The Shootist (1976): Choosing How to Die

J.B. Books is a famous, ageing gunfighter. He rides into town under a false name to see Dr. Hostetler, who treated him years before. The examination confirms a cancer that cannot be cut out.

Hostetler gives him roughly two months, admits the timing is unknowable, prescribes laudanum, and warns that the pain will eventually pass beyond what any drug can touch. He hints that Books may not want to wait for that.

Books takes a room in the boarding house of the widow Bond Rogers, whose teenage son Gillom idolises him. Word of his identity and his illness spreads. A reporter, an undertaker, an old lover and a gambler all try to profit from a famous man's dying. As the pain grows, Books arranges his own ending. He summons three enemies to a saloon on his birthday, kills all three, is shot in the back by the bartender, and dies watching Gillom throw a pistol away in disgust.

Spoilers throughout. How Books arranges his own ending is discussed in full below.

On screen, Hostetler says only that Books has "a cancer". He describes worsening pain in the lower back, hips and groin.

The novel is not so coy. Glendon Swarthout's book is explicit that Books is dying of cancer of the prostate, inoperable and incurable. The pain pattern in the film fits prostate cancer that has spread to bone, which is where it most often goes.

So this page treats it as prostate cancer, while being clear that the film itself never says the word.

The scene is better medicine than most modern films manage.

Hostetler refuses to give a tidy number and says the timing cannot be known. He describes the pain accurately. He is straight that the laudanum will stop working as well as it does now. And he raises the risk of it being habit-forming, which is a tension that has never gone away from pain management.

In 1901 there was no treatment and no screening to offer. The film does not pretend otherwise, which is more honesty than several films set a century later.

Early prostate cancer usually causes no symptoms at all. That is the central problem with it.

When symptoms do arrive, they are often urinary: trouble starting or stopping the stream, a weak or interrupted flow, needing to pass urine often and especially at night, or blood in the urine or semen. Almost all of those are far more commonly caused by benign enlargement of the prostate than by cancer. A new, persistent change is still worth checking.

Books's symptoms are the other kind. Pain in the back, hips, pelvis or ribs can be a sign that cancer has spread to bone. That is what the film is describing, and it is a late sign rather than an early one.

Advanced disease in bone also brings fractures, anaemia, deep fatigue, weight loss and urinary obstruction. Books shows none of that. He stays upright, riding, shooting and formidable to the last hour, so the film describes a decline it never lets us watch.

Prostate cancer screening is unlike the others on this site. There is no simple yes.

The US Preventive Services Task Force says that for men aged 55 to 69, the decision to have periodic PSA blood testing should be an individual one, made after a discussion of the benefits and harms with a clinician. That is a grade C. It adds that clinicians should not screen men who do not express a preference for it.

For men aged 70 and older, the Task Force recommends against PSA screening. That is a grade D.

The reason for the hedging is on the harms side. The Task Force names false positives that lead to more tests and a biopsy, overdiagnosis and overtreatment, and treatment complications including incontinence and erectile dysfunction. Against that sits a small chance of avoiding a death from prostate cancer.

It also says the balance should take account of family history and race or ethnicity. Black men, and men with a father or brother who had prostate cancer, are at higher risk and may want that conversation earlier.

This recommendation is currently under review by the Task Force.

Hostetler's warning that the drug will stop working is the film's grimmest line, and it is the one thing modern care answers directly.

When an opioid stops holding pain, the response today is not to give up. Doses are adjusted. One opioid is swapped for another. Nerve blocks and other drugs are added. A palliative care team exists to do exactly this, and can be involved alongside any other treatment.

Books is offered a bottle and a hint. That is the gap of a century, and it is the reason the film's ending exists at all.

The film substitutes a chosen, clean, violent death for the slow one the doctor predicts. As drama it is magnificent. As a picture of dying it is a fantasy, and the doctor's oblique encouragement of it would be indefensible practice now.

It is worth noticing what the fantasy is actually about. It is not really about guns. It is about control, and about not being watched by strangers while you die. Those are things people still want, and modern care can offer a great deal more of them than a saloon can.

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The Shootist is a fine film about a man arranging his own exit, and it is honest about 1901 having nothing to offer him.

The modern version of his problem has two parts. Prostate screening is a shared decision rather than a routine, with real harms on both sides. And pain that outruns a prescription is a reason to ask for a palliative care team, not a reason to give up on relief.

• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
• https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
• https://www.ebsco.com/research-starters/history/shootist-glendon-swarthout

This page discusses The Shootist for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].