Background

Diagnosis and sacrifice

The use of the diagnostic revelation as a means of underscoring acceptance and sacrifice is present in numerous films, for example, Iris,17 Love Story 18 and I've Loved You So Long. 19 We have chosen Still Alice as an exemplar.20 This 2014 film, starring Julianne Moore and Alec Baldwin, depicts a successful 50-something female professor of linguistics who learns that she has early-onset Alzheimer's disease. Still Alice illustrates what appears to be the dominant narrative use of diagnosis: the character's ability to assume the diagnosis and its transformative power. Because of the nature of her diagnosis, her children are also advised to have genetic screening and the results predict that one of her daughters is also at risk. The diagnosis reorganises the relations within the family, as Alice is both the centre of attention (she is the sick person) but loses all self-agency as a result of the diagnosis, despite her efforts to organise her future, including preparing instructions for herself on how to end her life. In melodramatic terms, this can be cast as the transcending nature of the experience and the possibility of illness as self-sacrifice which reveals the strength and determination of a character whose selflessness emphasises her devotion and courage. In other words, Still Alice is centrally concerned with suffering and virtue.15

The narrative progresses along the expected pathway of her disease by capturing Alice's responses to new challenges brought about by her progressive impairment and loss of herself, and her family's management of the circumstances. The narrative is, apart from the initial diagnostic moment, structured around events which imply chronological continuity and Alice's progressive disappearance (both metaphorically and literally) and increasingly subtle touches of self-awareness and agency the character demonstrates. It also reveals characters and especially those connected to the family and the domestic sphere.

Alice's experience of illness is, in melodramatic tradition, highly gendered. Her progressive departure from herself emphasises a particular grace and serenity linked to femininity. This points to the possibility of closure in terms of narrative (she withdraws gracefully) and the insistence of her humanity over the power of her disease, despite the fact that her professional, personal and domestic lives have collapsed.

The emphasis of traditionally feminine roles such as mother, wife and professionals facing gender-based injustices is common to melodrama (often grouped in a sub-genre called ‘women's films’21). In these films, the dramatic events in the female character's social and personal life reveal inextricable circumstances that the female character is forced to accept. The emotional and narrative premise is not so much the overcoming of forces of repression of the female character but her resilience. In Still Alice, Alice becomes closer to a daughter from whom she had grown distant, but inversely her husband leaves her for a job he thinks he cannot refuse; their respective life trajectories move apart. He disappears from her life and the narrative and the wrongs he has committed are left without explanation, justification or resolution. The title itself traces Alice's double journey as she becomes socially, physical and emotionally ‘still’, while struggling to remain herself. The significant narrative events in the film trace this progression and the oscillation in the ‘stilling’ of Alice.

The film follows Alice's emotional journey as character and underplays the broader social, medical, financial and institutional context of her illness. The fact that the character is introduced early on as a successful academic in an upper middle-class setting justifies this ellipsis but also allows for the contrasting images of a self-reliant woman and a person in need of constant care. In this, and in other films (see The Decline of the American Empire,22 for example, and the other films discussed in this essay), the protagonist is an educated and articulate person who has the material and emotional resources to express emotions.

The story telling does not solely rely on the social and psychological traits of the character because cinematic means contribute to showing the progression of Alice's disease via the shifting significance of the visual motif of Alice shot on her own, even when she is with other people. This includes the opening shot of the film which, rather than providing an establishing shot of the family around a restaurant table as they celebrate her birthday, focuses exclusively on Alice even though the first voice we hear her daughter's (“Okay. Happy birthday Mom”). This type of shot constitutes a visual motif which allows the viewer to trace the progression of the narrative through Alice's perspective and response, and helps measure the shifting signification of her disease.

This invitation to the viewer to measure the shifting mental state of Alice is, in traditionally narrative terms, foreshadowed in the first sequence where she inappropriately responds to her daughter's mention of sibling rivalry by referring to Alice's own youth. The implied temporal dislocation initiates the narrative and the viewer's recognition of symptoms from the start. It is important to signal that viewers will already be aware of the premise of the narrative, the story of a woman who struggles with the realities of early-onset Alzheimer's disease. The diagnostic announcement is therefore not a source of suspense, but the emerging symptoms of her illness focus the viewer's attention and generate a form of diagnostic deciphering. In other words, the motif of Alice captured in visual isolation marks the progression of the narrative, the emergence of Alice's confusion, the dramatic implication of the disease, and provides the means for the viewer to observe Alice's reaction.

