Cancer Ward, a semi-autobiographical novel that Aleksandr Solzhenitsyn finished penning in 1966 and which was later banned in Russia, revolves around a group of patients and medical professionals within the oncology department of a Soviet hospital. Infused with Solzhenitsyn's own beliefs, the novel has long been interpreted as a critique of the Soviet Union and Stalinism (Crichton 673). While the allegorical references may dominate discussion surrounding the novel, the realistic portrayal of cancer and its impact on those suffering from it has merited consideration. Through patient Oleg Kostoglotov and doctors Ludmila Dontsova and Dormidont Oreshchenkov, Cancer Ward illuminates the medical profession's emphasis on paternalism and the resulting ethical issues, especially with regard to compromising patient autonomy.
Firstly, it is important to establish the basic definitions of 'paternalism' and 'patient autonomy'. The British Medical Association describes 'autonomy' as the 'ability to think, choose, decide and act for oneself' (2). Conversely, paternalism can be thought of as the antithesis of autonomy, dictating that decision making is the duty of the doctor. It implies that patients do not have the right to and are also to be protected from information regarding their own health or illness. It was only in the mid-twentieth century that 'doctors' professional ethics encompassed a radical shift in thinking' (BMA 3), moving towards a modern approach that valued patient autonomy. However, Cancer Ward is set in a communist state in 1955, when traditional paternalistic codes still prevailed: 'medical philosophy and morality that did fit well with … communism was an exceedingly hierarchical and paternalistic culture and professional organisation of physicians' (Jennings 99). Lucija Murgic et. al echo a similar sentiment, claiming that 'paternalistic attitudes have been interwoven into all relationships including medical ones' (1) in communist countries. In this way, the novel's interrogation of these attitudes can be seen as a product of Solzhenitsyn's forward thinking, challenging the power struggle between doctor and patient and presenting an alternative relationship without the need for opposition.
Exemplification of paternalism is seen through Ludmila Dontsova, a clinical doctor in charge of the radiotherapy and fluoroscopy department of the oncology ward. The first indication of her brisk, objective manner is during her ward round and interaction with Pavel Rusanov who wants to learn more about his diagnosis. Dontsova retorts: '"Generally speaking, we don't have to tell our patients what's wrong with them, but if it will make you feel any better, very well – it's lymphoma"' (58). Here, she demonstrates her belief that information can be withheld from her patient even though it concerns his own health and body. Not only this, she also lies, telling him brusquely '"Of course [lymphoma's] not [cancer]"'. This suggests her assumption of his ignorance, asserting herself in a position of superiority that justifies that a patient must be protected. She later claims that 'doctors have one sacred principle: the patient must never be frightened, he must be encouraged' (90). Paul Crichton also points out that the purpose of the ward round is to 'improve the morale of the patients' (673). Therefore, this forms the basis of her deceit, in a misguided attempt to maintain the patient's spirits to improve recovery. As much as telling the truth can be emotionally tiring for both parties, like Raanan Gillon suggests, the 'assumption… that [looking on the bright side] generally makes… patients happier is highly suspect' (1971). And so, while Dontsova acts from a place of good, she indirectly harms patient autonomy. Declining to tell the truth about a patient's medical condition with the justification that the latter would be 'better off, or less harmed' remains an instance of paternalism (Dworkin, Paternalism n.p.).
The protagonist, Kostoglotov, is one character who most clearly fights for his right to autonomy. He continuously attempts to convey his wishes to her, that he isn't '"aiming at a complete cure"' and doesn't want to '"pay too high a price now for the hope of a life sometime in the future"' (63). Dontsova reacts with disgust and anger, questioning if he is in his '"right mind"' (63). Adamant that he should be able to decide for himself, he tries to reclaim ownership over his own body and the ability to decide whether his suffering is worthwhile. He demands to be heard and respected as a human being.
