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The most amazing special effect in Dallas Buyers Club is Matthew McConaughey's body.

To play the heterosexual, womanizing, bigoted drug addict and unlikely AIDS activist Ron Woodroof, McConaughey lost close to 40 pounds and, for the first several minutes or so of the movie, he's all you can look at. Woodroff may still kick up a storm of good ol' boy, politically incorrect cussing – the more to make his coming enlightenment and transformation especially dramatic – and he may drink like a fish, gamble like a riverboat dandy and sport with hookers, but all this is only made more alarming by the contrast between body and spirit.

He's a man in high denial of what's really happening, and the truth of that story is written in his afflicted flesh.

It's Robert De Niro's legendary feat of porking up for Raging Bull, in reverse. This is particularly striking, of course, because McConaughey is customarily so buff, vital and shirt-doffingly fit. As Woodroof, he's not only deathly thin but pale, drawn and bruised-looking around the eyes.

Set in 1986, Dallas Buyers Club tells the true story of what Woodroof does when he learns he's got HIV and 30 days to live and the only available officially approved drug (AZT) is making things worse. He sets up an underground smuggling operation to bring other forms of medication in from countries such as Mexico, and he finds himself fighting not only the medical establishment and the U.S. Food and Drug Administration, but becoming an enlightened hero of sorts to the dozens of mostly gay men who join his "buyers club" to get the medicine they'd otherwise be denied.

In his determination and needs-must activism, McConaughey's Woodroof becomes one of those underdog movie heroes who ends up risking everything he has on behalf of those he'd previously held in contempt. That he's also dying only lends his crusading that much more urgency and force, and that McConaughey committed to shedding almost a quarter of his body mass to become Woodroof only ramps up the emotional stakes even higher. Woodroof is one easy dude to root for.

But you've got to wonder: If the actor hadn't agreed to take the physical transformation quite that far – and apparently director Jean-Marc Vallée was perfectly content for McConaughey to stop at 30 pounds – or if this script, which has been kicking around for 20 years and variously had Ryan Gosling, Brad Pitt and Gael Garcia Bernal attached, had been produced with a less driven performer, would Dallas Buyers Club be nearly so wrenching?

The fact is, without McConaughey at its centre, expertly playing every scene as a contrast between Woodroof's inner spunk and combativeness against his outer deterioration, Dallas Buyers Club is a pretty rote, feel-good affair. It would be just one of those movies where the title that informs you that what you're watching is inspired by true events is less informative than persuasive, because otherwise you can't believe real life can ever have conformed to such tidy Hollywood clichés.

I mean, was there really a caring, gorgeous doctor (played in the movie by Jennifer Garner) who sided with Woodroof against the very establishment that provided her living? And was there really a quietly concerned doctor just waiting for Ron on the other side of the border? And did Woodroof really have a transgendered fellow patient named Rayon (Jared Leto) to play both as his foil and his ultimately redemptive best buddy? The answer, apparently in all three cases, is no.

As Vallée has made no bones about in interviews, just about everything in the movie apart from McConaughey's Woodroof is a fiction, a series of condensed, adapted and calculated scenarios designed in the service of keeping us emotionally involved and invested. Not to mention marvelling at that extreme feat of actorly dedication.

Yes, there was a real Ron Woodroof, and yes he created grey-area clubs where the sick could come for alternative treatments, and yes he probably saved – or at least prolonged – many lives. But this is apparently not enough for the purposes of providing the kind of emotional wallop Dallas Buyers Club seeks to deliver, so the antidote for a shortage of emotionally correct truth is a surplus of emotionally correct fabrication.

I'm not saying I ever expect movies to tell the truth: They never really have and likely never will, and that's not their function anyway. We wouldn't go if the lines between the inside and outside of the cinema weren't so clearly drawn. We need those fictions. But when those fictions are deployed in the interest of making us care about real people (who, in this case, suffered and died), the implication is that being a real person isn't enough to warrant our care.

Yes, that's real weight that McConaughey lost in order to play Woodroof. No denying that. But like so much else in this movie, it reminds you that what's not there is as conspicuous as what is.