The distinguished documentaries of Frederick Wiseman presuppose two things. First of all, there are the technical advances in film and cameras that allow him to shoot with less cumbersome equipment than would have been possible a generation ago and to do so in available light. Second, and rather more important, is Wiseman’s discovery of one of the truths of human nature, which is that most of us don’t have a great deal of range in our behaviors. People don’t change much in the presence of a camera, because they can’t. Even talented actors and actresses who have studied their craft cannot depart very far from the selves they’ve learned and earned. And when people are convinced that what they’re doing is correct—either necessary or justifiable, or positively admirable—they see no reason to change their behavior. This is where the drama and the comedy enter into a Wiseman documentary. We watch in amazement as he catches people in ethical and metaphysical quandaries and impossibilities and, if we are shrewd enough to see what is going on, we are both appalled and amused. The right way to watch a Wiseman film is to laugh a lot.
One would think that, sooner or later, some smart administrator would figure out that there is a pattern to these things. In each case, Wiseman comes in and shoots what he sees, sixty, seventy, or eighty hours of film. Then he goes back and edits this to make a documentary in which there is no narrative and no additional material, just the raw stuff of what the camera saw, albeit ordered and shaped. And what he offers is Titicut Follies, or High School, or Law and Order, or Welfare, or Manoeuvre, or Essene, or The Store, or, most recently, Near Death. Often he will show the film to the people who are in it—as happened, I think, with High School. The teachers there were just delighted, recognizing that, yes, this was just how it was with them. And then Wiseman shows these films to the outside world, more often than not on PBS, but frequently at film festivals and on campuses. And the outside world looks and sees what is really happening, which was, in High School, vastly less flattering, or defensible, or even sane than what the teachers in the Philadelphia high school assumed.
The tendencies to self-delusion are irrepressible, however, and we see, again and again, these do-gooders of one kind or another betraying themselves and everything they think they stand for. In Law and Order there is a memorable scene in a squad car in which, in the backseat, a Kansas City police officer is beating up a suspect who is, if I remember correctly, handcuffed. What is astonishing is that, while cameras are smaller and quieter than they used to be, they aren’t invisible, and Wiseman was in the front seat filming this. What had happened was that the suspect, a black man, had called the policeman a motherf—er, and this, to the cop, a lower-middleclass white man, was a legitimate warrant for a beating.
The general sense one gets, seeing a number of Wiseman films, is that there may be something pernicious in all cooperative human enterprises, and the more lofty the purpose of these collaborations, the more they are likely to arrogate to themselves a wide range of powers and perquisites, which they inevitably abuse. Wiseman seems not to be so much shocked by these perversions and betrayals as. amused. There is also the dolorous satisfaction in seeing the confirmation, yet again, of his more or less dismal expectations. Near Death is one of his most ambitious undertakings, running as it does to just under six hours. It was shot in the MICU (Medical Intensive Care Unit) of Beth Israel Hospital in Boston, and it shows the progress or, more often, deterioration of four patients, upon whom the doctors and nurses and technicians lavish their expensive attentions.
The work is a powerful one, as clear, simple, dramatic, and eloquent as any documentary in the history of film. Even at this epic length, it goes quickly, and one is amazed that so much time has elapsed. But for all its power and simplicity, it seems to have puzzled some of the professionals. Susan Wolf, a jurisprudent from the Hastings Center in Briarcliff Manor who reviewed it for The New England Journal of Medicine, remarked that “It performs a great service, revealing a reality many laypeople and doctors are sure to face. The film provides no overarching commentary, however, to put into perspective the practices it depicts.”
Well, what it doesn’t have is one of those great narrative voices lecturing us in a voice-over about the urgent need for action if the Amazon rain forests are to be saved. It doesn’t propose anything. But it asks some fundamental, even radical questions, the first one of which is whether these heroic measures of ICU care, including intubation and cardiopulmonary resuscitation, make any sense. Is there a benefit, either to the patients, or to their families, that justifies the enormous expense and the exquisite prolongation of suffering? Of the four patients we follow, two die in the unit, one makes it out of the unit and back to the ward and dies there, and one actually makes it out of the hospital and goes home.
But is this enough of a benefit to warrant the enormous distortion of resources that these units represent? As one discouraged senior doctor remarks in the course of the film, two-thirds of the medical care costs of an entire lifetime will be incurred during the last three weeks of a person’s life. “It falls to the viewer,” Wolf writes in The New England Journal, “to deduce the strengths and weaknesses of those practices and to glean the lessons of ‘Near Death.'” The first lesson is that there ought to be some consideration about these MICU’s, some discussion of whether they ought not to be just shut down tomorrow.
