María Teresa Icart Isern1, Rosa Rozas García1 y María del Carmen Icart Isern2
1Departamento de Enfermería de S. Pública, S. Mental y Materno-Infantil. Universidad de Barcelona (Spain). 2Área Básica de Salud “Sant Josep”. Instituto Catalán de la Salud. Barcelona (Spain).
Correspondence: María Teresa Icart Isern. Departamento de Enfermería de Salud P'ublica (215). Feixa Llarga s/n. L'Hosp. de Llobregat 08907. Barcelona (Spain).
Received10 June 2007; accepted2July 2007
Vera Drake (2004) by Mike Leigh and The Cider House Rules (1999) by Lasse Hallström portray the voluntary interruption of pregnancy and the circumstances surrounding it in a total of ten abortions and one childbirth.
Vera Drake shows us a woman of lower-middle class who “helps young girls” to end to unwanted pregnancies, without accepting money in exchange. Her secret is discovered when one of the young girls on whom Vera practices an abortion undergoes complications and Vera is caught. The Cider House Rules narrates the history of Homer Wells, a young man who is born and grows up in an orphanage where Dr Larch teaches to him in midwifery and to carry out abortions. One day Homer feels the need to experience his own wishes and desires, outside the orphanage, and begins a trip that will take him to other realities that will eventually lead to him to reconsider his position against abortion.
Both films offer useful material to study clinical, ethical, social and demographic aspects regarding abortion in the contexts of medicine, nursing and midwifery.
Keywords: Abortion, Ethics, Unwanted Pregnancy, Medical Education, Health Professions.
The voluntary interruption of pregnancy and the circumstances that surround it are a problem with strong ideological content regarding which the spectators tend to maintain a somewhat rigid stance. Nevertheless, the scenes (images and dialogues) of some movies [see Vera Drake (2004) by Mike Leigh, Punto y aparte (2002) by Francisco del Toro, The Cider House Rules (1999) by Lasse Hallström, If These Walls Could Talk (1996) by Nancy Savoca, Waterland (1992) by Stephen Gyllenhaal, among others]offer appropriate material for analysing ethical questions1, as well as for studying the clinical (obstetric) aspects of the procedure (abortion) and the socio-demographic characteristics of the women who opt for pregnancy termination.
Here, the films Vera Drake (2004) and The Cider House Rules (1999) were selected since, between them, they present a total of ten cases of induced miscarriage that are dealt with in varying degrees of detail; reference is also made to other health problems such as: hepatic cirrhosis, drugs addition, encephalitis, peritonitis and breathing difficulties.
Title: Vera Drake
Director: Mike Leigh
Music: Andrew Dickson
Screenwriter: Mike Leigh
Cast: Imelda Staunton, Philip Davis, Peter Wight, Adrian Scarborough, Heather Craney, Daniel Mays, Alex Kelly, Eddie Marsan, Ruth Sheen and Liz White.
Runtime: 125 minutes
Production Companies: Les Films Alain Sarde, Film Council, The Inside Track, Thin Man Films and Ingenious Film Partners.
Synopsis: Vera Drake is a working-class woman in her fifties who lives with her husband Stan (who works as a mechanic in his brother's repair shop) and their two children: Ethel (who tests light bulbs in a factory) and Sid (who works in tailoring). Vera is a happy woman but she has a secret: she helps young girls terminate unwanted pregnancies, although she does not charge for this. When one of these young women develops complications, the quiet life that Vera has built up around her family is irrevocably altered.
Awards and nominations: Golden Lion for best film and the Volpi Cup for best actress (Imelda Staunton) at the Venice Film Festival 2004. European Film Award 2004 for best actress. Nominated for a Golden Globe 2005 (best actress) and for an Oscar for best director, best actress (Imelda Staunton) and best original screenplay.
Vera Drake is structured in three parts: the introduction, where the characters and their social and employment environments are introduced; the development of the plot, which begins with the first of the six abortions that Vera Drake is to carry out over the following 50 minutes; and the outcome, which is introduced through the accusation by the mother of a young woman on whom Vera has performed an abortion.
