For my last installment in this series on Tolstoy’s short novel exploring the process of death and dying, I have selected a passage that occurs halfway through the story. In this passage, the protagonist identifies what has exacerbated his crisis beyond physical suffering as he compares the approach of his family, friends, and doctors to that of a young, honest servant named Gerasim:
Ivan Ilyich suffered most of all from the lie, the lie which, for some reason, everyone accepted: that he was not dying but was simply ill, and that if he stayed calm and underwent treatment he could expect good results. Yet he knew that regardless of what was done, all he could expect was more agonizing suffering and death. And he was tortured by this lie, tortured by the fact that they refused to acknowledge what he and everyone else knew, that they wanted to lie about his horrible condition and to force him to become party to that lie. This lie, a lie perpetrated on the eve of his death, a lie that was bound to degrade the awesome, solemn act of his dying to the level of their social calls, their draperies, and the sturgeon they ate for dinner, was an excruciating torture for Ivan Ilyich. And, oddly enough, many times when they were going through their acts with him he came within a hairbreadth of shouting: “Stop your lying! You and I know that I’m dying, so at least stop lying!” But he never had the courage to do it. He saw that the awesome, terrifying act of his dying had been degraded by those around him to the level of a chance unpleasantness, a bit of unseemly behavior (they reacted to him as they would to a man who had emitted a foul odor on entering a drawing room); that it had been degraded by that very “propriety” to which he had devoted his entire life. He saw that no one pitied him because no one even cared to understand his situation. Gerasim was the only one who understood and pitied him. And for that reason Ivan Ilyich felt comfortable only with Gerasim. It was a comfort to him when Gerasim sat with him sometimes the whole night through, holding his legs, refusing to go to bed, saying “Don’t worry, Ivan Ilyich, I’ll get a good sleep later on”; or when he suddenly addressed him in the familiar form and said: “It would be a different thing if you weren’t sick, but as it is, why shouldn’t I do a little extra work?” Gerasim was the only one who did not lie; everything he did showed that he alone understood what was happening, saw no need to conceal it, and simply pitied his feeble, wasted master. Once, as Ivan Ilyich was sending him away, he came right out and said: “We all have to die someday, so why shouldn’t I help you?” By this he meant that he did not find his work a burden because he was doing it for a dying man, and he hoped that someone would do the same for him when his time came.
The need to convey information is great, and within this task lies the greater challenge of finding the right balance between honesty and compassion. This exchange belongs to the art of medicine, not the science, which many students of medicine lack at the beginning of their training. During our education, it is though that we will learn from our clinical instructors and physician mentors: in emulating them, we may adopt their attitudes, behaviors, prejudices and passions. On this account, I am concerned about a great many doctors in the generation of physicians in their late thirties and forties, embittered by their experiences with managed care, malpractice litigation, and increasing demands for credentialing and record keeping without a concomitant rise in respect or salaries. I am worried about what lessons and models might be learned from physicians who are tired, beaten, rushed, and unhappy with their careers.
I have often learned best in defiance of odds or models to which I refuse to conform. Although probably not a bad physician, one doctor propelled me onto the road to becoming a physician when she failed me as the young child of a dying cancer patient. Brimming with hope from my mom’s slightest sign of recovery from a unconscious state, I approached the rounding physician wearing my feelings on my shoulder. However, in response to my hopeful comments, the physician gave no words in response: only a look, more brutal and crushing than any combination of words that can convey a bad prognosis. There was no hand on the shoulder, no compassionate smile and probing of my understanding. And furthermore, I never saw the physician again. She did not lie, but she also did not tell the truth or offer any understanding: she completely disengaged from any potential interaction, whether for lack of ability, energy, or feeling of responsibility. In her, I found a model of what not to be and what not to do: if I can do better, if I can teach others to do better by engaging the emotions and confusion, I will have done something worthwhile. Soon enough, I will be on the wards, and the situations in which I find myself will put my own art and ability to the test. Will I be able to detect and speak to the unspoken fears and suffering? Will I be able to speak truthfully and still offer hope, guidance, and companionship?