possible quality of life. Among the measures seen in the film we find stabilization of the fracture in an intensive care unit, transfer to a specialised unit, admission to a rehabilitation centre, moving to prevent sores from pressure, and their appearance, the use of a wheelchair designed for this type of pathology with respirator included, her difficult mobility and of course the constant need for intubation for artificial respiration, since in such a high lesion the frenic nerve is affected and there is no spontaneous breathing. This is an important cause of morbi-mortality in these patients. In fact a lesion of this type shortens life expectancy.

In the ICU Maggie appears paralysed, she can only move her facial muscles, surrounded by monitors, with a fenestrated cervical collar, full of cables and tubes, intubated by means of a tracheotomy, connected to a respirator and to a pulsioximeter and in a special bed. Later she will have a nasogastric tube (figure 8).

In a conversation with Eddie, when he asks Maggie if she is in pain and she answers no, the loss of feeling, characteristic of the condition, becomes apparent. Other types of measures relating to the control of sphincters are not reflected.

From the very first, Maggie speaks and requires permanent mechanical ventilation. Here there is a mistake, Clint Eastwood either did not receive good advice or he did not pay heed; in this type of circumstance the patient cannot talk unless there is a speaking valve. Patients with mechanical ventilation because of tracheotomy with a standard valve, which is what Maggie apparently has, cannot speak because the air breathed out goes out through the cannula and does not pass by the vocal cords which are higher up. To be able to speak a fenestrated cannula is required or a speaking valve. The former is not possible because owing to her pathology Maggie is absolutely dependent on mechanical ventilation and the speaking valve is not seen. This mistake is crucial in the film, since if she had not spoken the development of the action would have been different. Speaking valves allow the air to be blown in but at the moment of breathing out they close and the air goes through the trachea thus allowing phonation.

How difficult it is for those close to the patient to accept the fact that a process of this nature does not have a solution! Frankie has his doubts about the doctors who are looking after Maggie and trusts that someone will be able to cure her. Second opinions lead him back to the crude reality: at present quadriplegia has no cure.

Two scenes inform of and reinforce the disability caused by quadriplegia, in one the lack of feeling when she confesses to Eddie that she feels no pain and in the other, much later, the motor limitation, when her family intended to keep her assets and her sister said that she had to sign with her mouth (figure 9).

Two months go by before they can move her; as her position cannot be changed bedsores appear; the film shows them on her arms.

The transfer from Las Vegas to Los Angeles is made in an ambulance with the elements necessary for her safety and accompanied by a paramedic.

At the rehabilitation centre they lift her and put her into a suitable wheelchair, with a neck support and respirator; she no longer wears a cervical collar. To prevent her arms from falling, they tie them to the arms of the chair.

Soon other evolutionary complications proper to the condition appear, infection of the skin and soft tissues and psychological affection. She has an infection in her left leg which means that it has to be amputated. This process is only outlined by the image and the bad smell and there does not seem to be general malaise (figure 10). The cinema offers image and sound but not smells, so Maggie says that her leg doesn’t smell too good, doctor? After the operation, effectively reflected in the film, she appears monitored and receiving fluid therapy.

Throughout this period it can clearly be seen how the protagonist is deteriorating both physically and mentally. To encourage her Frankie tells her about chairs that work by blowing through a straw so that she can go to the university.

During the short time of evolution, months, Maggie shows some of the typical complications of the condition.

The brutal invalidity that characterizes this disability, the lack of affection of her family and the amputation of her leg lead Maggie to ask Frankie to take her life, just as her father did with the sick dog; as he does not agree to do so she attempts suicide.


How important the family is under these circumstances!

The physical limitations that quadriplegia imposes mean that Maggie has to sharpen her wits in order to find a method for taking her own life, and this is by biting her tongue to cause a haemorrhage. When this is discovered, the necessary measures are set in motion to keep her alive, but as she tries it again, even ripping out the stitches, they pad her tongue and sedate her.

In the face of this situation and against his own beliefs, Frankie finally agrees to take her life.

Really, the method chosen by Frankie is somewhat “crude” and has nothing of a good death to it. After telling Maggie what he is going to do and the meaning of mo cuishle first he disconnects the respirator, hence Maggie must feel a few moments of asphyxia, and then he administers a massive dose of adrenaline which causes cardiac arrest (figure 11).

In western societies, euthanasia (from the Greek eu good and tanasia death) is currently a topic of debate, when not of confrontation. It is a “hot potato” that politicians have on their desks. For its detractors it is an ethical problem, for its defenders a right and for medicine a bioethical matter, with toxicological and forensic implications. For these reasons this core of the plot has been intelligently chosen; it has pulling power, it arouses passions and involves the spectator’s feelings2. But in the film it is an individual who carries it out, not a doctor.

