In 1869, just after he finished War and Peace, Leo Tolstoy experienced a profound spiritual crisis as the result of an incident during a journey through the city of Arzamas, which is on the Tyosha River about 250 miles east of Moscow. As he described it in his unfinished story Notes of a Madman (so titled because Tolstoy was convinced his readers would find the tale implausible), a few hours after midnight he awakened “seized by despair, fear and terror such as [he had] never before experienced.” After asking himself what there was to be afraid of, none other than Death himself answered, “I am here.” Tolstoy, confronting the inescapability of his own death, panicked and raged against its power.

That evening stayed with Tolstoy for the rest of his life; he became permanently preoccupied with mortality. Writing his Confessions a decade later, Tolstoy would ask: “Is there any meaning in my life that will not be destroyed by my inevitably approaching death?” “He engaged in long and laborious meditations”, wrote Tolstoy’s long-suffering wife, Sonya. “Often he said his brain hurt him, some painful process was going on inside it, everything was over for him, it was time for him to die.”

Tolstoy’s “Arzamas Horror”, as the Russian dramatist Maxim Gorky called it, also served as the basis for his masterful novella, The Death of Ivan Ilych. In this slim book, a 45-year-old Russian judge realizes he is dying and acknowledges that he has wasted his life attaining comfort and status. While outwardly appearing successful, Ilych suffers from an unhappy marriage, a meaningless career and a selfish existence. “Ivan Ilych’s life had been most simple and most ordinary and therefore most terrible”, reads one typically devastating Tolstoyan line.

Melancholy as this is, the most harrowing parts of the story lie in Ilych’s terror at confronting his own mortality, much as Tolstoy had years earlier in the dark morning hours in Arzamas. Perhaps nowhere else in all of world literature is the sheer horror of the fact of death laid so bare: “He would go to his study, lie down, and again remain alone with it. Face to face with it, and there was nothing to be done with it. Only look at it and go cold.”

Ilych dies at the end of the story despite the exertions of a skilled and esteemed doctor, but not before achieving a measure of redemption. He takes comfort in the belief that his demise will relieve the suffering of his family and appreciates his caregivers’ devotion. More grandly, Ilych accepts his fate, even experiencing a brief moment of joy, before his body succumbs to a kidney ailment.

When The Death of Ivan Ilych was published in 1886, it was instantly hailed as an artistic masterpiece. Tchaikovsky said it proved Tolstoy was “the greatest author-painter who ever lived.” The great Russian literary critic Vladmir Stosov wrote in a letter that, “in comparison to those seventy pages, everything is little and petty.” Just past 125 years after it was written, Tolstoy’s story has come to be appreciated in another capacity. Rather than rest content with its narrative brilliance, medical journal writers and Pulitzer Prize-winning authors turn to its pages for applied wisdom about dying. Whatever the mysterious sources of his genius, Tolstoy described and diagnosed psychological conditions so acutely that scientific research is confirming his insights more than a century later. Tolstoy’s suffering, and Ilych’s, it turns out, were not for naught.

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he story’s literary merits were never in doubt, but its status as thanatology took some time to develop. It failed to register with European and American psychologists for most of the 20^th century, probably because Freud’s brand of psychoanalysis emphasized dreams, sex and childhood, relegating death largely to the background. But in 1973, cultural anthropologist Ernest Becker published The Denial of Death. In it, Becker argued that the fear of death “haunts the human animal like nothing else; it is a mainspring of human activity—activity designed largely to avoid the fatality of death, to overcome it by denying in some way that it is the final destiny of man.” Man’s subconscious fear of death and desire to transcend its inevitability leads him to create or achieve something “heroic”, so that the immortality of that creation or act might redeem the mortality of its maker. Fear of death is universal, and denial of it is equally cross-cultural.

What Becker was saying was not entirely new. He drew heavily from Kierkegaard and the Austrian psychoanalyst Otto Rank, among others. Yet by synthesizing and popularizing their ideas, Becker brought death back into the American consciousness, at least for a time. The Denial of Death won the Pulitzer Prize in 1974, but it reigns as “the most unread Pulitzer winner” in the award’s history, according to the philosopher Sam Keen. No doubt the subject matter itself accounts for both its acclaim and popular neglect, but any volume mentioned in both Annie Hall and Bill Clinton’s list of favorite books can’t be as culturally obscure as all that.

