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For over a century, Leo Tolstoy’s The Death of Ivan Ilych has been one of the most influential examinations of how we come to terms with our own mortality. Of the many who care for Ivan Ilych, only the uneducated peasant, Gerasim, is able to help him find meaning and resolution before death. An excerpt that describes Gerasim’s key interaction with Ivan Ilych is provided. Analysis of the text reveals how cultural values may hinder a patient’s ability to confront mortality and how unique social barriers inhibit different caretakers’ ability to care for a dying patient.
How it came about in the third month of Ivan Ilyich’s illness no one could have said, because it came on imperceptibly, by stages, but it happened that all of them—his wife, and daughter, and son, and the servants, and their friends, and the doctors and most importantly he himself—everybody knew that the only interesting thing about him now was whether it would take him a long time to give up his place, finally release the living from the oppression caused by his presence, and himself be released from his suffering.
How it happened it is impossible to say because it came about step by step, unnoticed, but in the third month of Ivan Ilych’s illness, his wife, his daughter, his son, his acquaintances, the doctors, the servants, and above all he himself, were aware that the whole interest he had for other people was whether he would soon vacate his place, and at last release the living from the discomfort caused by his presence and be himself released from his sufferings.
For his excretions also special arrangements had to be made, and this was a torment to him every time—a torment from the uncleanliness, the unseemliness, and the smell, and from knowing that another person had to take part in it.
But just through his most unpleasant matter, Ivan Ilych obtained comfort. Gerasim, the butler’s young assistant, always came in to carry the things out. Gerasim was a clean, fresh peasant lad, grown stout on town food and always cheerful and bright. At first the sight of him, in his clean Russian peasant costume, engaged on that disgusting task embarrassed Ivan Ilych.
Once when he got up from the commode too weak to draw up his trousers, he dropped into a soft armchair and looked with horror at his bare, enfeebled thighs with the muscles so sharply marked on them.
Gerasim with a firm light tread, his heavy boots emitting a pleasant smell of tar and fresh winter air, came in wearing a clean Hessian apron, the sleeves of his print shirt tucked up over his strong bare young arms; and refraining from looking at his sick master out of consideration for his feelings, and restraining the joy of life that beamed from his face, he went up to the commode.
“Gerasim!” said Ivan Ilych in a weak voice.
“Gerasim started, evidently afraid he might have committed some blunder, and with a rapid movement turned his fresh, kind, simple young face which just showed the first downy signs of a beard.
“That must be very unpleasant for you. You must forgive me. I am helpless.”
“Oh, why, sir,” and Gerasim’s eyes beamed and he showed his glistening white teeth, “what’s a little trouble? It’s a case of illness with you, sir.”
And his deft strong hands did their accustomed task, and he went out of the room stepping lightly.
After that Ivan Ilych would sometimes call Gerasim and get him to hold his legs on his shoulders, and he liked talking to him. Gerasim did it all easily, willingly, simply, and with a good nature that touched Ivan Ilych. Health, strength, and vitality in other people were offensive to him, but Gerasim’s strength and vitality did not mortify but soothed him.
What tormented Ivan Ilych most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and the [sic] only need keep quiet and undergo a treatment and then something very good would result. He however knew that do what they would nothing would come of it, only still more agonizing suffering and death. This deception tortured him—their not wishing to admit what they all knew and what he knew, but wanting to lie to him concerning his terrible condition, and wishing and forcing him to participate in that lie. Those lies—lies enacted over him on the eve of his death and destined to degrade this awful, solemn act to the level of their visitings, their curtains, their sturgeon for dinner—were a terrible agony for Ivan Ilych. And strangely enough, many times when they were going through their antics over him he had been within a hairbreadth of calling out to them: “Stop lying! You know and I know that I am dying. Then at least stop lying about it!” But he had never had the spirit to do it. The awful, terrible act of his dying was, he could see, reduced by those about him to the level of a casual, unpleasant, and almost indecorous incident (as if someone entered a drawing room defusing [sic] an unpleasant odour), and this was done by that very decorum which he had served all his life long. He saw that no one felt for him, because no one even wished to grasp his position. Only Gerasim recognized it and pitied him. And so Ivan Ilych felt at ease only with him. He felt comforted when Gerasim supported his legs (sometimes all night long) and refused to go to bed, saying: “Don’t you worry, Ivan Ilych. I’ll get sleep enough later on,” or when he suddenly became familiar and exclaimed: “If you weren’t sick it would be another matter, but as it is, why should I grudge a little trouble?” Gerasim alone did not lie; everything showed that he alone understood the facts of the case and did not consider it necessary to disguise them, but simply felt sorry for his emaciated and enfeebled master. Once when Ivan Ilych was sending him away he even said straight out: “We shall all of us die, so why should I grudge a little trouble?”—expressing the fact that he did not think his work burdensome, because he was doing it for a dying man and hoped someone would do the same for him when his time came.
Many readers find The Death of Ivan Ilyich a demanding text. Author Zadie Smith wrote “Every time I read it, I find my world put under an intense, unforgiving microscope.” Internists will find the central theme—the human refusal to acknowledge death—especially unforgiving given that Ivan Ilyich’s physicians cannot cure or even empathize with him. Only an uneducated peasant, Gerasim, can help Ivan Ilyich find resolution before death. The physician-reader will benefit from asking ‘Why?’ What about Gerasim’s care is unique? How might we emulate him or encourage students to do so?