The film begins with Vera, a smiling middle-aged woman, returning home after visiting a sick elderly man. In her modest flat, she makes the dinner that she will share with her husband, Stan (Philip Davis), and their children, Ethel (Alex Nelly) and Sid (Daniel Mays). The film’s score, the surroundings, and the topic of conversation which, after dinner, Vera and her family share with Reg (Eddie Marsan) (who Vera considers as a possible son-in-law) situate us in post-war London, where episodes from the conflict are remembered (the invasion of Dunkirk, the bombing in which Reg’s mother died, etc.).
The first abortion takes place at minute 19, and involves a young girl who Vera tries to calm down (table 1). Vera prepares for the procedure in her kitchen: she puts water on to boil and tells the girl to go and sit on a towel she has placed on the bed. Meanwhile, Vera removes from a bag a metallic box and a package, from which she takes a bottle and a grater. The box contains a nail brush, and a bulb attached to a rubber tube and a bar of soap. Vera then grates some soap into the bowl and adds a jet of liquid from the bottle. The following shot shows a confused-looking young woman seated on the bed; she looks a little stunned and her nervous breathing can be heard. Still in the kitchen, Vera cleans her fingernails with the brush and then pours water into the bowl that contains the bulb and the tube; she then goes into the bedroom.
Table 1: Details of the abortions in Vera Drake (2004)
|Abortion 1||Abortion 2||Abortion 3||Abortion 4||Abortion 5||Abortion 6||Abortion 7|
|Social class||Middle||Low||Bourgeoise||High||Poor (mulatta)||Middle||Middle-low-|
|Marriage status||Unmarried(¿)||Married with three children||Repeat||Unmarried Rape||Adultery|
|Emtions||Panic Shame Mear||Anxiety Guilt Mistrust||Nervous Unworried Pedantery||Despair Mear Lonliness Sadness||Mear Guilt Nervousness||Nervousness Annxieety Worry|
|Abortion||We see the technique and the tools used in the abortion||Few details.||Few details||No details of the aborrtion||Few details||Few details||Few details|
|Observations||Prior explanations about the procedure. Distraction during the abortion Explanations about what will happen later||Friend accompanying Toast for all to go well||Examination by physician (150 pounds) Referral to psychiatrist and interview||Mother accompanying. Physician’s exploration after complications|
|Place||On a towel placed on a bed||Sitting on edge of bed||Private clinic (with nurses)||Spartan room|
The fade-out to black, added to Vera’s words (I am already here) and the sound of the closing door, shows the room where the young woman is waiting. We are no longer left doubting as to the nature of Vera’s secret.
Vera explains what she will do: … to touch a little to see that everything is as it should be; she also says that she will introduce … some soapy water inside. Vera then tells the young woman to relax and explains the manoeuvres she will carry out (she wets her hands, introduces the tube, and tells the girl that she will feel the water enter her). The mention of the girl's work and the change in the weather are simple formulae to distract her while the water is entering, until the girl responds affirmatively to the question: Do you feel it full? At this point Vera considers the job to be done. In the kitchen she puts on her coat (at no moment has she taken off her hat), and then returns to the room and explains to the girl what will happen next: tomorrow or the day after she will feel some pain there below, she will go to the bathroom, …it will begin to bleed and everything will leave, and she clarifies: Everything will be finished; you will feel very well.
Lillian appears on screen: she is the woman who puts Vera in contact with the women who want an abortion.
The following abortion (minute 28) is that of a mother of seven children, and takes place quickly: Vera doesn't even take off her hat or coat. The woman's husband, sick and unaware of his wife's decision, is in the next room with some of their children. Vera repeats the use of soapy water and disinfectant; during the whole procedure, as Vera indicates, the woman remains sitting on the edge of the bed.
