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.

What do hospice nurses and teenage heroin addicts have in common? One may be an unintended consequence of the other.

A pair of articles published this week in two prestigious medical journals help make the case.

The Lancet reported (Shetty, Priya. The Lancet:376; 1453-1454.) that 47 million of the 58 million deaths occurring annually worldwide take place in developing countries, and that of these, fully 27 million die without having received proper palliative care. The article attributes this dismal performance to the overly restrictive regulation of narcotic pain relievers in an effort to help combat drug trafficking; morphine is unavailable in more than 150 of these countries. The regulatory burdens are so great that most pharmacies are reluctant to even order it. The strongest analgesic available to many cancer patients in developing countries is aspirin. Of 1 million cancer patients requiring pain medication in India in 2008, only 40,000 received morphine.

Such grisly data can’t help but make one grateful to be living in the developed world, where—in no small part thanks to Leo Tolstoy, whose short story The Death of Ivan Ilyitch greatly increased public awareness of the need for palliative care—the situation is much different. Cancer patients in the United States have widespread access to hospice programs—modern day Mercy Queens—and narcotic pain relievers. But we may be victims of our own success. The movement to relieve pain and suffering at the end-of-life has morphed into an effort to relieve pain and suffering in the general population, with extended-release, long-acting opioids the agents of choice. An editorial in The New England Journal of Medicine discusses the consequences (Okie, Susan. N Engl J Med: 363;21. 1981-1984):

There are approximately 1 million prescribers of controlled substances registered with the Drug Enforcement Administration and about 4 million patients receiving long-acting opioids annually. Deaths from unintentional drug overdoses are now the second leading cause of accidental death in the United States, with 27,658 such deaths in 2007. 41% of these—11,499—were due to synthetic opioids. Emergency room visits for opioid abuse more than doubled from 2004 to 2008, and admissions to chemical dependency treatment programs rose by 400% from 1998 to 2008, with prescription narcotics second only to marijuana as the cause of addiction. Since 1990, the medical use of opioids has increased ten-fold. Drugs such as Oxycontin “are essentially legal heroin.”

The proliferation of these drugs has put them in the medicine cabinets of citizens—and parents—all across the country. So much so that it is just as easy for a thrill-seeking 14-year-old to filch some Oxycontin from the medicine cabinet as it is to siphon some Jack Daniels from the liquor cabinet. But Oxycontin is highly addicting—and expensive. Teenagers who develop an addiction to it—whether taken from the medicine cabinet of their parents or that of their friends’ parents—soon have trouble scoring enough to maintain them. They quickly discover a much more affordable and readily available alternative: heroin, which when smoked is dirt cheap compared to Oxycontin. A two-hour exposé on local TV in San Diego this week referred to the problem of teen use of Oxycontin with subsequent migration to heroin as “epidemic.”

So there you have it: from genuine Mercy Queens to teenage heroin fiends, the rise of opioid use in America.

We should perhaps not be so quick to condemn our developing world counterparts for their reluctance to embrace our more permissive use of prescription narcotics.