The diagnostic scenes in the film take place early in the narrative. There are three of them, all inter-related: the neuropsychiatrist telling her she has Alzheimer's disease, Alice telling her husband, and Alice and her husband announcing her diagnosis to the children and advising them to be tested. The three sequences function as necessary moments in the narrative progression. The neuropsychiatrist's diagnosis emphasises the evidence of the disease, based on uncontested acceptance of medical authority. As is the case in many such medical diagnosis scenes, the sequence is organised around a shot/reverse shot editing structure in which declarations and reactions are registered and observed. Dialogue does not necessarily accompany these shots; most of the camera's focus remains on Alice's face, the visual motif noted above. While her physician announces her fate, it is Alice's response that the camera focuses upon; she has come to the physician's alone and there is no room for her to externalise her emotions. The scene, while important in the narrative and in screenwriting terminology, is ‘an inciting incident’ which becomes the turning point after which she must transform her life. In this instance and in many other films with diagnostic announcements, the medical pronouncement of her diagnosis has an instrumentalised function in the narrative. It advances the story and challenges the character whose evolution and transformation audiences will observe, measure and with which they will be affectively and emotionally connected.

The mise-en-scène, including setting and performance, emphasises the institutionalised interaction: the roles and functions of patient and physician are implied and the process of diagnosis is bypassed to focus on the uncontested delivery of a diagnosis as fact. The film treats this sequence economically in the sense that none of the impact of the information lands fully in the character or in the emotional emphasis in the film, even though viewers will have already noted memory slippages and disorientation but have not yet been given space and time to register the impact on the character. The same applies to the second diagnostic moment, the almost matter-of-fact manner with which she announces her diagnosis to her husband. This is a moment where the relationship with her husband is revealed as serene, yet will turn into distance as the narrative advances. He does not contest the diagnosis or invite her to fight back. He also accepts the diagnosis as a sentence which then has to be managed and dealt with.

The third scene in which the diagnostic announcement is fully shaped as a social, personal and emotional moment is a key sequence in terms of narrative. Alice tells her two daughters (one of whom is married and pregnant and whose husband is present) and son that she has early-onset Alzheimer's disease. The sequence plays itself out beyond the medical and practical detachment of the earlier diagnostic moments: the fabric of the family and the ties between each member are instantly revealed in the ways they react and interact with one another. The scene is the emotional and social climax of the inciting incident we referred to above. That the disease can be transmitted across generations is a key narrative ingredient driving the narrative. In contrast to Alice's own response, her children reflect the gamut of attitudes from fear and denial, to incomprehension and compassion.

The disclosure of the diagnosis is the starting point for a narrative exploration of illness as a familial and social trajectory, a dramatic event to be managed and controlled and yet revealed to others. The family sequence demonstrates Alice's increasing isolation, while later in the film she will grow closer to her previously distant or even estranged daughter to form, in melodramatic tradition, a resilient form of female bounding. Her visual depiction as alone in the shot shifts from that of an assured, successful and empowered woman, to that of a lonely figure. In the last shots of the sequence, she is totally isolated. Her husband, earlier shown sitting next to her, is no longer in shot. She is transformed into a sick person in other people's eyes. Family members start talking about her as if she were not there, using the third person. The diagnostic revelation in the medical context paradoxically did not inscribe her narratively as transformed; it is her family's response which changes her from a driven and self -reliable character to a person whose existence is now entirely shaped by others' knowledge and discourse about her illness.