Vera also offers her services to women of a higher social class; this is the case of the next abortion (minute 32), which involves a woman who had had a previous abortion and is now accompanied by a friend who is drinking and laughs at Vera’s aspect.
The next abortion is the only one not carried out by Vera (minute 37). It involves a young upper-class woman who was raped by her boyfriend while still a virgin. She visits a doctor (figure 1), who sets the terms for the abortion (a fee of 150 pounds) and refers her to a psychiatrist. After the interview, for which the girl has been advised to appear depressed (in fact she is) and to allege some psychological dysfunction in her family, the psychiatrist advises her to abort. We do not see the procedure, and only know that it takes place in the relaxed and comfortable environment of a private clinic.
The film’s music serves as a transition to the following abortion (minute 42): that of a young woman of mixed race. The close-up highlights her fear, loneliness and desperation, and these emotions do not escape Vera’s attention; once again she explains the pain and bleeding that will follow, and that at the end she will be Perfect.
Lillian interviews the next woman to be seen by Vera and charges her two guineas in advance; she makes it very clear that this is a matter between the two of them, and we realise that Vera doesn't receive any money for her services. A foreground shot of Vera shows us her pity and compassion for the woman, who appears nervous, concerned and clearly feeling guilty (her pregnancy is the result of an adulterous relationship). Vera tries to calm her down (minute 46).
The following scenes show the development of the relationship between Ethel and Reg, who decide to marry; the sister-in-law's pregnancy is also announced. Then we come to the seventh abortion (minute 52), the one involving Pamela; she is accompanied by her mother, who immediately recognizes Vera. In the following shot Vera is on the sofa at home; she is sewing and having a cup of tea. Meanwhile, Pamela is shown to be increasingly unwell in bed, with her mother at her bedside. At this point, we know that something is about to change in Vera’s quiet life. Pamela is taken to hospital and is seen by a doctor. He attributes the patient’s signs and symptoms to an infection caused by an induced miscarriage, and the mother acknowledges this. Since the procedure has been illegal the doctor is obliged to report it.
Vera, with her family, remains unaware that a police investigation is under way, one that culminates in the discovery that Vera Drake had been responsible for Pamela's abortion. While Vera’s family are toasting to the future marriage of Ethel and Reg as well as the sister-in-law's pregnancy (figure 2), the police arrive, asking for Mrs. Drake (minute 64). The entry of the police into the dining room involves a still shot in which Vera’s expression is fixed in the field of view, where it remains in suspension. Thus begins the third part of the movie: the outcome (figure 3).
For Vera, the reason why the police have gone to her house is because she helps young girls when they cannot manage. When questioned she says: I help them to have their period again. She never pronounces the word abortion, and when the inspector asks her if she carries out abortions, she denies it: I don't do that. They need help. They don't have anybody to appeal to and I help them. We also learn that Vera had to have an abortion in her youth.
From the interrogation at the police station we learn that she has spent about twenty years helping young girls and that no girl has ever ended up in hospital; she always uses a syringe (never a crochet hook or any other metallic object) and never charges for her services. She is held at the police station and accused under article 58 of the law of Protection of People of 1861. However, she is released on a bail of 50 pounds. The trial is held and the evidence against her is presented: a Higginson syringe, a nail brush, a bottle of disinfectant, a cheese grater and a bar of phenol soap.
Finally, Vera is sentenced to two years and six months in prison. In the last sequence Vera is in jail, where she speaks to two other women who have been sentenced to three and four years for the death of the women on whom they had performed an abortion.
Title: The Cider House Rules
Director: Lasse Hallström
Music: Rachel Portman
Screenwriter: Based on the novel Princes of Maine, Kings from New England, by John Irving
Cast: Tobey Maguire, Michael Caine, Charlize Theron, Delroy Lindo, Paul Rudd, Kathy Baker, Jane Alexander, Erykah Badu, Kieran Culkin, Kate Nelligan, Heavy D, K. Todd Freeman, Paz de la Huerta, J.K. Simmons and Evan Parke.
