Rereading the Classics: The Death of Ivan IIych

The Death of Ivan IIych, by Leo Tolstoy, a masterpiece of Russian fiction and a classic of world literature, develops several themes of enormous relevance to health professionals. One of them is the doctor-patient relationship.

According to Edmund D. Pellegrino, one of the founding fathers of contemporary Bioethics, “literature has proven an effective way to teach empathy for the sick, suffering, and dying. Through the creative words of George Eliot, Tolstoy, Chekhov, Camus, or Thomas Mann, the experience of being ill, being a doctor, or dying can be powerfully evoked and vicariously felt.”

The description of the appointment of the patient Ivan IIych with a famous doctor, who IIych consulted pressed by his wife when the first symptoms of the disease that eventually killed him started, reveals the exacerbated paternalism of the clinician, lack of compassion and insensitivity to the patient's concerns. The physician was apparently more interested in his bright diagnosis than in the well-being and recovery of the patient's health. This attitude of unbearable superiority was no strange to IIych, as it was the same attitude he took before the defendants in his career as 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.

The doctor said that so-and-so indicated that there was so- and-so inside the patient, but if the investigation of so-and-so did not confirm this, then he must assume that and that. If he assumed that and that, then...and so on. 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 not a question the doctor solved brilliantly, as it seemed to Ivan Ilych, in favour of the appendix, with the reservation that should an examination of the urine give fresh indications the matter would be reconsidered. 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. From the doctor's summing up Ivan Ilych concluded that things were bad, but that for the doctor, and perhaps for everybody else, it was a matter of indifference, though for him it was bad. And this conclusion struck him painfully, arousing in him a great feeling of pity for himself and of bitterness towards the doctor's indifference to a matter of such importance.

"I have already told you what I consider necessary and proper. The analysis may show something more." And the doctor bowed.

He said nothing of this, but rose, placed the doctor's fee on the table, and remarked with a sigh: "We sick people probably often put inappropriate questions. But tell me, in general, is this complaint dangerous, or not?..."

The doctor looked at him sternly over his spectacles with one eye, as if to say: "Prisoner, if you will not keep to the questions put to you, I shall be obliged to have you removed from the court."

Ivan Ilych went out slowly, seated himself disconsolately in his sledge, and drove home. All the way home he was going over what the doctor had said, trying to translate those complicated, obscure, scientific phrases into plain language and find in them an answer to the question: "Is my condition bad? Is it very bad? Or is there as yet nothing much wrong?" And it seemed to him that the meaning of what the doctor had said was that it was very bad. Everything in the streets seemed depressing. The cabmen, the houses, the passers-by, and the shops, were dismal. His ache, this dull gnawing ache that never ceased for a moment, seemed to have acquired a new and more serious significance from the doctor's dubious remarks. Ivan Ilych now watched it with a new and oppressive feeling.»

One of the most important elements for establishing a relationship of trust between doctor and patient is an effective communication, which includes listening with empathy to their history, let the patients express their real needs and concerns and provide them with words they can understand the diagnosis (if known) and possible treatment of their condition.

The great British physician Sir William Osler (1849-1919) is quoted as saying: "It is more important to know what kind of patient has the disease than to know what kind of disease the patient has." None of this has occurred in the several clinical encounters between Ilych and the doctors he consulted. They were more concerned about the accuracy of their diagnosis than in seeing the patient as a person with not only a body but also with a psychological, social and spiritual dimensions.

As John Coverdale (Acad Psychiatry 2007; 31: 354-357) reminds us, “the best part of being a doctor is the ability to listen to what patients have to say, to understand it, and to offer relief through compassion, knowledge, and humanity.”

[Texto que escrevi para o PRIME International E-mail de Setembro de 2010]

A UTILIZAÇÃO DO CORPO HUMANO APÓS A MORTE

O Manual de Conduta sobre a Transplantação de Órgãos de Cadáveres, que rege a atividade dos médicos do Reino Unido, refere que, depois da morte, não há qualquer objeção legal à administração de fármacos necessários para otimizar o funcionamento de órgãos a transplantar ou à realização de quaisquer exames que se julguem necessários, desde que daí advenha um benefício óbvio para terceiros.

