Kings College, London (Winter 2014)
Anton Chekhov (1860-1904)
Throughout his life, Anton Chekhov was often faced with the reality of suffering in human existence. His family’s bankruptcy and life of poverty in Moscow influenced young Anton’s thoughts about suffering and degradation in society, and his brief period of medical practice in Moscow provided him with enough experience to write over 150 short stories. These stories were heavily influenced by his perception of the effects of suffering on those he encountered. His journey to the Russian penal colony of Sakhalin influenced the short story Ward No. 6, which examines the idea that suffering is an inevitable part of human existence.
Chekhov repeatedly satirizes the belief that suffering is intrinsic to human existence and should be accepted as inevitable and ignored, portraying the stoical view of suffering as a means some people use to ignore or dismiss the suffering of others. In the story Misery1, a sledge-driver who has recently lost his son tells a passenger of his loss and the simple response is: ‘We shall all die’1. This story explores a belief that society when unchecked can drastically increase the suffering of those humans it is supposed to protect. When describing the hard life of the sledge-driver and his mare he suggests that the dumb animal is ‘probably lost in thought’1, because anyone who faces the tumultuous degradation of life in the city would be ‘bound to think’. Chekhov acknowledges the problem that humankind as a species faces, our ability to recognize and reflect on our own suffering. While Chekhov recognized that reflection can lead to more suffering he also shows how our ability to reflect on our suffering can lead us to recognize suffering in others and feel compassion for them. In The Night Before Easter2, written the same year as Misery, the narrator in the story meets a young monk ferryman called Jerome who is grieving the death of his friend and fellow monk. The narrator at first offers the monk the stoical phrase: ‘We must all die’2. However later whilst in church, which Jerome must miss to run the ferry, he listened to the beautiful singing of the choir and his ‘heart ached unbearably for Jerome.’2 He laments that the young man with his capacity for ‘feeling’2 the beauty of the song should not be there to experience it himself. This outburst of feeling from the narrator is unexpected and demonstrates the capacity of humans to share in the suffering of others, this ability, known as empathy, forms the driving force for acts of compassion and is fundamental to medical practice.
The story, A Nervous Breakdown3, follows three students on their travels through the red light district of Moscow. One of the students, Vassilyev, ventures into the underworld of prostitution for the first time, hoping to cast away his thoughtful nature for an evening of unconcerned pleasure. He imagines a romantic picture of ‘dark passages’ and ‘guilty smiles’3. The real world of prostitution that Vassilyev encounters makes him question what tempts man to the ‘horrible sin of buying a human being for a ruble’3. The other two students in the story, one a medical student and the other an artist feel indifferent to the suffering around them. The indifference of these characters represents the view that all suffering is an inevitable part of life and nothing should be done to alleviate it. Vassilyev is disgusted by what he sees as the apathy of humanity to this suffering. When he reproaches the other students for their indifference the medical student remarks: ‘We human beings do murder each other…but philosophising doesn’t help it.’3 This cold indifference is in contrast to Vassilyev, who ‘could reflect in his soul the sufferings of others.’3 Vassilyev consequently has a nervous breakdown and is brought to see a psychiatrist. He is amazed that the others mistake his lack of indifference for madness: ‘Because I cannot speak of fallen women as unconcernedly as of these chairs, I am being examined by a doctor, I am called mad!’3 This story presents a clear criticism of the belief that suffering is inherent to human nature and as such should be treated with indifference.
Chekhov’s most direct challenge to those who ignore suffering comes in the story Ward No.64, set in the mental ward of a district hospital. One of the protagonists is Gromov, a paranoid patient who closely resembles Vassilyev from A Nervous Breakdown in his capacity for empathy. His character is contrasted to Dr. Ragin, the doctor in charge of the hospital, who has become desensitised to the suffering of his patients and justifies his indifference through his philosophy. He argues that ‘suffering leads man to perfection’4 and that alleviating suffering would lead people to ‘abandon religion and philosophy’4, the thoughts of a doctor who has become insensitive to the suffering of his patients.
When Ragin meets Gromov, who rails against the injustice of society, there is a palpable conflict in philosophy between the two. When Gromov questions the injustice of his plight Ragin explains to Gromov his belief that suffering is an inevitable part of life and that it is ‘idle chance’4 that decides who suffers. Ragin claims that Gromov can become ‘insensible to cold as to every other pain’4 and argues that true pleasure is found through ‘the comprehension of life’4. Gromov breaks Ragin’s philosophy apart by challenging him: ‘Have you ever suffered? Have you any idea of suffering?’4 Gromov goes on to explain to the doctor how his philosophy has arisen out of a life absent of any real suffering, describing it as a ‘convenient philosophy’ for the lazy ‘sluggard’4. Ragin’s philosophy is laid bare when by a twist of irony he is later believed to be insane and forcibly admitted to Ward No. 6. He breaks down to Gromov: ‘I used to be indifferent…but at the first coarse touch of life upon me I have lost heart’4. Ragin finally loses control when he realises that he is ‘longing for a smoke and for beer’4; his indifference to suffering doesn’t even last beyond being denied those simple pleasures. He struggles to escape the ward, is severely beaten by the guard and dies the following day.
The idea of emotional detachment within the medical profession is strongly criticised by many, including Jodi Halpern. She presents some of the reasons healthcare professionals give for the approach5 of detachment. The main reason she identifies is the belief that the subjective nature of emotions interferes with an objective scientific method, thus preventing the most effective care for the patient. She goes on to demonstrate that empathetic involvement from the doctor is an integral component of the healing process.
Chekhov’s career as a doctor gave him particular insight into how doctors respond to the suffering of their patients. He was quick to recognize the insensibility to suffering that can come from being exposed to decay and disease and to viewing patients as collections of symptoms and pathological processes rather than human beings. Chekhov exposes this flaw in several stories by depicting characters in situations of grief and presenting the response of those around them.