In addition to Kierkegaard and Rank, Becker read Tolstoy closely. The son of Russian-Jewish immigrants, Becker references the novelist in four of his books. While Becker does not specifically mention The Death of Ivan Ilych in The Denial of Death, passages of his book echo Tolstoy’s novella. Becker writes of “men marching into point-blank fire in wars: at heart one doesn’t feel that he will die, he only feels sorry for the man next to him.” Nearly every individual secretly believes himself exempt from the rules of mortality that govern all living creatures. Similarly, Tolstoy writes of Ilych that he had always believed death was something that happened to someone else. “Caius is indeed mortal, and it’s right that he die, but for me, Vanya, Ivan Ilych, with all my feelings and thoughts—for me it’s another matter”, Ilych thinks. “For the man Caius, man in general, it was perfectly correct; but he was not Caius and not man in general, he had always been quite, quite separate from all other beings.”

Becker also echoes Tolstoy in his description of what he calls the paradox of existence: “the ever-present fear of death in the normal biological functioning of our instinct of self-preservation, as well as our utter obliviousness to this fear in our conscious life.” This is what Becker means by the denial of death. Despite the pervasiveness of the fear of death, we are loathe to even acknowledge it. Likewise, Ivan Ilych struggles on his deathbed to “restore the former ways of feeling that had screened him from death.” For Ilych, that meant immersing himself in work:

He would rouse himself, try to come to his senses, and somehow bring the session to an end and return home with the sad awareness that his work in court could no longer, as before, conceal from him what he wanted concealed; that by his work in court he could not rid himself of it.

Indeed, Tolstoy is clear that all of Ilych’s sad life, so outwardly satisfying and impressive, was an attempt to deny to himself the horrors of death and its associated implications for the meaning of human existence.

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rawing heavily from Becker, a group of social psychologists at American universities developed Terror Management Theory (TMT) in the 1980s. They carried out a series of experiments that convincingly demonstrated the salience of death in human behavior. For instance, one experiment showed that participants standing in front of a funeral home were more likely to be positive about making charitable donations than those standing 150 feet away. In other words, when an individual is forced to confront human mortality, he is favorable toward values and ties that are larger than himself and will outlive him.

More than 300 studies have now been conducted demonstrating that people are deeply, but largely unconsciously, motivated by a fear of death. By 1993, TMT substantiated enough evidence to help start the Ernest Becker Foundation. The foundation now hosts an annual conference, a blog (“The Denial File”), and boasts active members in North America, Europe, East Asia, South Asia and Oceania. Tolstoy is acknowledged as one of the inspirations behind the foundation. “Becker refers to Tolstoy a number of times, and others have seen a connection between the two thinkers”, says Daniel Liechty, a Becker-TMT expert at Illinois State University.

Becker was not the only Vietnam-era writer in touch with Tolstoyian themes. Elizabeth Kubler-Ross, probably the best known among them, published On Death and Dying in 1969. The book is most famous for introducing the concept of the Five Stages of Grief through which dying individuals pass. James J. Napier, a professor of humanities at the New Jersey Institute of Technology, argued in the journal College Literature that Kubler-Ross’s On Death and Dying strikingly confirms the insights of Ivan Ilych. Tolstoy had in effect provided a fictional representation of the Kubler-Ross model, which was based on more than 200 patients with terminal illnesses similar to Ilych’s. Tolstoy “anticipat[es] freely and indirectly the revelations of the medical analyst”, Napier wrote. Ilych evolves though stages of denial, anger, bargaining and depression before arriving eventually at a tragically short-lived state of acceptance: “Well, then, let there be pain”, Ilych thinks to himself before finding that his fear of death has been finally extinguished. After examining Tolstoy’s novella beside On Death and Dying, Napier writes that “science with its striking examples supports fiction.”

Kubler-Ross’s book was a surprise bestseller and profoundly influential in popular culture, but her model has been controversial within psychiatry. More accepted has been the work of the Stanford psychoanalyst Irvin Yalom, who in the late 1970s developed an approach known as existential psychotherapy. This method, based on the idea that individuals’ inner conflicts frequently occur due to confrontations with facts of existence, had been practiced since Otto Rank and the European existentialist philosophers, but Yalom codified it and gave it a cohesive framework. The inevitability of death is only one of these conflicts in Yalom’s framework—the others being freedom and the burden of responsibility it confers, isolation, and meaninglessness.

Unsurprisingly, Yalom relies on The Death of Ivan Ilych in two important books. In Existential Psychotherapy (1980), Yalom writes, “No one has ever described the deep irrational belief in our own specialness more powerfully or poignantly than Tolstoy . . . through the lips of Ivan Ilych.” According to Yalom, humans develop a false sense of specialness as a defense against the certainty of death. “[D]eep, deep down, each of us believes, as does Ivan Ilych, that the rule of mortality applies to others but certainly not to ourselves.” Yalom tells us that in his work with cancer patients, many literally do not even hear their physicians tell them their prognosis. His argument strongly echoes Ivan Ilych, who “tried to make himself think he was better. And he could deceive himself as long as nothing worried him.” Tolstoy writes: “The worsening went on so gradually that he could deceive himself comparing one day with another—the difference was so slight.”

