The Sea Inside (Mar adentro) is a Spanish film
with English subtitles, directed in 2004 by Alejandro Amenábar, and
starring Javier Bardem. It won the 2004 Oscar and the 2004 Golden
Globe award for Best Foreign Language Film.
It is based on the true-life story of Ramón
Sampedro, a Spanish ship mechanic who
broke his neck at the age of 25 diving into shallow sea from rocks
near his home in Galicia, a region in northern Spain. He spent 29
years as a quadriplegic confined to bed, cared for by his family
with enormous love and commitment, aware that his mind was sharp
and highly functional but that his body was capable of only
occasional involuntary spasms.
With much time to consider his situation,
Ramón became certain that life in this state was not dignified and
not what he wanted. He fought for the right to end his life knowing
that, due to his quadriplegia, he would need assistance to die. His
was a 28-year battle for the right to assisted suicide, appointing
a lawyer and petitioning the lower courts in Spain for permission,
then its higher courts and finally the European Commission on Human
Rights in Strasbourg, without ultimate satisfaction. His case
attracted countrywide, and later worldwide, interest.
His determination to raise the profile of his
struggle was demonstrated by the fact that he managed to write a
book about it, using his teeth to hold the pen.
Of particular poignancy is the fact that
Ramón’s family held religious pro-life beliefs and so, with that in
mind, when left with no other option, he left the family farm to
stay and be cared for by friends approximately two months before he
was helped to die using a cyanide laced drink. He made a video of
himself voluntarily drinking the poison through a straw whilst
telling the camera “When I drink this, I will have renounced the
most humiliating of slaveries: being a live head stuck to a dead
The film opens with Ramón Sampedro engaged in
a relaxation exercise with guided imagery in which he is imagining
himself walking along a picturesque beach, the waves lapping at his
feet. We then see him lying in bed, only able to move his head and
soon learn just how much he depends on the care that his family
provide for all of his daily needs.
His sister-in-law, Manuela, who is his main
carer, her husband who is Ramón’s older brother, their son Javier
and Ramón’s elderly father all live together in the family
farmhouse and support Ramón in a variety of different ways.
The Sea Inside recounts Ramón’s
struggle to end his life and it tells the story through the
relationships he forms with three women. First is Gené, who works
for the Association for the Right to Die with Dignity. The second
is Julia, a lawyer recommended by Gené, who takes on his case and
has her own reasons for being interested in the topic of assisted
suicide. Julia helps him to write the book about his life story and
it is through their collaboration that a strong emotional bond
develops. Last is Rosa, a local woman who is initially attracted to
him because she is energized by the challenge of persuading him to
choose life but who subsequently finds herself drawn to him for the
strength she finds in his presence.
Through these relationships, his resilience
and determination is revealed as well as the very powerful positive
influence he has on others. The Sea Inside provides some
interesting reflections on the nature of love and intimacy as,
despite his quadriplegia, we watch the relationships with two of
the women deepen and intensify.
The painfully complex emotions and views of
each family member are also portrayed particularly well in several
scenes, resulting in a balanced consideration of the film’s
sensitive subject from all viewpoints.
Dream sequences are used to communicate
Ramón’s psychological release from his immobility as he imagines
himself flying across the countryside that he can now only glimpse
from his window.
In the later stages of the film we are shown
Ramón’s death through the home video scene. But this is not the
end: The Sea Inside actually finishes by focusing on
another character who has made a very different choice from
Relevance to the field of Mental Health
This film brings to life the debate about
assisted suicide and assisted dying and helps the viewer to
consider the issues concerning the quality of life and the right to
choose death for mentally competent people in certain
circumstances. As such it offers a brilliant starting point for a
discussion on the topic especially because it presents the various
sides of the argument in this complex debate so vividly.
The particular relevance that The Sea
Inside has for those interested in psychiatry concerns the
topic of Mental Capacity. In countries where assisted suicide is
legal, it is usual for medical practitioners to examine the
person’s mental state and assess their Mental Capacity for making
the decision to end their life. It is possible to argue that the
film invites the viewer to act as a virtual psychiatrist in
assessing whether Ramón has the Mental Capacity to make his
decision. We are encouraged in this process by the large number of
close up shots of Ramón as he speaks to friends and family, and
especially when Julia is eliciting his history. In this way, we
slowly build an understanding of his life story and form an opinion
about his personality.
For a good introduction to the process of
assessing Mental Capacity, I would recommend the article by M.
Church & S. Watts in The
Psychiatrist (2007) 31: 304-307. More detailed
guidance on the topic can be found in the Mental Capacity Act 2005
Code of Practice.
As relevant today as ever, this film brings to
mind the recent case of 23 year-old Daniel James, a promising young
England rugby player, paralysed in a training session, who
travelled to a Swiss assisted suicide clinic, accompanied by his
parents, in September 2008, where he died. After investigation by
the police, his parents were not charged (for more information
about this case, there is a good
report in the Telegraph newspaper on 9
December 2008) but the case raised the profile of the issue for the
The British Medical Association’s guidance is
clear. It remains opposed to doctors taking a role in any form of
assisted dying including giving advice on fatal doses of drugs or
writing medical reports that would facilitate assisted suicide
abroad. However, the need for further debate on the subject is
demonstrated by the existence of a recently set up group called
Dignity in Dying: Healthcare Professionals for Change (BMJ
2010;341:c5498) who aim to challenge the BMA and
a number of royal colleges in their stance against assisted dying
for the terminally ill.
The Sea Inside also offers valuable
insights to anyone wanting to gain a greater empathic understanding
of life confined to a bed, without the freedom to move, toilet or
eat independently. The film additionally provides an excellent
portrait of the strains imposed on a family willingly engaged in
providing fulltime care for a relative.
Minds on Film blog is written by Dr J Almeida, Consultant