As if this was the revelation which mattered most to Alice, it is at the end of that sequence that she finally breaks down. This completes the impact of the diagnosis pronouncement in its narrative trajectory. This also drives the rest of the film as Alice's illness and the family's reaction to her illness paradoxically reveals Alice's determination but the character of each family member. The husband lets her down by accepting a new job when it is clearly not in Alice's interest, and the wayward daughter becomes Alice's carer. In this sense, the diagnosis ends up ‘diagnosing’ the other characters in the film. Following melodramatic conventions, Alice's fate provides the terms by which her immediate world is organised and where those who are close to her find and occupy roles, including through their metaphorical and actual disappearance from the film.

Diagnosis and social negotiation

Diagnosis in film is frequently used to initiate the narrative. In these cases, the diagnosis comes early in the story and frames what is to come. This is the case in films as different as Terms of Endearment,23 50/50,24 Beginners 25 and Biutiful.26 Films in which the diagnosis initiates the narrative often use an accepting central character, even when the diagnosis will prove to be mistaken.27 He or she will engage in negotiation with themselves and others around them about the social implications of the disease and often about underlying emotional and relational issues and unfulfilled desires.

A Late Quartet 28 explores the impact of the life-altering diagnosis of Parkinson's disease on Peter Mitchell (played by Christopher Walken), the cellist in, and oldest member of, a world-renowned string quartet and the implication that this long-standing musical partnership will come to an end. While this film, like Still Alice, is also a melodrama, the fact that the diagnosed character is male changes the place that the diagnostic revelation takes in the narrative. As argued by Laura Mulvey and illustrated in the distinction between Still Alice and A Late Quartet, the masculine melodrama traditionally results in reconciliation and the female melodrama combines emotional excess (not entirely relevant to Still Alice) and unresolved contradictions.29

The transformative power of the diagnosis provides a narrative engine, as it sets adrift multiple partnerships within the quartet. The medical problem develops into an emotional, social and creative problem for the three other members. Mitchell becomes the one who needs to soothe the tensions within the quartet, rather than being the one around whom the others gather. In this, and other examples where the character accepts the diagnosis, the character accesses a form of wisdom and serenity (in a mode reminiscent of melodrama) in which acceptance of fate provides closure and resolution of narrative tensions.

There are two diagnostic revelation sequences in this film. Similarly to Still Alice, there is one scene in a medical setting, and another when the performer announces his diagnosis to the other members of the quartet. The physician is portrayed as a gentle and caring older general practitioner. She delivers her assessment on the basis of a simple physical examination and his history. While she does request further tests, she assures the Walken character that she has little doubt. The announcement of the diagnosis is so clearly unequivocal in the narrative that the film does not even confirm the announcement with the results of the further tests.

The second diagnostic announcement is when Mitchell shares the news with his long-standing collaborators. The meeting takes place in his elegant home, around a table. The soundtrack (a piece we can assume is meant to be from one of the quartet's recordings), as well as the editing (a series of shots where the other three members of the quartet engage in a conversation we cannot hear) suggest that Peter Mitchell observes his friends and collaborators, feels isolated from them, and bears the emotional weight of the announcement he is about to make. As in Still Alice, the character is shot in isolation, reflecting and observing his surroundings and those close to him. The first shot of the sequence shows in medium close up, looking off-screen to the left of the frame, then lowering his eyes as if he were taking stock of the moment and the emotional and psychological weight of the pending announcement.

The sequence also emphasises his dominance by using a few over-the-shoulder shots which frame his body in the foreground and while his friends discuss among themselves, or while he is making his announcement and immediately afterwards, they look at him. His revelation is emotionless and concise, and while he is aware of the impact of the news, he insists on taking control. Without preamble, he states: “I spoke with Dr Nadir. This difficulty I've been having, Parkinson's, she says, early stages, maybe”. Then, as his collaborators start negotiating the gravity of his illness he retorts: “I need to be real about this. Deal with it. Name it”. Finally, as they cannot grasp that this will have an immediate impact on their creative collaboration, he unambiguously makes them confront the inevitable: “I've made up my mind, it's best for the quartet to plan ahead, to think about what comes next”.