Elsewhere in Existential Psychotherapy, Yalom writes that Ivan Ilych’s hopeful ending should illustrate to therapists that they must not be overawed by their patients’ pasts. Even if patients have only a small time left to live, they can cram untold and precious meaning into their final days. After all, “Tolstoy’s Ivan Ilych, through his confrontation with death, arrived at an existential crisis and, with only a few days of life remaining, transformed himself and was able to flood, retrospectively, his entire life with meaning.” Though the story is fictional, Yalom offers it as actual evidence for his psychiatric claims.

Nearly thirty years later, Yalom again turned to Tolstoy and Becker in Staring at the Sun: Overcoming the Terror of Death (2008). There he argues that death anxiety is lessened by the sense that one has lived a full, meaningful life. Ilych “is dying so badly because he has lived so badly”, he writes (emphasis in original). Yalom argues that individuals usually require a climactic or irreversible experience to be awakened to the finitude of existence. Of course, that awakening is exactly what happens with Ivan Ilych, who confronts a terminal illness before he can reckon with the fact of his own mortality. According to Yalom, “Tolstoy’s story is not only a literary masterpiece but also an instructive lesson and, indeed, is often required reading for those being trained to offer comfort for the dying.”

Here Yalom points to one of the most unexpected appropriations of The Death of Ivan Ilych. The story features the aforementioned brilliant and famous doctor who acts much as Ilych performed his career as a lawyer: formally, impersonally, unfeelingly and with great self-importance. The doctor—tellingly unnamed—has no patience for Ilych’s terrified questions about the seriousness of his condition. The doctor is concerned only with diagnosing the condition correctly, not with comforting the dying patient. His visible indifference actually worsens Ilych’s anguish.

In contrast, Ilych’s servant Gerasim shows him great compassion and humility. He performs small thankless nursing tasks that provide Ilych with relief, and does so pleasantly, even though he has to attend to his other duties. Indeed, he does it “easily, willingly, simply, and with a kindness that moved Ivan Ilych.” Gerasim comes closest to providing Ilych with what he most wants, pity. (Notably, this servant is the only character with a stoic and self-aware attitude towards death: “It’s God’s will. We’ll all come to it some day”, he says).

The doctor and the compassionate Gerasim have become instructive figures for physicians working with dying patients. A 2008 Lancet article, for example, argues that Tolstoy’s “observation helps explain the strong identification and sympathy judges almost invariably have with physicians who they see as engaged in similar acts of judgment that require a certain emotional and even professional detachment from the patient or litigant.”¹ A paper in the Journal of General Internal Medicine similarly infers from the story the lesson that “Death, like life, cannot be reduced to physiology.”² A 2006 article in Theoretical Medicine and Bioethics uses Ivan Ilych to argue that the portrayal of the unfeeling doctor is not only realistic but typical. Clinicians often lack the “moral perception” required to translate clinical data into ethical terms, writes University of Pennsylvania M.D. David J. Casarett.³ Thus physician and patient have naturally opposing perspectives. A piece in Humane Medicine uses Tolstoy to contrast “the former (biomedical) concerned primarily with the pathophysiology of a particular disease process and the impact of disease on the body”, with “the latter overwhelmingly preoccupied with the existential impact of illness on one’s person (the disruption of the life that is lived in and through this particular body).”⁴ It is not just life in general that imitates art, it would seem, but psychiatry as well.

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eading The Death of Ivan Ilych causes profound, somber reflection; the novelist Zadie Smith wrote, “Every time I read it, I find my world put under an intense, unforgiving microscope.” But it is nevertheless a hopeful tale. The tortured lawyer ultimately finds relief and redemption in confronting the end of his own existence: “Just then Ivan Ilych fell through, saw light, and it was revealed to him that his life had not been what it ought, but that it could still be rectified.” He ultimately takes solace in the fact that his own death puts an end to his family’s suffering, and finds joy in his realization of the power of altruism.

This was clearly a hard-earned lesson for Ilych, as it was for Tolstoy beginning on that lonely night in Arzamas. It was perhaps harder than it needed to be, but if Tolstoy had not gone through the process, Ilych could not have either, and we would all be the poorer for it. Alas, novelists suffer so that we might know better. Perhaps no other novelists suffer as well as Russian ones, but, thankfully you don’t have to be a Russian to learn from them. The whole world is the beneficiary of that inheritance.

¹George J. Annas, “Doctors and Lawyers and Wolves”, The Lancet, May 31, 2008.

²Vinay Prasad, “Language in the End”, Journal of General Internal Medicine (August 2010).

³Casarett, “Moral Perception and the Pursuit of Medical Philosophy”, Theoretical Medicine and Bioethics (1999).

⁴S. Kay Toombs, “Listen: Two Voices”, Humane Medicine (January 1996).