In The Doctor7, a mother grieves for her only son after the doctor has told her he is dying from a brain tumour. The attitude of the doctor seems strange; he offers no words of comfort though he knows the mother well, and rather than comforting the young boy simply tells him that ‘one can’t go through life without illness.’7 The doctor then reveals that he isn’t at all concerned about the pain of the mother or the boy but only about the truth of his paternal relations to the boy. The mother has claimed in the past that the doctor is his father but he cannot accept her word. He describes to the mother how these lies hurt him: ‘you cannot imagine how deeply my feeling is wounded’7. But he fails to even begin to comprehend the extent of the mother’s misery. His blindness to her suffering is further shown when he questions himself, ‘How can I make her see?’7 It is clear that his insensibility to the suffering of others has prevented him from properly treating the dying boy and comforting the anguished mother.
Chekhov’s observations can be of great service in encouraging healthcare professionals to reflect on the nature of suffering and how humans respond to it, to view the patient as a suffering person rather than a collection of symptoms and signs as medical education encourages. Rita Charon in her essay Narrative Medicine9, suggests that the narrative story plays a pivotal role in establishing an empathetic relationship between physician and patient. Charon implies that by listening to the problems of the patient in the format of a story, the physician ‘enters into and is moved by’ the patient’s life. Accordingly, she advocates a role for reflective study of literature at all levels of medical training.
The story Misery illustrates the failure of many to recognize and react to other people’s suffering. The plight of the sledge-driver draws attention to the importance of social interaction for humans coping with emotional trauma. He continually seeks to share the news of his son’s death with his passengers, to vocalise the pain he feels that is ‘immense, beyond all bounds’. Several psychological studies that have been carried out demonstrate that humans are encouraged to share socially. This may be a mechanism to promote cognitive processing of the traumatic experience thereby reducing the emotional distress felt.
Chekhov also demonstrates how people can change when they move from a position of indifference to one of caring for their fellow man. The narrator in Easter Night is at first dismissive of Jerome’s suffering but then undergoes a transformation of empathy. A similar change occurs to Korolyov in A Doctor’s Visit6 when finally listening to the ‘neurotic girl’ and allowing her to tell him what she believes is the problem, he experiences a transformation and instead of viewing her as a case of ‘nerves’ sees her as the ‘sorrowful and intelligent’6 girl that she is. This change allows an empathetic relationship to form between the doctor and the patient, putting him in a position where ‘she trusted him’6, allowing him to help her. Chekhov clearly saw this relationship as benefiting both patient and doctor.
Many people inside and outside the medical profession have argued that detachment in a doctor is a more important quality than empathising with patients, allowing him to make rational decisions rather than be swayed by emotions. John L. Coulehan argues in his essay Tenderness and Steadiness: Emotions in Medical Practice10, that it is not enough for the doctor to look on as a detached sympathiser but it is necessary that the doctor ‘imaginatively experiences’, i.e. empathises with the position of the patient. He introduces the example of The Steel Windpipe, a short story by Mikhail Bulgakov where a young doctor filled with empathy for his patient, a young girl with diphtheria causes him to fight to persuade the family to let him operate to save her life, despite their ignorance almost preventing him. It is possible to see the attraction of the argument for detached concern; nobody would want a doctor who became so involved in the emotional life of his patient as to lose his sense of self and role as doctor, something one could imagine happening to Vassilyev in A Nervous Breakdown. Charles Aring provides a compelling approach to the problem of detached concern versus empathy11. He describes empathy as not just the ability to enter into and experience the feelings of another but also an ‘awareness of one’s separateness from the observed’ and it is only by achieving this empathy combined with detachment that the physician can be of greatest benefit to their patient.
Clearly Chekhov believed strongly in the importance of working to reduce suffering in humans. His short stories contain many examples of the impact of suffering on individuals and the response of humans to the suffering of others. His work as a doctor on the penal colony of Sakhalin contributed to his profound understanding of human suffering. He recognized the value of empathy in promoting trust between patient and doctor. Such empathy on the part of the doctor is an integral component of the healing process, enhancing the lives of both patient and doctor.
- Chekhov, A. 1886. “Misery”. Retrieved from http://classiclit.about.com/library/bl-etexts/achekhov/bl-achek-misery.htm. Accessed on 28.02.2013.
- Chekhov A. Selected Stories. Wordsworth Editions Limited. 1996; 7-15
- Coulehan J. Chekhov’s Doctors. Kent State University Press. 2003; 72-90
- Coulehan J. Chekhov’s Doctors. Kent State University Press. 2003; 91-134
- Halpern J. From Detached Concern to Empathy: Humanising Medical Practice. Oxford University Press. 2001; 15-18
- Coulehan J. Chekhov’s Doctors. Kent State University Press. 2003; 174-182
- Coulehan J. Chekhov’s Doctors. Kent State University Press. 2003; 21-25
- Coulehan J. Chekhov’s Doctors. Kent State University Press. 2003; 30-40
- Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust. JAMA. 2001; 286; 1897-1902
- Coulehan J. Tenderness and Steadiness: Emotions in Medical Practice. Literature in Medicine. 1995; 14.2; 222-236
- Aring CD. Sympathy and Empathy. JAMA. 1958; 167; 448-452
PETER MCCANN is currently in his 5th year of studying for an MBBS in medicine at King’s college London. He has undertaken an MSc in neuroscience and has a strong interest in cognitive neuroscience and the neurobiology of addictive disorders. He has long held an interest in literature and the strong link between the medical sciences and humanities. The works of Anton Chekhov, John Keats, and Mikhail Bulgakov are of particular inspiration to him, and he believes that they hold great relevance to medical professionals today.