Runtime: 128 minutes
Production Companies: Film Colony, Miramax Films and Nina Saxon Film Design
Synopsis: Homer Wells is a boy who was born and raised in an orphanage. There, Dr. Wilbur Larch educates him according to the rule Be useful, and teaches him how to deliver babies and perform abortions. Homer, however, is against this latter, illegal practice. One day Homer feels the need to live his own life, outside the orphanage, and he starts a journey that will eventually bring him into contact with other realities that will teach him to live according to his own rules and to reconsider his principles.
Awards and nominations: National Board of Review award for best adapted screenplay in 1999. Oscars 1999 for best actor in a supporting role (Michael Caine) and for best adapted screenplay, Nominated for the 1999 Oscars in the categories best picture, best director, best art direction, best editing and best original score. Nominated for the 1999 Golden Globes in the categories of best actor in a supporting role (Michael Caine) and best adapted screenplay.
The Cider House Rules shows the conflict between theory and practice. The script combines romance and drama, and shows us real life as a mixture of all genres.
The film has two main settings. The first concerns the orphanage of St. Clouds (Maine, United States), where couples go to adopt orphans and pregnant women leave their children for future adoption or simply to abort. The orphanage staff comprises Dr. Larch (Michael Caine), who has taught Homer Wells (Tobey Maguire) to perform practical obstetric and gynaecological procedures, and two nurses: Angela (Kathy Baker) and Edna (Jane Alexander). Homer, an orphan who was born and raised in St. Clouds, does not support abortion, which was an illegal practice in the 1940s, although he doesn't pass judgment on Dr. Larch. In this first setting we observe most of the abortion scenes, childbirths, and other health problems that appear in the film. The second setting is Cape Kenneth, the place where events occur that will make Homer reflect on his principles and discover the rules by which he will lead his life from then on.
The first abortion (minute 5) is performed by Dr. Larch. Homer is in charge of taking the foetus to the incinerator, which is located in the garden of the orphanage. Shortly after, a close-up shows us a newborn being attended to by the nurse Angela. In the delivery room, Homer has overseen the birth of a child (minute 7) and reassures a woman who doesn't want to see her baby or know its sex (table 2).
Table 2: Details of birth and abortions in the Cider House Rules. (1999)
|Birth 1||Abortion 1||Abortion 2||Abortion 3|
|Class||No information||No information||Middle||Low (black)|
|Marriage status||Single (¿)||Single||Single||Single Incest|
|Emotions||Nervous Sorrow Fear||Nervous Fear||Sadness Fear||Apathy Sad Worried|
|Intervention||Birth, the instruments are seen on a table Homer uses a mask and rubber gloves||Abortion The foetus has not been expelled Uterine perforation Acute peritonitis Foreign object||Abortion Gestation: Two months Few details||Abortion: Gestation 2-3 months. The instruments are spoken about aloud. Homer uses a mask and rubber gloves|
|Observations||The woman does not want to see the baby or know its sex She gives it up for adoption||Patient arrives with a fever of 40ºC A deep sleep is induced. The patient dies||Patient arrives with boyfriend She asks about the sex of the foetus Says she would like a child||Pregnancy with morning sickness On awakening patient receives counsel from another woman who has also had an abortion|
|Place||Birthing room (gurney)||Birthing room (gurney)||Birthing room (gurney)||On a cot in the shackwhere she lives|
One morning the children find an unconscious young woman in the garden; she has a fever of 40ºC (minute 20). When questioned by Dr. Larch, she responds by saying: He said he was a doctor. I would never have put this inside. During the young woman’s gynaecological examination, a foreground shot shows Homer visibly affected, while the voice in off of Dr. Larch is heard to say: The foetus is unexpelled, the uterus is punctured. She has acute peritonitis. There’s a foreign object — I think it’s a crochet hook. Still in the delivery room, Dr. Larch asks Homer what he would have done if the girl had requested an abortion four months previous, and criticises him, saying that if he doesn't do these things it will simply be done by someone else who doesn’t know what he’s doing. While Homer and Buster (Kieran Culkin), an adolescent who lives in the orphanage, dig the girl's tomb, Dr. Larch says She has died from secrecy, from ignorance..., and he explains to Homer that if one expects people to be responsible for their children, then they should have the right to choose if they want to have them. Homer defends his position against abortion with the example of his own life and that of Buster, people who would otherwise have ended up in the incinerator.