The discord between Dontsova and Kostoglotov heightens in the chapter titled 'The Story of an Analysis.' Frustration mounts in both parties as they discuss Kostoglotov's situation. As Kostoglotov speaks, Dontsova '[separates] the essential from the superfluous (in patients' stories there is always plenty of the superfluous), [coming] backing to the point that [interests] her' (83). Here, she fits the description of the paternalistic doctor who Brian McKinstry describes as 'believing that a doctor who appears to listen is a more effective doctor' (340). Emphasis should be placed on 'appears'. Dontsova has, in fact, little interest in hearing her patient's narrative fully. While this may be appropriate in some situations, it is possible that there are times when she could miss valuable information among what she deems 'superfluous'. As Rita Charon proposes, 'the individual story of illness is pivotal to the person's suffering' and by dismissing this, Dontsova fails to 'contextualise' events and 'honour all voices' (209). Here, Solzhenitsyn presents the clash that can arise when doctors focus solely on the illness and fail to acknowledge the impact of other factors on a patient's life.
Her paternalistic tendencies also suffuse into her communication skills. When she starts 'talking like a doctor, she always [speaks] much more quickly. In one breath she [leaps] through long sentences and difficult terms' (81). Her use of jargon can be seen as a deliberate move to avoid informing Kostoglotov about the nature of his illness. Thus, she believes that her actions are promoting good for his own protection. The lack of simplified language can also be interpreted as a way for her to reaffirm her superiority, to highlight that her medical authority somehow gives her the right to judge what is best for him and override his wishes. Kostoglotov expresses his vexation towards her patronising attitude, imploring 'Can't we get away from this tone of voice? You sound like a grown-up talking to a child. Why not talk as an adult to an adult?' (85). Dontsova becomes the literal definition of paternalism: a 'practice of managing or governing individuals … in the manner of a father dealing benevolently and often intrusively with his children' (dictionary.com n.p.). Kostoglotov is subordinate to and dependent on her, therefore she depersonalises him and sees him only as an illness that needs to be cured.
As their exchange develops, Dontsova increasingly becomes the 'autocratic doctor' that McKinstry describes (340), embodying the extremes of paternalism. Her exasperation surfaces as Kostoglotov 'runs her into the ground, prising explanations out of her about the course of his disease' (87). She doesn't have time to 'spend days talking to patients about the principles on which they were being treated!' (87) and prefers to proceed efficiently with treatment. To an autocratic doctor, 'questions … about the treatment are considered irritating as they signify a lack of recognition of the general practitioner's abilities, or a sign of ignorance on the part of the patient' (McKinstry 340). She does not believe that informing patients about her decisions regarding their health is part of her professional duty. To her, what is important is that she fixes them in a way she sees fit.
However, Kostoglotov disagrees. He is frustrated by his lack of autonomy, exclaiming that she '"does all his thinking for him"' and that he has become a '"grain of sand… nothing depends on me"' (86). Metaphorically, he laments his insignificance as a patient who has no control over what happens to him. As Merle Spriggs argues, it's not so much the illness that results in a 'loss of specific freedoms' but the way they are treated (125). Although Kostoglotov's mind remains intact and rational, he has been stripped of his identity and lumped into a collective of cancer patients, cut off from the outside world. Here, he is subjected to a doctor whose autocratic approach means that she has 'little regard for the [his] opinions' (McKinstry 340). She continues to interrupt him and labels his concerns as 'incoherent rubbish' (88). In this way, Solzhenitsyn emphasises that illness is harrowing enough without paternalism's dehumanising effects.
