Pity me as I wish to be pitied. That is the plea of the tortured protagonist in Leo Tolstoy’s brilliant 1886 novella, The Death of Ivan Ilyich.

Tolstoy was born in 1828 into Czarist Russia’s landed gentry. Though orphaned at a young age, he enjoyed the typical privileges wealth and title afforded—passive income, summers in the country, and enrollment at Kazan University. But it was later, after dropping out of school and joining the army, that Count Tolstoy would launch his career as a writer from the Crimean front.

There is perhaps no other literary character who gives voice to the agony of the afflicted more profoundly than Ivan Ilyich, a forty-five-year-old parvenu who assiduously wends his way through Czarist Russia’s bureaucracy to become a respected judge, only to develop an insidious illness that announces its presence while he is hanging curtains in a stylish home beyond his means to afford.

…he made a false step and slipped…but only knocked his side against the knob of the window frame. The bruised place was painful but the pain soon passed…

But not for long.

…Ivan Ilyich…had a queer taste in his mouth and felt some discomfort in his left side.

His symptoms begin to disrupt his carefully ordered and superficially fulfilling life. He grows irritable from discomfort and more quarrelsome with his wife, with whom his relationship is abysmal to begin with, a thing to be endured to keep up appearances. Her patience with him is soon exhausted.

She began to wish he would die; yet she did not want him to die because then his salary would cease.

Tolstoy passes judgment on the spiritual emptiness of social striving with one of the most famous and devastating sentences in Russian literature.

Ivan Ilyich’s life had been most simple and most ordinary and therefore most terrible.

Ivan’s symptoms intensify, mystifying a bevy of doctors who attribute it one day to a “floating kidney,” and the next to appendicitis.

The pain in his side oppressed him and seemed to grow worse and more incessant, while the taste in his mouth grew stranger and stranger…It seemed to him that his breath had a disgusting smell, and he was conscious of a loss of appetite and strength.

The nephrologist in me cannot resist pointing out that with the exception of his pain, all of Ivan Ilyich’s symptoms can be explained by uremia, an advanced stage of kidney failure. But whatever the cause, he becomes angry and bitter over his doctors’ failure to cure him. He realizes he is dying.

And he had to live thus all alone on the brink of an abyss, with no one who understood or pitied him…

He becomes resentful, especially of his still-healthy wife.

While she was kissing him he hated her from the bottom of his soul and with difficulty refrained from pushing her away.

Why is he so resentful? Because no one gives him what he wants. We come, now, to the heart of things, to what patients want and need and crave with all their being.

…what most tormented Ivan Ilyich was that no one pitied him as he wished to be pitied. At certain moments after prolonged suffering he wished most of all (though he would have been ashamed to confess it) for someone to pity him as a sick child is pitied. He longed to be petted and comforted.

He finally gets the succor he seeks from the peasant Gerasim, who holds him the way he wants to be held—and talks to him about death openly and honestly. The authenticity of Gerasim, in contrast to the hypocrisy of the aristocrats Ivan Ilyich has lived his life to please, has a powerful effect on him.

“Maybe I did not live as I ought to have done,” it suddenly occurred to him…“What if my whole life has been wrong?”

He softens and allows a priest to hear his confession, then endures an agonizing three days, during which…he struggled in that black sack into which he was being thrust by an invisible, resistless force.

In the end, Ivan Ilyich rejects the lie of his life and embraces the truth of his death; in so doing, he is at peace.

He sought his former accustomed fear of death and did not find it. “Where is it? What death?” There was no fear because there was no death.

In place of death there was light.

“So that’s what it is!” he suddenly exclaimed aloud. “What joy!”

Ivan Ilyich wanted nothing more than to be stroked like a child. Tolstoy’s insight into the enormous frustration patients feel at the end of life, the agony they endure, at not being touched in a compassionate way is a call to physicians—to all caregivers—to lay hands on our patients not only in a clinical way, as part of an examination, but also in an emotionally meaningful, loving way. Embrace them. Pity them. And patients: express your need. No pathos, no pity. Let people know you want to be held like a baby.

For from this will come a relief no surgery or medication can bring.

Richard Barager is a nephrologist who blogs at his self-titled site, Richard Barager.

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