The One Flew Over The Cuckoo's Nest Ending Explained

In the decades since One Flew Over the Cuckoo's Nest debuted in 1975, it's become widely accepted as one of the greatest movies of all time. Also one of the most well-regarded book-to-film adaptations in cinematic history, the screenplay honors Ken Kesey's original '62 novel of the same name, even with some fairly significant changes. 

The film centers around the Oregon psychiatric hospital ward overseen by the nefarious Nurse Ratched (Louise Fletcher), who shepherds her charges in the most oppressive and damaging way possible. In walks Randall Patrick (Mac) McMurphy, a con man faking insanity to avoid incarceration, who locks horns with Ratched and becomes hellbent on causing an uprising among the patients in the ward. Unbeknownst to him, more dangers await him in the hospital than he ever faced during his numerous prison and work farm stints.  

Throughout the film, viewers get a realistic look at some of the inhumane treatment psychiatric patients faced at the time — some of which is sadly still prevalent today. Mental health care is still a widely underfunded and misunderstood field that often leads to mediocre and sometimes damaging care. 

Given the film's mental health and treatment themes, the ending can be hard to understand without knowledge of the time period, the history of abnormal psychology, and the analysis of the many symbols the movie incorporates. So who is this Mac character, and did his revolution actually make a difference? What was Chief trying to accomplish in his final scenes? And how does Nurse Ratched represent women in the 1960s? What does it all mean? This is the One Flew Over the Cuckoo's Nest ending explained.

Every time someone has sex (or mentions it) in the film, the characters in Cuckoo's Nest get punished, whether it's on the ship when Mac goes below deck with Candy and the patients panic and almost crash the boat, or the way Ratched gets manipulative and hostile any time someone brings up sex during group. In Billy's case, his punishment is death when he loses his virginity to Candy. 

This is an outdated TV and film trope that is especially prevalent during periods when society frowns hardest upon expressions of sexuality. In 1963, when the film is set, the hippie movement was just beginning, continuing through 1975, when the film debuted. Along with the idea of peace and making strides to end the Vietnam War, embracing sexuality was a huge aspect of the movement — which was one reason some other parts of society shunned the hippie lifestyle. Characters like Ratched, who are completely unwilling to embrace change, represent the idea that sexuality or promiscuity are punishable, reflecting a major bias of the time (one that still continues today). 

Out of all characters on Ratched's ward, McMurphy impacts Chief the most. By watching Mac refuse to take anything lying down, Chief learns how to be as "big" in his actions as he is in stature — and he feels like he owes that to McMurphy. Without the con man giving him the confidence to talk and break free from the ward's toxic environment, Chief would still be silently sweeping the hospital floors at the movie's close. Chief knows that someone like McMurphy — who is so full of life — would never want to live after being lobotomized. Being a prisoner on Ratched's ward was hard enough for Mac without being a prisoner in his own body.

Chief understands that feeling better than most, as he lived for years silently taking insults, cut off from socialization, and going through the monotonous motions without feeling like he could be himself. Witnessing McMurphy forced into that type of existence is too much for Chief. After a goodbye hug, Chief makes the choice he believes McMurphy would make for himself by suffocating him with a pillow. The scene is hard to watch, as Mac's body involuntarily fights back. But Chief succeeds, and he finally feels like he's done all he can do on the ward, later escaping Ratched's reach. Whether he did the right thing or made a call that wasn't his to make is up to the viewer.

Despite directly playing a hand in Billy Bibbit's suicide, Ratched faces no consequences for her actions — including lobotomizing a patient whose crime was lashing out the woman primarily responsible for the death of his close friend. Ratched's victory in the ward highlights the stigma that surrounds mental health patients. A larger problem in the mental health industry, even today, is the failure to listen to and respect psychiatric patients, who deserve to have a say in their care.

Earlier, Ratched throws a fit when McMurphy dares to ask which medicine the orderlies are giving him. But anyone has a right to know what they're putting in their bodies. It's the staff's job to work with the patients to determine, as a team, what medicine is helping, if the medication is doing more harm than good, or if the side effects are too much to bear. Instead, she just threatens them if they ask questions, whether the pills are helping or hurting.

Ratched has the entire ward hardwired to do her bidding, and no amount of patient lobotomies or deaths seem to lead her to face any kind of reckoning. Because who is anyone going to believe? The decorated war nurse or the psych patients? The situation underscores a major problem with mental health care.

Imagine getting a Nobel Prize for inventing a procedure that would go on to leave 50,000 patients in the U.S. alone either dead or virtually comatose, with very few "successes.'" Egas Moniz held that honor in 1949 when he modified earlier attempts at brain alteration procedures to create the leucotomy. One year later, Walter Freeman took the surgery to the States, renaming it the "lobotomy" and using what was essentially an ice pick to go through the eye instead of drilling through the head. While it looked a lot less messy, the results were the same. Often touted as a "miracle cure," the horrific procedure forced on McMurphy at the end of the film was supposed to help patients control their emotions. Spoiler alert: It mostly took them away entirely.

In an interview with Life Science, medical historian and NYU Langone Medical Center professor Dr. Barron Lerner described the procedure, referring to the after effect as "mental dullness." He noted that most patients "could no longer live independently, and they lost their personalities." The doctor explained that doctors could maintain control of overcrowded wards by handing out lobotomies to unruly patients: precisely what happens to McMurphy. Lerner praised One Flew Over the Cuckoo's Nest for its accurate depiction of the procedure, noting that movies tend to exaggerate things like this, but that the portrayal in Cuckoo's Nest is "disturbingly real."

Lobotomies were dwindling by the time Kesey wrote the One Flew Over the Cuckoo's Nest novel, and were banned in the U.S. when the film was released, but the message was clear. Far too many patients are subjected to life-altering procedures in psychiatric wards — and both families and facilities have far too much say in forcing patients to undergo irreversible procedures they don't want. 

We see it when Ratched manipulates Billy with details she shouldn't share about his care, even to his family. We see it when the nurse forces Mac into electroshock and a lobotomy. We see it in the way the hospital staff uses fear of these procedures to control the ward. We see time and time again that staff cares more about power and dominance than the patients' actual health. The shock of how cruel and ineffective the lobotomy "treatment" was adds a poignant and powerful ending to get readers and viewers to care about mental health and poor treatment ramifications.

Hospitals still face massive overcrowding. Patients often have to wait days, weeks, or even months for a bed in a ward or even an appointment — even for severe cases of suicidal ideation and conditions like schizophrenia. While the lobotomy has been outlawed in the States for decades, a modern version called psychosurgery is still performed (albeit rarely) today. Mental health care has come a long way since the '50s. However, there's still more work to do.