A new character then arrives at St. Clouds: Candy (Charlize Theron), a young woman who is two-months pregnant. She is accompanied by her boyfriend, Wally (Paul Rudd), a young air force officer who is on leave. For the first time, Homer contemplates the possibility of leaving to know another world, and decides, against the wishes of Dr. Larch, to go with the couple. At one point during the trip he approaches Candy, who is still recovering from her abortion, and calms her down: If you don’t lose too much blood, it’s normal. Tomorrow you will feel better.
In Cape Kenneth, where the families of the engaged couple live, Homer begins to work in Wally’s family business, which involves collecting apples and cider-making (figure 4). He settles in a hut (“the cider house”) with the black seasonal workers, their foreman Mr. Rose (Delroy Lindo), who is also black, and his young daughter Rose Rose (Erykah Badu). On the wall of the house there is a piece of paper that sets out the Rules (where the film gets its title from) (figure 5) that the seasonal workers reject because they do not consider them their own: they were drawn up by others.
Meanwhile, Homer falls in love with Candy, whose boyfriend has returned as a volunteer to the war front. Dr. Larch sends him a package containing a doctor's briefcase. Homer keeps it under his bed, convinced that he won't have to use it. The letters exchanged between Homer and Dr. Larch (figure 6) reveal the respective philosophies of their lives that have governed their respective behaviours. Homer says that Dr. Larch has opted for … the role of playing God. For the doctor, this is the only option, except for … leaving everything to chance. We appreciate his feelings toward Homer when he says: Homer, you are my masterpiece: the rest is only my work.
During the film the foreman's young daughter, Rose appears to be out of sorts and shows the signs and symptoms of pregnancy. When she starts vomiting, Homer suspects her state and asks her if she knows how far on she is, in clear reference to her pregnancy. After admitting it, Rose speaks out about the problem that is tormenting her: What will I do with a baby? I cannot have it. Homer begs her not to do anything by herself and offers his help: If you decide not to keep the baby, I know where you can take it. Soon, Candy finds out about Rose’s condition and tells her she was also pregnant the previous year; she also offers her help: If you don't want to have the baby, Homer will take you to a place where you will be safe… (figure 7). When she asks Rose about the baby’s father, Rose’s expression (an excellent example of non-verbal communication) reveals that her pregnancy is the result of an incestuous and evidently unwanted relationship with her father, Mr. Rose.
Homer reproaches Mr. Rose for his behaviour and decides to help the young woman by performing the abortion himself: My business is medicine. I want to, and I can, help you Shortly after, we see Homer reviewing the surgical material that he has spread on a table aloud: Gauzes, Kocher, forceps, cervical sterilizer, a dilator kit, disinfectant ...
After the abortion, while Rose is resting, Homer reads the Cider House rules, and ends up burning them because he is convinced that everybody should create their own rules. In the following scene, Mr. Rose lies bloodstained on a cot (figure 8). During the night, his daughter stabbed him and fled. Before dying, Mr. Rose asks those present to lie to the police so that they won’t accuse his daughter. His dying words are: At times we must jump the rules, mustn’t we Homer?
A letter from nurse Angela tells Homer of Dr. Larch’s death, caused by accidental over-inhalation of ether (figure 9). The relationship with Candy comes to an end, and she goes to take care of Wally, who has returned from the front with encephalitis, leaving him unable to walk. At this point Homer decides to return to St. Clouds.
