The doctor-patient relationship in selected literary works.

Language is a key element of the assistance relationship between doctor and patient. In order to prepare this article, we followed the challenge of Edmund D. Pellegrino1, one of the innovators of bioethics, to think about this unique meeting based on some works of several recognized authors. We will begin with the book The death of Ivan Ilych, by Lev Tolstoy, deemed a Russian fiction masterpiece and a classic of world literature, which analyzes in details the main aspects involved in the doctor-patient relationship2. In this regard, we will use this narrative as a paradigm for a reflection on bioethics, although also making some references to other literary works that address this subject. Thus, we intend to refute some arguments of those who criticize the inclusion of literature and the humanities in medicine courses, as only an obsolete entertainment of clinical activity or intended for an elite of scholars. Lev Tolstoy, also known as Leo Tolstoy or Lev Nikolayevich Tolstoy (1828-1910), was a Russian writer very influential in the literature and politics of his country. He is considered, along with Fyodor Dostoyevsky (18211881), one of the best novelists of Russian literature of the 19th century. Linked to the realist school, his most famous works are War and peace, in which Tolstoy represents, through the life of five families, the Russian society at the beginning of the 19th century, during the Napoleonic invasion in 1812, and Anna Karenina, which reflects the moral and social values of Russia in this period. The death of Ivan Ilych has few pages, especially if compared to the aforementioned works, and it is written in a simple and direct style about a subject that is always not only difficult and complex, but timeless. The senselessness of suffering and death, the desire of immortality, and the (apparent) absence of God are universal human feelings expressed in this novel in a sublime manner. In the preface of the edition we used, António Lobo Antunes cites that “there is no feeling not included in it, there is no emotion that is absent. Everything that we are can be found in a few pages, written in a masterful way”3. The description of the meeting of the judge Ivan Ilych, the main character of this work, with a famous doctor, who Ilych visits by insistence of his wife, when the first symptoms of his deathly disease arise, reveals the doctor’s excessive paternalism, surely common in the Russia of the 19th century, as well as a total insensitivity regarding the patient’s concerns, because he is probably more interested in his brilliant diagnosis than in the patient’s well-being and health recovery. This attitude of unbearable superiority was not uncommon to Ilych, because it was the attitude he himself assumed before the accused persons in his work as a judge: “Everything took place as he had expected and as it always does. There was the usual waiting and the important air assumed by the doctor, with which he was so familiar (resembling that which he himself assumed in court), and the sounding and listening, and the questions which called for answers that were foregone conclusions and were evidently unnecessary, and the look of importance which implied that ’if only you put yourself in our hands we will arrange everything – we know indubitably how it has to be done, always in the same way for everybody alike’. It was all just as it was in the law courts. The doctor put on just the same air towards him as he himself put on towards an accused person. To Ivan Ilych only one question was important: was his case serious or not? But the doctor ignored that inappropriate question [.] From his point of view, it was not the one under consideration; the real question was to decide between a floating kidney, chronic catarrh, or appendicitis. It was a question the doctor solved brilliantly, as it seemed to Ivan Ilych, in favor of the appendix... All this was just what Ivan Ilych had himself brilliantly accomplished a thousand times in dealing with men on trial. The doctor summed up just as brilliantly, looking over his spectacles triumphantly and even gaily at the accused.