Contrary to Alice, and in line with gender distinctions in melodrama, he keeps a tight control of the narrative and is not willing to become the object of others' responses and management. While Alice's family starts discussing her as if she were not there, Peter Mitchell maintains complete control of the narrative and does not let others start negotiating the implications of his illness or the decisions he has made. The premise of the narrative and the nature of this inciting incident is that it is not the illness which needs negotiation and management (it is a given that all accept the diagnosis) but rather, the social consequences of the disease on others. As a consequence of the announcement of the illness, the group's latent frictions erupt into full-blown conflicts, including between the married couple and the revelation that the third member was in love with the female performer. As in Still Alice, the diagnosis becomes a narrative engine which reveals characters and brings to the fore conflicts and tension which threaten, even more than the illness of the musician, the existence of the quartet. At the darkest point in the film, the mere possibility that the members of the quartet could recover the intimate understanding and trust which has distinguished their quartet is under radical threat.

The film achieves closure, emotional and narrative balance, through the transcending gesture and benevolence of the retiring and ill member of the quartet in distinctly melodramatic terms: the illness gives the Walken character serenity and grace and redeems (narratively) the others. As in Still Alice, the ill character metaphorically, and in this instance, literally, walks off-stage in a gesture of acceptance of his illness and its consequences and as a gift and redemptive offer to the others. Here, even more than in Still Alice, the diagnosis and the illness are an illustration of their ability to transform characters and their social relations in ways that are threatening and yet, ultimately affirmative. Both Still Alice and A Late Quartet offer variations on this theme.

Diagnosis and relationship to medical authority

While the first two films are examples of the deployment of diagnostic scenes as a moment of compliance with diagnostic authority, there are other films when the moment of diagnosis is a point of contestation, and the patient enters into conflict and/or negotiation with the doctor. In these films, the diagnosis is a threat to the character's agency, core principles and belief, and self-image. Even though the conflict might resolve throughout the film, the diagnostic moment is one of opposition. The person receiving the diagnosis will find his or her position affirmed during the diagnostic scene, but not necessarily at the resolution of the narrative. We have chosen Wit as an example of diagnosis as a source of narrative conflict.30

This film also starts with a diagnosis, but in this case, it is in ‘media res’, that is to say, the beginning of the story precedes the beginning of the film. There might have been symptoms, concern, a series of medical tests and a diagnostic process, but none of this is shown to the viewer; it is implied by the diagnostic scene which is in fact, the very first shot of the film. This is also the case in the television series Breaking Bad, and Médecin de campagne (which unabashedly replicates elements of the television series).

Wit centres almost exclusively on the paradoxical intimacy of an intelligent, articulate and successful female professor (diagnosed with ovarian cancer) with the medical institution into which she is thrust and with which she is in permanent resistance. The film's original form as a play remains visible in the treatment of space as ‘huis-clos’ which intensifies the inter-relation of institutional and personal tensions.

The film opens with a close-up of an oncologist whose face awkwardly enters the frame: the film has no ‘establishing shot’, one which provides a context, background information, or a sense of the characters or the stakes. The first line of dialogue in the film is delivered by the physician: “You have cancer. Miss Bearing, you have advanced metastatic ovarian cancer”. As a reverse shot shows Bearing, caught in what looks like emotional suspension, in two medium close-up shots and one line of dialogue, the entire premise and dramatic tension of the film is revealed. This is, as in Still Alice, something of a convention of diagnostic sequences: the announcement does not seem to register immediately.

Already implicit in this scene are the power relations of this situation: a male expert delivers a life-threatening diagnosis to a female patient. As if the power relations were not already overdetermined, the medium close-up which reveals Bearing catches her looking upwards, more stable in the frame than the doctor is but also more passive and more vulnerable. Her response after a moment of silence, “Go on”, marks the intensity of the moment and the ceremony-like occasion as the receiver of medical news. The next short exchange encapsulates the terms by which the gender and power tensions between these two different characters will play out:

“You are a professor Miss Bearing” in a tone which is more condescending than inquiring.

“Like yourself, Dr Kelekian”, Bearing answers sullenly.