At the beginning of the above excerpt, Ivan Ilyich is profoundly isolated. A lifelong pursuit of social approval has won him only an acrimonious marriage and a few superficial friendships. Illness has replaced his pleasure in social gatherings and card games with pain. He has struggled to confront mortality and railed against his family. Soon he will rage against God’s cruelty and absence. Being with such an anguished patient is difficult; analogously, so is reading Ivan Ilyich’s narrative. We experience his torment and fear; we feel our anxiety rising. Others have illustrated how intricate this transition is and how such complexity challenges the simplified Kubler-Ross stages of dying.2 Indeed, The Death of Ivan Ilyich does a better job than most formal texts of helping us understand our own negative emotions toward dying patients.3
Though Ivan Ilyich’s journey is bleak, its conclusion is graceful. This is possible because of Gerasim’s actions in the above passage. Unlike Gerasim, Ivan Ilyich’s physicians and family feed him what Anthony Brings, in his translation, names “the polite lie” that following medical advice might improve his health. In doing so, they impede his recognition of the significance of his death. The polite lie is attractive, especially to physicians. Denying it requires us to admit our limitations and acknowledge that we too will succumb. Gerasim does not denounce the polite lie; rather he absolves Ivan Ilyich of guilt. In doing so, Gerasim allows his patient to see himself differently. To Ivan Ilyich, a successful lawyer, analogies between disease and judgment abound. During an appointment with a prominent physician, the narrator remarks, “The doctor put on just the same air towards him as he himself put on towards an accused person.” Both the reader and Ivan Ilyich know his disease is not his fault, but initially only the reader sees the hardship Ivan Ilyich’s disease causes others. Ivan does not realize his illness affects others until he asks Gerasim to forgive his inability to use a chamber pot. Gerasim replies not with forgiveness, but with the observation that Ivan Ilyich does not need forgiveness for a disease. This opens the door for Ivan Ilyich’s deathbed discovery of compassion for his wife and family.
Gerasim’s avoidance of the polite lie is only part of what allows him to connect so profoundly to Ivan Ilyich. Interestingly, Gerasim is a more effective caretaker because of his extraordinarily low social status. Russian peasants were emancipated only 25 years before the novella’s publication. They remained separated from a middle class that was culturally more Western European than Slavic. Tolstoy illustrates this gap by describing Gerasim’s “Russian peasant costume” and unschooled manner. As a peasant, Gerasim accepts death as natural. He would not understand the middle class refusal to acknowledge death. Moreover, Gerasim, unlike the others who care for Ivan Illyich, has time. He has no social engagements like Ivan Ilyich’s friends, or opera tickets like Ivan Ilyich’s wife, or appointments like his physicians. Gerasim is successful because his status enables him to spend more conflict-free time with Ivan Ilyich. Sadly, both rank and restriction of time are as limiting to today’s caretakers as they were in Tolstoy’s time.
In 1886, when Tolstoy published The Death of Ivan Ilyich, William Osler was serving as chair of clinical medicine at the University of Pennsylvania. Two years later, Osler would become chief of staff at Johns Hopkins Hospital. He and the physicians of his generation would formalize medical education based on the social hierarchies of their time. Because of this, medical hierarchy is the descendant of the Victoria society that Tolstoy critiqued. The same obstacles that hindered Ivan Ilyich’s doctors hinder today’s caretakers. A doctor is estranged from the patient both by rank and a scarcity of time. Though it might be unwise to liken them to peasants, students enjoy a less estranging rank, more time with their patients, and a reduced investment in the hospital hierarchy. So often it is the student who obtains nuances of the history, and so often patients express gratitude to the student as the one person who had the time to hear them out or simply sit with them. The point is not that physicians cannot perform Gerasim’s role and that students must; rather, it is that each member of a medical team must overcome different obstacles to fulfill Gerasim’s role or an aspect of it.
Over a century after publication, The Death of Ivan Ilyich remains poignant to medical educators. It reminds us that as knowledgeable as we might be, it is still difficult to put ourselves in the patient’s shoes. It reminds us that the same forces that distanced Ivan Ilyich from his caretakers continue to separate patients and physicians. The fact that we have allowed a payment scheme to put more value on doing to patients than being with patients is to some degree our fault.
Gerasim shows us that the goal of medical education should be to preserve the capacity to imagine a patient’s suffering; we don’t need to ‘teach’ empathy as much as we need to preserve the innate empathy the student brings. The study of medicine, the focus on disease and organ systems, can rob one of the qualities that brought one to medicine. The Death of Ivan Illyich is a touchstone, a means of reconnecting with the sense of calling, and a reminder of how potent being fully present with the ill can be, a timeless therapeutic tool.
Conflict of Interest None disclosed.
1Tolstoy Leo, The Death of Ivan Ilyich, translation Louise and Aylmer Maude, 1886. The Tolstoy Library, 2009, October 22, 2009 <http://www.ccel.org/ccel/tolstoy/ivan.txt>.
2Holleman WL. Death Education in American Medical School: Tolstoy’s Challenge to Kubler-Ross, The Journal of Medical Humanities 1991; 12(1):11–8.
3Yong-Mason J. Tolstoi’s The Death of Ivan Ilych: A Source for Understand Compassion, Clinical Nurse Specialist. 1988 Winter; 2(4):180–3.