A fade-to-white takes us from the inside of the train, where Homer is travelling, to the outside, the train station, which appeared in the first sequence of the film. The film ends with Homer reading a fragment of David Copperfield by Charles Dickens to the orphans, who are happy about Homer’s return (… and that was how I began my new life……. I only know that it happened and that now it is different, as it had to be, and as I want that to be).
From the cinematographic point of view, both films include magnificent foreground and intermediate shots, detailed settings (the wallpaper, the teapot cosy or the fireplaces in Vera Drake), well-chosen exteriors (the apple groves, the English countryside, or the alleys that lead down to the pier in The Cider House Rules), with excellent casting and very good music scores. The historical research was carried out at the archives of the London Hospital, the Imperial War Museum and the Metropolitan Police History Museum for Vera Drake and in the archives of the Northampton State Hospital for The Cider House Rules, as indicated in the respective credits.
In both films, the cinema itself is used as a temporal reference: in Vera Drake the characters watch films in two sequences (the film is not identified), while The Cider House Rules includes scenes from Rebecca (1940) by Alfred Hitchcock) and King Kong (1933) by Merian C. Cooper and Ernest B. Schoedsack; the poster for Wuthering Heights (1939) by William Wyler can also be seen.
The films discussed here could be used in the teaching of medicine, nursing and midwifery2,3.
Depending on the learning objectives and the time available, selected sequences or certain shots could be viewed, although it would be advisable for students to see the complete version of both films. Aspects that might serve as a sounding board for discussion include the following:
Women who abort and their socio-demographic characteristics; the explicit and implicit reasons behind their decision, and the emotions they experience before, during, and after the abortion.
The actual abortion procedure: the technique, the surgical material and the characteristics of the place where abortions are performed.
The person(s) responsible for performing the abortion, their training and competence, as well as the ideology that leads to such a practice.
In addition to reflecting upon the content of the films, it is also possible to study the context in which abortions are carried out as well as the causes and consequences of the positions held by people for and against it.
Vera Drake portrays a harsh reality: the more favoured social classes get rid of “the problem” more easily than other classes do and do not have to resort to household remedies such as those performed by Vera. Furthermore, private clinics will never reveal the secret and, since they have specialized professionals, the risk for women is reduced.
Another aspect is that the ideologies underlying the behaviour of Vera Drake and Dr. Larch are radically different. In the first case, nothing is argued in favour of abortion, and we are left to wonder what Vera’s motives are (Simply to help? Could she not do this in some other way?). Vera does not seem fully aware of the serious consequences of her behaviour, although she does know that what she does is illegal. In contrast, Dr. Larch justifies his practice on the grounds that it will avoid the damage that will be done by others "… who don't have no idea, in clear reference to people such as Vera Drake.
Without wishing to enter further into the ethical dilemmas that may lead health professionals to perform or collaborate in abortions (which could be a teaching objective), it is clear that both movies present the voluntary interruption of pregnancy as an almost compassionate act: Vera Drake and Dr. Larch act more out of compassion and social awareness than for any other reason, and neither of them does so for personal gain.
Figure 1: Visit and examination of the young woman who aborts in a private clinic
Figure 2: Vera Drake and her family, with her future son-in-law (right) and in-laws (left)
Figure 3: Vera Drake when the police are about to arrive. Second plane: her children and husband
Vera Drake (Imelda Staunton). USA movie poster (1 Sheet) design by Crew Creative Advertising
Figure 4. Homer in the apple plantation owned by Wally’s family
Figure 5. Homer reads the Rules that give the title to the movie
Figure 6. Homer reading a letter from Dr. Larch
Figure 7. Candy explains her experience (abortion) to Rose and tries to help her
Figure 8. Mr. Rose lies dying in his rough old bed
Figure 9. Homer reads the letter telling him about the accidental death of Dr. Larch due to an overdose of ether
The characters in The Cider House Rules are Homer Wells (Tobey Maguire) and Candy (Charlize Theron). USA movie poster (1 Sheet ) design by Concept Arts