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The Royal College of Psychiatrists Improving the lives of people with mental illness

The Sea Inside


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.

The Sea Inside


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 body”. 

The Film

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 Ramón.


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 general public.


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 Psychiatrist.

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Re: The Sea Inside
I turned the tv on and The Sea Inside came on, i sat and watched it, the fact that it was subtitled didn't hinder my viewing. I was enthralled and drawn into the story, with its complexities, about relationships. I had never heard of Ramon' before, out of interest i googled the title and the information was it was based on a real life events. I don't judge his actions. The film, however, gave as much insight into Ramon's mind as it could. It is a sensitive subject matter. The film itself was sensitive and had a certain sensuality to it, i.e softness. I will say for certain, its easirer to be on the outside looking in, than in the persons mind, thats what being judged, sad isnt it that even that piece of freedon is denied santuary.. a beautiful film. I hope it has a positive note for the future....
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About this blog


Minds on Film is a monthly blog that explores psychiatric conditions and mental health issues as portrayed in a selection of readily available films.

Please note that this blog may contain plot spoilers. Any views expressed are purely my own.

Dr Joyce Almeida
Dr Almeida is a consultant
psychiatrist working in the private sector in the UK.