The Shootist (1976): Choosing How to Die

January 1901, Carson City. J.B. Books, a famous and ageing gunfighter, rides in under a false name to consult Dr. Hostetler, who treated him years before. The examination confirms an advanced 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, hinting that Books may not want to wait for that. Books takes a room in the boarding house of widow Bond Rogers, whose teenage son Gillom idolises him. Word of his identity and his illness spreads, and 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, summoning three enemies to the Metropole saloon on his birthday. He kills all three, is shot in the back by the bartender, and dies watching Gillom throw a pistol away in disgust.

Spoilers throughout. Discussing the cancer storyline means discussing how this ends.

The consultation is unusually honest for a Western. Hostetler refuses to give a tidy number, describes the pain in the lower back, hips and groin that spread-to-bone prostate cancer really does cause, and is clear that laudanum will stop working. The concern raised about laudanum being habit-forming is a real and enduring tension in pain management. The film is also truthful about the social experience: a terminal diagnosis makes a person into an object of curiosity and profit, and Books spends his last days on the practical business of dying, settling accounts, arranging a burial and deciding where and how to die. In 1901 there is no treatment and no screening on offer, and the film does not pretend otherwise.

Books stays upright, riding, shooting and physically formidable to the last hour. Advanced prostate cancer in bone typically brings fractures, profound fatigue, weight loss, anaemia and urinary obstruction long before that point, and the film describes a decline it never shows. Everything is compressed into a single examination and a verdict, with no follow-up care. Above all it offers a fantasy exit, a chosen clean violent death substituted for the slow one the doctor predicts. That is a dramatic device, not a clinical option, and the doctor's oblique encouragement of it would be indefensible practice today.

Early prostate cancer usually causes no symptoms at all. When symptoms appear they are often urinary: trouble starting or stopping the stream, a weak or interrupted flow, needing to urinate often especially at night, or blood in the urine or semen. These are far more commonly caused by benign prostate enlargement than by cancer, but a new persistent change is worth checking. Pain in the back, hips, pelvis or ribs can be a sign the disease has spread to bone, which is what the film is depicting. Screening exists, but as a decision rather than a routine. The USPSTF (2018) says that for men aged 55 to 69 the choice to have periodic PSA blood testing should be an individual one made with a clinician after discussing benefits and harms (Grade C), and recommends against PSA screening for men aged 70 and older (Grade D). The harms include false positives, biopsy complications and finding slow cancers that would never have caused trouble. Black men and men with a father or brother affected are at higher risk and may want that conversation earlier. The USPSTF has this recommendation under update.

A film is not a diagnosis, and a dramatised illness is not a guide to your own. What a story like this is genuinely good for is lowering the barrier to a conversation you might otherwise put off.

If something in your body has changed and stayed changed for a few weeks, that is worth raising with a doctor — not because it is likely to be cancer, but because most of the time it will not be, and finding that out is the point. Where screening exists for a cancer, it is the one thing you can do before anything is wrong at all. See screening and possible warning signs.

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The Shootist is worth watching as a film. It is not a guide to the disease it portrays. The gap between the two is what this page is for — and the thing worth carrying away is that a change which persists is worth a conversation, whatever a story led you to expect.

This page describes a work of film or television 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].