“Ah yes” he retorts as if surprised by her claim and as if the allowance he already made for her social and intellectual status was sufficient and did not require an answer. The semblance of her comparable status he concedes suggests that he trusts she can process the information, take a detached and objective views of the situation and recognise that the power of evidence makes the prognosis ineluctable. His talking to her as if she were a peer is not as much about erasing the power imbalance inherent in the situation (one person holds life-transforming information over the other) as it is about her having to abide by the informed and authoritative position he occupies.

The rest of this opening sequence, centred on the diagnostic announcement, oscillates between moments where the protagonists share observations about the qualities of their respective students, or lack thereof, and the visible excitement the doctor reveals when trying to convince his patient to enrol in a “very aggressive”, and experimental new treatment, “the strongest thing we have to offer you”. His pitch relies not so much on the fact that the treatment might offer her some hope for the future, but rather that “as research it will make a significant contribution to knowledge”, a statement which is at best an appeal to the inquiring mind of the professor of English, and at worst, an acknowledgement that her illness is a way of advancing his scientific ambitions. At the conclusion of the film, and despite the itinerary she and her medical carers have taken to both humanise her and for her to be at peace with her mortality, a young doctor finds her unresponsive and he calls for the resuscitation team, the code team. When a nurse who knows Bearing well implores that he stop resuscitation (she is ‘no code’—an expression of her will not to be revived), his answer is “she's research!”, a statement which is paradoxical. It is simultaneously confirming the diagnostic power relations against which she's constantly resisting, and her own previously voiced attempt to retain agency through research, a defining feature of being an academic.

This opening sequence sets the pattern that unfolds during the film: her illness is challenging her search for independence and personal achievement though professional success, the sharpness of her intellect and her ability to stand against adversity. It is not so much the diagnosis which she contests throughout the film but the threat the illness poses to her determination and ambitions, and those who supposed to use their professional skills and judgement to treat her. Wit explores the predicament implied in acquiescing to medical care and the inherent power relations.

Diagnosis and dénouement

Rare are the instances in which films conclude with a diagnosis, however, they do exist. A notable example, and importantly not from traditional American cinema, is Agnès Varda's Cléo From 5 to 7 which narrates, over a 90-minute film, a woman's wait between 17:00 and 19:00 for the appointment where she will receive, she presumes, her diagnosis.31 The film also begins in media res, in the middle of a Tarot reading session where the fortune teller reveals the death card for the main character. The viewer has no idea of what affliction has caused the character to seek medical attention, or indeed a fortune teller, but while she is awaiting the verdict from her doctor, she has received this ominous portent. We then follow her over the course of 2 hours, where the tension is built around great uncertainty and her restlessness.

The film ends, after a ‘flânnerie’ through Paris, when she is told by her oncologist that she has cancer and that treatment will start urgently. The scene itself is remarkable among all the examples of films with diagnostic announcement. The character, Cléo, arrives at the hospital at the time she has been told to come, but her doctor is in his sports car, just getting ready to leave, implying that he did not consider delivering the news that she has cancer sufficiently important to wait for her and deliver the news in his office. He has forgotten her appointment, just as she has waited all day for it. He abruptly informs her companion—who isn't a life partner, just someone she's picked up while she is impatiently waiting, and curiously, whose life is also in suspended animation, as he is a soldier on leave—in the parking lot, and her life will change forever.

In this counter-example, where the diagnosis serves as closure (it's the last scene of the film), the viewer is, like Cléo, relieved to finally find out what's happening, even if the diagnosis is ‘bad’. This film, like the others we have reviewed in greater depth above, punctuates the power of the diagnostic moment to perform numerous narrative functions in film and in cinema, just as it does in the life of the patient receiving a serious diagnosis.

Other examples of using diagnosis as, or in place of, dénouement include the Hitchcock classic Psycho 32 in which a psychiatrist delivers a courthouse diagnosis about Norman Bates' split personality, and another French film, I've Loved You So Long,19 where the diagnostic revelation at the end explains the otherwise inexplicable behaviour of the main protagonist throughout the film. In Psycho, the diagnosis hardly stands for an explanation in the narrative, whereas in I've Loved You So Long, the revelation of the diagnosis at the conclusion retrospectively explains the perceived criminal acts of a desperate mother and as noted above, her untold and unrecognised sacrifice until the films dénouement.