In The Sea Within/ Mar adentro (2004) by Alejandro Amenábar, which was released the same year and also won an Oscar, for the best foreign language film, it is also someone close to the patient and not a doctor who takes his life at his request.

One may or may not agree with euthanasia, but one cannot be in favour of the way in which it is carried out in the film. It is done out of pity, against the protagonist’s own beliefs, at night (figure 12), avoiding the staff, in the darkness of the room and without having set in motion a suitable psychological treatment. Of course it is clear that this affects Frankie deeply and he disappears from circulation. Hence it is difficult to know whether Clint Eastwood is for or against euthanasia; what he does manage to do is put up for discussion, once again, the controversy between those for and against and tries to involve in it the Christian denominations that are against this practice, since the camera lingers over the cross that Maggie is wearing around her neck when she asks Frankie to take her life and when he does so. It is clear that for those in favour, this film is not seen as a good reflection since before reaching this situation adequate medical attention for the patient is necessary, including psychiatric care3. After a situation in which a quadriplegia occurs there are patients who want to die but their number decreases over time and palliative care has to make this so, in fact many of the severely handicapped begin again to feel a desire to live and fight, especially if they have family support; remember Christopher Reeve. Some have even made important contributions in the field of their disability. The speaking valve most used was developed by David Muir, a patient with Duchenne muscular dystrophy, with a tracheotomy, who wanted to speak4. The political, social, legal, medical, ethical and religious dilemma is posed when a patient, despite everything, does not want to live and asks someone to take his/her life.

The last part of the film reflects Frankie’s constant suffering because of self-blame, his pupil’s situation, his moral convictions and an anticipated mourning. In this part of the film dark and sombre tones prevail. After Maggie’s death his grief is such that he leaves everything, the gym, Eddie, his only friend, boxing and his daughter.


Conclusion

Million Dollar Baby is a good, prize-winning American film in which the plot and dénouement hinge around a high quadriplegia. In its final part there are countless medical aspects, many related to the end of life, some correctly reflected, others not. If in True Crime (1999), Clint Eastwood made a statement against the death penalty motivated by an erroneous sentence, in Million Dollar Baby he brings into debate, with the excuse of a boxing story, the possibility of pity causing one to take the life of someone close with a severe disability. It is not a film where the debate on euthanasia is brought up on a medical level, since the one taking the person’s life is not in the health field. He does not, therefore, act suitably and there is no petition on the part of the patient (Maggie) to a medical worker, as is seen in Whose Life Is It Anyway? (1981) by John Badham. Once again the cinema focuses on a quadriplegic who wants her life to be taken; here, to be fair, it is necessary to say that not all quadriplegics or others with a severe disability want to die. Their care and attention fall within the field of the palliative care that should be given to these patients and their families, for the best quality of life possible, both in the physical and mental sphere. Quadriplegia does fall within the medical field at the end of life since diverse complications may shorten life expectancy. How hard it is sometimes to earn a million dollars.


Acknowledgements

The Editors would like to thank the translation team of the Languages Service of the University of Salamanca for their collaboration in the English version of this Journal.


References

  1. Toole FX. Rope Burns: Stories From the Corner. New York: The Ecco Press/ Harper Collins Publishers; 2000.
  2. García Sánchez JE, García Sánchez, E. The Sea Inside (2004) and Million Dollar Baby (2004). Two Oscars to medicine. J Med Mov [serial on the Internet]. 2005 [cited 2006 Oct 20];1(2):25-26[2 p.] Available from: this article.
  3. Quill TE. The million dollar question. N Engl J Med. 2005; 352:1632.
  4. Andrist J, Koch M. Passy-Muir Valve Helps Wean from Tracheostomy. International Ventilator Users Network [serial on the Internet] 1996 Spring. [cited 2006 Oct 12];10(1):[about 1 p.]. Available from: link

Figure 1: The main characters, Frankie, Maggie and Eddie

Figure 2: Frankie’s Catholic Church

Figure 3: Maggie begins to train alone

Figure 4: Sequence of the severing of Maggie’s spinal cord

Figure 5: Morgan, Clint’s daughter, in a sequence which is pure cinematographic poetry

Figure 6: Frankie is an expert at controlling haemorrhages

Figure 7: Danger

Figure 8: Maggie in the ICU

Figure 9: Physical disability

Figure 10: Infection of the skin and soft tissues which make amputation necessary

Figure 11: Adrenaline to cause cardiac arrest

Figure 12: Under cover of darkness