I Know This Much Is True S1E1 and the Right to Self-Determination

Photograph by Atsushi Nishijima/HBO

I Know This Much is True S1E1 opens with Thomas (Mark Ruffalo) in the Three Rivers Library in Connecticut, saying a prayer, while his twin brother Dominick (also Mark Ruffalo) narrates the action, but after he raises his knife we cut to the two brothers having lunch the day before. It’s 1990, and George H.W. Bush is on the TV at the restaurant. It’s the Gulf War and Thomas objects. He sees it as a war for oil and says that you can’t worship God and money at the same time.

Back to the library, and Thomas cutting his right hand off.

And if thy right hand offend thee, cut it off, and
cast it from thee: for it is profitable for thee
that one of thy members should perish, and not
that thy whole body should be cast into hell. (Matthew 5:30)

He seems to think of it as a sacrifice, and it’s not clear how his thinking relates to the Bible verse. Thomas is a schizophrenic, and it’s been well documented how this can intersect with grandiose views about one’s place in relation to the supernatural and the fate of everything. Judge Schreber apparently thought that God was trying to impregnate him through sunbeams in his anus.

I want to be clear that my point is not to mock any of this. Rather, we see a troubling intersection of what we might call psychotic delusion and religious belief, and one of the interesting questions I Know This Much Is True raises from the beginning is about how to parse such things, or where to draw a certain line.

This is personal for me, however indirectly. Time was I knew a fellow who told me that the demons wanted him to be their leader. He didn’t want to do it. He’d just gotten out of an institution and was on the outs with his family at the time (because they didn’t want him to leave, I think). So he stayed with us for a moment—more of a friend of friend than a friend of mine I guess. I learned later that he went back in, only to wander off one day and jump off a bridge.

There’s someone else I know, who is even closer to me, who isn’t schizophrenic but perhaps bipolar. I’m not sure how much the terms matter. The point is that she has not been good for some time now. But she has these spiritual beliefs that pre-existed what I am tempted to call a psychotic break in a certain way. She’s told me there is a spiritual evolution going on, and she’s on the forefront. This is how she conceives of her struggle.

How do we parse these things? On the one hand, it seems to be a question of what is a reasonable religious belief and what isn’t, but that gets fraught really quickly. Jehovah’s Witnesses don’t believe in blood transfusions. Christian Scientists don’t believe in medicine, basically, even if they don’t necessarily forbid treatment. Dare we call them “crazy”? And if not, what ground do we have to stand on when it comes to someone like Thomas sacrificing his hand? Should we maybe respect that, too?

I’ll presume that you probably don’t know that there are certain individuals in the world who want to be amputees. Apparently they don’t identify with the limb or whatever in question—they view it as not being a part of them—and desire to get rid of it. Of course, there is a debate about whether we should let them do so, or whether doctors should (ethically) be able to take part in such procedures.

Advocates, who label this as Body Integrity Identity Disorder (BIID) tend to point to two main things: 1) that those who want to do this may perform an amputation on themselves in an unsafe way, only turning to medical help later (a situation that broadly resembles what happens with Thomas); and 2) that while such an amputation might seem extreme and irrational to most of us, it (unfortunately) seems to be the best available option when it comes to treating the suffering of these patients.

But there are many caveats, and one is about mental illness. A big question is whether the desire to amputate in itself renders one mentally ill and thus incompetent to make decisions for oneself, or whether we should respect the wish if the person is seemingly competent in all other regards, understanding the implications and consequences of the procedure, and so on.

But Thomas isn’t that. He’s a diagnosed schizophrenic. Whither then his autonomy, or right to make decisions for himself? Is Dominick right to respect Thomas’s demand that his hand not be re-attached, or does the emotional aspect of the situation overcome his reason? I frankly don’t know.

Dominick gets the manuscript from his mother in I Know This Much Is True
Photograph by Atsushi Nishijima

The other main story in I Know This Much Is True S1E1 centers around a manuscript that Dominick’s mother (Melissa Leo) gives him as she is dying of cancer. It is a memoir written by his grandfather in Italian. Since he can’t read it, he takes it to Nedra (Juliette Lewis) and arranges to pay her to translate it.

There are also some flashbacks to Thomas and Dominick’s childhood, how their stepfather Ray (John Procaccino) was at least a bit abusive, and how their mother would never tell Dominick who their biological father was.

As Nedra is in the middle of translating his grandfather’s memoir, Dominick asks her what he is like. She says something about how, if she had kids, she wouldn’t let this guy around them and makes a remark about his relationship with his daughter. This makes me wonder if maybe he sexually abused his daughter and is actually also the biological father to Thomas and Dominick.

