The Palliative Gaze: A Star Beside the Moon

Many days later, as I face the close of an endless 24-hour hospital shift, I find myself remembering that distant afternoon when I first discovered The Metropolitan Museum of Art in New York City. ¹ On an ordinary Tuesday night, beneath a crescent moon, my mind is too exhausted to think of anything but the overwhelming amount of suffering a hospital can hold. So much loneliness in a place full of people—a reflection I would revisit, unexpectedly, before two paintings.

It was during an exhibition dedicated to Caspar David Friedrich, a leading exponent of nineteenth-century Romanticism, that I encountered them both. ² Just as Nature became central in German Romantic philosophy, landscape was foundational in Friedrich’s work—not as imitation, but as a result of a complex interplay between visual impression and mental and emotional reflection. Nature as allegory. ³ Through barren settings and solitary figures, he explored our bond with the natural world. His pictorial spaces resonate in the psyche. The painter of stillness. ⁴ The vastness of the atmosphere contrasts with the smallness of the person, which nevertheless holds extraordinary power: without it, the composition would be nothing. That tiny silhouette animates the entire scene. ⁵

Beholding his most famous painting, Wanderer above the Sea of Fog (1818), ⁶ I understood: it is the silent dialogue between the individual and nature that gives the work meaning—just as the patient’s relationship with affliction endows medicine with purpose. In Romantic philosophy, nature is not an external object but a living process culminating in human consciousness. ⁷ Likewise, disease only matters in relation to the self who endures it. That relationship justifies our practice: without the patient, there is no picture. The small protagonist is what transforms a simple landscape into a timeless masterpiece—just as focusing on the person living with advanced illness defines palliative care.^5,8 We must comprehend the full topography of mutations present in cancer and their potential targeted therapies, yet it is the human being sitting in front of us, about to hear the news of radiological progression, who grounds our clinical activity.

This iconic canvas struck me as deeply aligned with palliative care. It is an image about watching. ⁵ And the essence of our specialty lies in the gaze. The palliative gaze: knowing where to focus a when cure is no longer in view. A gaze evoking the Romantic sublime—an experience of nature that is at once frightening but also beautiful. ⁹ This duality mirrors the ultimate aim of our discipline: to find light amid darkness. This piece also meditates on uncertainty and existential solitude—which speak to our profession. Is anything more uncertain than serious illness? How many patients have described the loneliness of staring at the ceiling in a palliative care unit?

Too much metaphysics for a night on call. I try to clear my head by looking out the window, but it does not help: the moon draws me back to the moment I rediscovered the second artwork in question: Two Men Contemplating the Moon (1819–20). ¹⁰ Two figures, seen from behind, stand in a craggy terrain under an evergreen spruce, a symbol of permanence. ¹¹ One rests his arm gently on the other’s shoulder, who stands upright with composure. It seems to be dusk. They gaze intently at a crescent moon nearing the horizon, beside which a single star gleams. A dead, uprooted oak stretches its dark roots and branches across the foreground, in stark contrast to the background. It appears ready to fall. The Rückenfigur invites us to share their contemplation. ¹²

Interpretations abound, yet consensus remains elusive. The decaying tree on the verge of falling might represent the state of Germany during Friedrich’s time ³ — but it could allude to many other things. Cancer, for instance, also darkens nature, uproots foundations, makes leaves fall, lets winter defeat spring, and weakens what once stood tall. I see this painting as a visual expression of what I love most about palliative care: shared presence. We cannot alter the course of incurable illness. The tree will fall. But we can focus on the sunset—to enjoy the moon until it disappears. And perhaps, just perhaps, we will catch a glimpse of the small star beside it.

Friedrich offers a landscape that is less a place than a state of the soul (Stimmung). ¹³ The moon—a classical symbol of the unreachable and the eternal—points toward transcendence; the barren vegetation, toward earthly transience. ¹⁴ There is, then, a dialectic between the fleeting and the everlasting: the two figures are finite, but their act of contemplation connects them to the infinite. Attitude shades the meaning of the dusk. The fact that they are together declares something essential, with palliative echoes: silent fellowship in the face of the sublime. Pain is eased through human communion.

In this image, as in palliative care, the gaze is everything. The two companions scan the horizon with complicity. The palliative gaze mirrors this stance—not a search for answers, but a mutual witnessing of what is unfolding. It is not merely a clinical focus; it is a moral and emotional posture. It entails perceiving beyond diagnoses, attending to the whole person with clarity and compassion, even when curative options become unattainable.

Like the two friends who hold the gaze, the palliative perspective dares to look decline in the eye—unlike much of modern medicine. The moon suggests that even immediate darkness can be illuminated—a key idea in the ethical promise of palliative care. This composition offers lessons that resonate with our practice: a friend’s shoulder makes it easier to discern faint lights. The trees will fall; the moon will not. We will always have the moon.

The sunrise prompts me to stop wandering and finish my last patient’s note, but first I thank Friedrich for expressing the ineffable. “Dusk was his element,” read one of his obituaries, pointing to a central theme in his work: the cycles of life, with their inexorable endings. ¹⁵ Day and night, rise and fall, growth and decay, birth and death. Nature contains the forces that shape end-of-life suffering, reminding us of our place within it. In these turbulent times—when reclaiming art’s authentic voice amid so much artifice has never been more urgent—finding shared sanctuaries (a museum, a journal) for artistic reflection that brings meaning to our daily routine feels nothing short of a quiet miracle.