O que é eticamente inaceitável e condenado por todos os principais códigos de ética e deontologia médicas, é a comercialização de órgãos humanos, quer sejam procedentes de dadores vivos ou de cadáveres. No artigo 21.º do capítulo VII da Convenção sobre os Direitos do Homem e a Biomedicina, do Conselho da Europa, é claramente expresso que «o corpo humano e as suas partes não devem ser, enquanto tal, fonte de quaisquer lucros» (Diário da República, 2001).

Para Daniel Serrão (1996), «no rigor da análise ética o cadáver não constitui, nem configura, nenhum valor positivo; o único valor que se lhe atribui é um valor negativo: o da sua perigosidade para a saúde pública e o bem-estar dos vivos e, por isso, a autoridade pública regulamenta a inumação ou a cremação». Frei Bernardo (1995) defende que «a máxima dignificação dum cadáver com órgãos em boas condições, será a sua adequada utilização para transplantes, cumprindo assim, mesmo para além da morte, a natural vocação humana para a partilha solidária e gratuita».

A colheita de órgãos não constitui uma forma de mutilação do cadáver, pois não se traduz em alteração morfológica do corpo nem acarreta a sua desfiguração. Trata-se de uma intervenção cirúrgica efetuada com todo o cuidado e dignidade inerentes a qualquer ato médico. A mesma ideia encontra-se expressa no artigo 18 do capítulo IV do comentário explicativo do Protocolo Adicional da Convenção dos Direitos do Homem e da Biomedicina, sobre a Transplantação de Órgãos e Tecidos de Origem Humana (2002), assinado por Portugal: «Durante a colheita, o corpo humano deverá ser manuseado com respeito e deverão ser tomadas medidas consideradas razoáveis para restaurar a aparência do corpo».

Esta situação é totalmente distinta da dos pacientes em estado terminal ou moribundos, aos quais deverão ser prestados os cuidados básicos, médicos e de enfermagem, tendo em vista a melhor qualidade de vida possível até ao momento da morte, à luz do princípio da dignidade da pessoa humana. Tal como refere Daisy Gogliano (2000), Professora da Faculdade de Direito da Universidade de S. Paulo, «o ser humano, a pessoa dotada de personalidade, com aptidão genérica de adquirir direitos e contrair obrigações de ordem civil, portanto, na qualidade de sujeito de direitos, não deixa de ser pessoa como paciente terminal ou sob manutenção cardiorrespiratória assistida, quando mantida por circulação extracorpórea e respiradores artificiais, enquanto não for declarada morta. A personalidade jurídica só termina com a morte».

O INFANTE

             Deus quer, o homem sonha, a obra nasce.

             Deus quis que a terra fosse toda uma,

             Que o mar unisse, já não separasse.

             Sagrou-te, e foste desvendando a espuma,

             E a orla branca foi de ilha em continente,

             Clareou, correndo, até ao fim do mundo,

             E viu-se a terra inteira, de repente,

             Surgir, redonda, do azul profundo.

             Quem te sagrou criou-te português.

             Do mar e nós em ti nos deu sinal.

             Cumpriu-se o Mar, e o Império se desfez.

             Senhor, falta cumprir-se Portugal!

                                      Fernando Pessoa

MODELO BIO-PSICO-SOCIO-ESPIRITUAL

Este célebre quadro de Picasso, de 1897, intitulado “Science e Charité”, retrata uma abordagem holística e integral dos cuidados de saúde, na sua dimensão não apenas biológica e mental, mas também social e espiritual, bem expressas pela figura do médico, da freira e da criança.

Deve-se privilegiar este modelo antropológico ou bio-psico-socio-espiritual, centrado na pessoa doente, em vez do modelo biomédico ou biomecânico, que a própria Organização Mundial de Saúde (OMS) considera inadequado: «Até agora, o ensino médico tem geralmente seguido o modelo de procurar tratar os pacientes com base na medicina e cirurgia, dando menos importância às convicções das pessoas e à fé no processo de cura, quer por parte do médico quer na relação médico-doente. Esta perspetiva mecânica e redutora de considerar o paciente já não é satisfatória. Os pacientes e médicos começaram a compreender a importância de elementos como a fé, a esperança e a compaixão durante o processo de cura.» (Relatório da OMS de 1998).