But the more interesting thing is when Nedra arrives to Dominick’s place without warning. He never seems quite comfortable with her presence but lets her stick around, gives her booze, and orders a pizza with her. Maybe he is just feeling things out. It is pretty clear that he is still in love with his ex-wife, Dessa (Kathryn Hahn), as we see him move to kiss her later in the episode (and several years later in terms of the timeline of the story), but I think this actually explains his behavior with regard to Nedra. Part of him feels like he should move on, and this is maybe a chance to do so, but another part of him can’t. And so when she makes a move on him, he’s awkward. He doesn’t know what to do with himself.

And then she goes to the bathroom. The door won’t open as she tries to get out. She thinks he’s locked her in, but it would seem the door just sticks. Regardless, she freaks out on him and storms off, drunk and unwilling to take his offer of a ride or a cab.

And then he can’t find her or the manuscript. He doesn’t have her home number, and she is no longer at the University. She didn’t call him before arriving to his place (based on the address on his check apparently), and anyway caller ID didn’t exist yet in the late ‘80s. So he’s seemingly left lost with regard to the whole thing, with no way to apologize or try to clear the air, and no way to get his grandfather’s manuscript back, much less her translation.

Further, all of this has to make us question Nedra’s mental health. There is, of course, a lot that we don’t see, and the way she freaks out on Dominick could maybe be put down to alcohol and overreaction. But there’s more than that. She’s not at work anymore. She seems to have disappeared. And even the way she showed up to Dominick’s and how she acted when things were going fairly well that evening is a bit suspect when you think about it. To be clear, I’m not trying to judge her, but I think there is more going on here than we get in I Know This Much Is True S1E1, and I highly doubt that this will be her last appearance in the series.

Nedra gestures at Dominick
Photograph by Atsushi Nishijima

I Know This Much Is True S1E1 ends with Thomas being transferred out of the hospital and back to the mental institution where he had been, or at least that’s where he and Dominick think he is going. The cops inform them that their orders are instead to take him to the Hatch Forensic Institute, which is basically in a high-security prison.

Thomas freaks out when he hears this, and so does Dominick, who spends the rest of the episode arguing with people that his brother does not belong in this place to the point where he is physically assaulted by the authorities, who will not listen to him or call Thomas’s doctor.

This is a nightmare. It’s an ongoing nightmare in terms of how our society treats the mentally ill, but I suppose we have to ask whether they have some grounds here given that Thomas has cut his own hand off.

This is the standard we always hear: whether one is a threat to themselves or others. Is Thomas a threat to himself? I would argue that he isn’t. Sure, he cut his hand off, but within his own system of belief about the world that was a sacrifice to God. It wasn’t about harming himself in a direct way, and there is every indication that he’s done. He might not fit the bill in terms of thoughts about BIID in general, but it seems like he does in this regard. He tells his brother that if they reattach the hand he’ll just do it again, but he shows no signs of intending further self-mutilation.

And that’s the hard question with BIID anyway. You have the right to have your breasts augmented or removed. You have the right to a sex-change operation, which is arguably even more severe. Do you have the right to cut off your own hand, whatever be the reason? And if not, why not? Of course, it’s different from my cousin Stephanie having her breasts removed because of worries about cancer, but how much do you want to hang on the reason? What if she just didn’t want to have breasts anymore? What if Thomas just didn’t want to have this hand anymore? And if he views it as a sacrifice to God, does that make it better or worse?

A diagnosis of schizophrenia certainly complicates things further, but even there, where are the lines? How do we determine whether someone who is mentally ill is competent to make decisions for themselves, and about what? Cutting off your hand seems objectively bad, but there are certainly amputees in the world who live perfectly well.

To say no because of a mental illness might make sense, but it’s not like we can cure things like schizophrenia or BIID. At best, we manage them. How much right do we have to impose our will, then, on those who are suffering from such disorders?

That we have such a right at least to some degree is, I think, noncontroversial. But drawing the lines gets hard very quickly. Do we have the right to force them to take meds, for example? And by “we” I don’t necessarily mean the State or something like that, though the State might be the mechanism. Do we have the right as family members who are worried about the well-being of our daughter-sister-cousin-whatever to force treatment upon them that they do not want? What allows us, precisely, to decide that their expressed desires can and should be overridden?

This is the question that I Know This Much Is True S1E1 leaves us with as it closes and Thomas is taken into Hatch. Do they have the right to do this? Are they right to do this? I’m pretty sure the answer is no, but the underlying questions are hard. I’m curious to see where I Know This Much Is True goes with all of this.

Caemeron Crain

Written by Caemeron Crain

Caemeron Crain enjoys staring into the abyss, especially when it stares back. He also has a cat.

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