There are several shots in the film of janitors who come around to sweep the floors and to empty the wastebaskets. These are not just background events or devices to allow for cutaways; Wiseman repeats them so that there is no question but that he is making a particular point of them. They intrude, at first simply as punctuation and then, as they continue to recur, as metonymic commentary. We come to see that the MICU is like a giant organism with the doctors and nurses as its attendants, taking care of the garbage just as the black janitor is doing. He pushes his mop and empties the trash, trying not to get too involved in his depressing surroundings and the interminability of his own tasks. The doctors and nurses are doing more or less the same thing, but their efforts to keep uninvolved are less successful. Their patients fail and die and they can’t help feeling failure and grieving for these inevitable losses. We see these people extending themselves not only as scientists but as humane sources of comfort and strength to the patients and their families. But highly trained health care professionals though they may be, they don’t seem to have any control of the direction in which they are going. The hospital and the unit might as well be running on automatic pilot. The questions these doctors and nurses face are not strategic, but only tactical and logistic.
The direction of medicine, after all, has been taken from physicians by a society that recognizes how these are questions in which we all ought to have some say. Medical care changes outcomes (which it didn’t use to do), and it is no longer a luxury, but is perceived as a social or civil right. The allocation of resources is something we all have a stake in. And we don’t trust the doctors any longer to do the right thing by each of us. So the politicians have had their say, and through them, the people.
But what is it that we have said? The message is that we are cheap and cowardly. A more generous or merely more intelligent expenditure of medical resources would provide some of the things that aren’t necessarily reimbursed by third-party payers (or at least not under the present operating rules) but that save lives. Pap smears for all the women in the hospital’s cachement area and sigmoidoscopies for all men over 50 would cost comparatively little and would produce enormously greater benefits than these fortunes that are being spent in the MICU’s. The advantages are not merely economic but medical—in the early diagnosis of disease (which is critical if there is to be a cure). But we’re too cheap for that. And yet when we are faced with death, when it’s right there at the door, huffing and puffing like the big bad wolf, our tight-fistedness relaxes, and we become suddenly generous and even profligate, throwing vast sums around as if we could buy immortality and revise the human condition, or at least snatch one or another poor sufferer back from the yawning of the grave.
Well, who can be against that? How can one question the motives and practices of an institution that dedicates itself to such an enterprise? We are all in favor of life and against death, aren’t we? But we see that the realities are being ignored, and the death of reason is also something to worry about. The agonizing exchanges between the doctors and the family members that Wiseman shows us with searing intimacy and poignancy are unimaginably complicated as the doctors cajole or bully or just wait for the poor wife or husband to realize how there isn’t anything more to be gained by these grotesque and invasive methodologies. There are now hard decisions to be made about whether to continue to strive for a cure or to bow to the inevitable and supply only palliative care, and although the families now get to collaborate in these decisions, there is something terribly unfair about how unprepared they are and how the collaborative process results in their feeling a much greater degree of complicity and guilt.
The doctors do what they do; the families and the patients do what they do; and then there is the ultimate garbage-bag scene, in which a team of nurses runs a corpse down to the morgue and (one, two, three, heave!) gets it from the guerney onto the slab. And later on, the hearse comes from the mortuary to take away the remains. This isn’t what always happens, but the survival rate of the MICU’s is not good, is in fact much less good than the rate of survival of Wiseman’s group of patients. The question then suggests itself as to what these people suppose themselves to be doing.
The answer is not spelled out. Wiseman doesn’t do that. But anyone who knows anything about medical training can see that there are teams of interns and residents who are passing through, learning how from the patients no matter what the outcome. There are attending physicians who are competent and decent but who can’t work miracles, and one of them admits that this one month a year in the MICU is about all he can stand. The steady players are the nurses who work here year-round, and the hospital itself, a huge machine that has contrived a way of converting the suffering of the doctors and the patients and their families to reimbursement from insurance companies and agencies of the government.
Wiseman’s first documentary film was Titicut Follies, about the Bridgewater State Hospital for the Criminally Insane, and he found in that film that the doctors were crazier than the patients. The guards were the only human and helpful people around, and their efforts were more or less eclipsed by a system that was at once grotesque and pleased with itself Wiseman has since aimed his camera at other institutions, all of which to one degree or another resemble hospitals for the criminally insane. That the doctors and nurses are performing admirably, doing their best in a hopeless and absurd situation, only makes it more painful to watch. Near Death isn’t just about Beth Israel’s MICU but about all of American society, or even life itself, for another way to describe life is to say that it isn’t death but only—and always—near it.