Katharine Lawrence, MPH
Herbert Wertheim College of Medicine, Florida International University, United States
Ivan Ilych saw that he was dying, and he was in continual despair.
“Vermiform appendix! Kidney!” he said to himself. “It’s not a question of appendix or kidney, but of life and…death. Yes, life was there and now it is going, going and I cannot stop it….”
“Maybe I did not live as I ought to have done,” it suddenly occurred to him. “But how could that be, when I did everything properly?”
“What if my whole life has been wrong?”
It occurred to him that what had appeared perfectly impossible before, namely that he had not spent his life as he should have done, might after all be true. It occurred to him that his scarcely perceptible attempts to struggle against what was considered good by the most highly placed people, those scarcely noticeable impulses which he had immediately suppressed, might have been the real thing, and all the rest false. And his professional duties and the whole arrangement of his life and of his family, and all his social and official interests, might all have been false. He tried to defend all those things to himself and suddenly felt the weakness of what he was defending.
There was nothing to defend.
[He saw] — all that for which he had lived — and saw clearly that it was not real at all, but a terrible and huge deception which had hidden both life and death.
He asked himself, “What is the right thing?” and grew still, listening.
– from The Death of Ivan Ilych, by Leo Tolstoy (1886)
Great literature is a powerful lens through which to view the truth of human experience. Nowhere is this more apparent than in the literature of death. In a sense, stories about death serve as the best period pieces for readers, offering a window into particular moments in man’s struggle with the unknown. The Death of Ivan Ilych captures both the particulars of 19th century Russia as well as the political and social ideologies of its illustrious author, Leo Tolstoy, who in his writing famously ruminated on topics of Russian bourgeois culture, Christianity, spirituality, war, politics, and anarchy. Beyond that, however, Leo Tolstoy hits on something deeper; with his exquisite rendering of the life and death of his protagonist, Ivan Ilych, Tolstoy is able to depict for his readers – some eighty years before its “discovery” by thanatologist Elizabeth Kubler-Ross – the Five Stages of Grief.
Ivan Ilych, prominent official of the Court of Justice and 19th century Russian socialite, passes through the process of his death in a confused mix of the classic stages of grief: denial, anger, bargaining, depression, and acceptance. In particular, he spends a great deal of time moving back and forth between bargaining and depression. At one moment he is determined to follow the physician’s orders to the letter, to take his medication, and resume his legal work. But when his attempts to do so do not alleviate his chronic pain, Ilych quickly succumbs to fear, depression, and apathy. Tolstoy takes us through every moment of Ilych’s death, winding us through the confused passage of a mind tortured by pain, fear, and uncertainty. He brilliantly captures the central caveat of the five stages – that not every terminal patient expresses all five emotions, and that the process of emotional expression is not necessarily chronological. Hence the rapid movement of Ilych’s mood from optimism and determination to despair and horror, and back again.
In the process of writing Ilych’s death, Tolstoy also manages a disturbingly timeless jab at the medical community. Ilych visits a renowned physician for his chronic pain, and while the two go through the classic performance of two respected men in their field – talking past each other about things neither of them may really know, ultimately the important question for Ilych – “was his case serious or not?” – is never addressed. This represents a lost opportunity for the physician to step into the crucial role of care provider and guide in the end-of-life process.
In the end, the question is: does Ivan Ilych reach acceptance? Critics suggest that Ilych finds meaning when he sees the impact his suffering has on his loved ones. The pain instantly disappears as Ilych’s life undergoes this new ascription of meaning. Some believe this catharsis reflects Tolstoy’s own spiritual evolution in his later years, specifically his movement towards Christian anarchism and anarcho-pacifism. Perhaps Ilych’s suffering is a reminder and a warning to the unexamined life, to encourage us towards continuous reflection and introspection? If this is so, how do we, as physicians, family members, loved ones, and the inevitably deceased, ensure that we too have lived rightly?
KATHARINE LAWRENCE, MPH, is a second year medical student at the Herbert Wertheim College of Medicine in Miami. Originally from New York, she received a Master’s in Public Health degree in community health from the Mount Sinai School of Medicine in New York. She is a member of the Delta Omega Public Health Honorary Society. Currently, she acts as co-president of the HWCOM American Medical Student Association and is an editor-in-chief of the HWCOM arts and literary magazine, Eloquor. She believes strongly that creativity of thought and expression have an important place in medicine, and supports the inclusion of arts and humanities curriculum in medical education.