Furthermore, when he challenges her right to decide for him, she tells him: '"doctors are entitled to that right – doctors above all.… Without that right there'd be no such thing as medicine"' (89). In her opinion, it is not just an ethical principle, but her professional duty to do so. She believes the very foundations of her occupation rely on this. In order to coerce Kostoglotov into complying with her, she decides she must resort to 'shock'. She tells him most harshly that he is 'going – to die!' (90). Just as she has little regard for his opinions, she fails to acknowledge the validity of his feelings and by extension, his existence. She continues to wave statistics in his face, signalling an utter lack of compassion. As Dennis Sansom argues, 'bureaucratic paternalism' is at work in Dontsova's approach, as she appeals to the whole profession for support (104). In this way, she feels able to override patient autonomy because she is not simply using her individual authority, but the authority of an entire institution.
In autocratic fashion, she condescendingly demands that he 'accept [his] treatment not just with faith but with joy!' (92). This links to an earlier remark when she reprimanded him for 'daring' to 'attack' the treatment that turned him from a 'corpse into a living human being' (87). She displays a steadfast belief that he should be grateful for the 'expert advice' he is given, reflecting the sort of doctor who is of the opinion that 'patients exist for the sake of medicine rather than medicine existing for the sake of patients' (McKinstry 340). In this way, paternalism elevates medicine as a precious gift for which patients should graciously accept without question. However well-intentioned, this view disables her from recognising their right to refusal.
Later, in a turn of events, Dontsova discovers that she has cancer, becoming the patient who submits to the medical authority that she readily imposes on others. From this, we can see that her paternalistic style emerges from prioritising beneficence, without realising that her patients may define what is 'good' differently. She goes to Oreschenkov – her teacher who runs a private practice – to ask for a medical examination. In his home she feels 'confident that … only the best possible decisions could be taken' (445) and she is more than ready to relieve herself of the 'burden' of responsibility and deciding what 'she ought to do with her life' (445). This reveals that she treats her patients how she would want to be treated in their position, and this includes '[knowing] nothing' (448) about her diagnosis which she thinks would only fuel her worries. She is thankful that Oreschenkov will 'take all her anxiety upon himself' (445) and as a doctor, this is what she trusts she is doing when making decisions on behalf of her patients.
It isn't until later that Dontsova realises the harmful effects of paternalism, when she experiences the emotional turmoil that she overlooked in her patients. As Sansom argues, 'in realising her mortality, she recognises her own unique humanity and also the unique humanity of her patients' (105). Suddenly she is overwhelmed by doubts and fears, 'human weaknesses' that didn't previously 'count for anything' but now render her into an 'unreasoning, resistant lump of matter' (478). Her illness gives her much needed perspective, allowing her to see the reductiveness in thinking that an illness can be explained in 'logical terms' (478). During her next rounds, she is able to empathise with Kostoglotov and even recognises that the treatment she has been giving him is 'barbarous' (490). In this moment, she identifies that disregarding someone's wishes about their body is what Dworkin calls an 'insulting denial of autonomy' (The Theory and Practice of Autonomy 113). As Dworkin points out, 'one's body is irreplaceable and inescapable' (113) so that one's individual right to choose for themselves is paramount. Finally, she realises the grim realities of the treatment that she once held such high regard for. Thus, Dontsova's character arc allows Solzhenitsyn to highlight that while paternalism may be necessary to an extent in some cases, it is wrong to assume that it suits every patient and that some decisions cannot simply be made on the basis of objective, medical judgements.
Alternatively, Solzhenitsyn offers a more idealistic approach in Oreschenkov, who acts as Dontsova's foil. Attentive and intuitive, he allows for the type of doctor-relationship that Charon calls for: one that is dependent on benevolence and 'need not be adversarial' (206). He gives both parties the opportunity to reveal one another's 'goals, hopes, desires and fears' and contribute 'regard, trust and courage' (Charon 208), exemplified in how he listens without interrupting and makes Dontsova feel comfortable enough to express concerns about her family. Furthermore, his professional duty encompasses answering 'every single [question]' (456) patients may have, instead of thinking it a hindrance. There is no sense of arrogance, no superiority; he strives to return the profession to one of true caring so that he does not become the patient's 'enemy'.
Similarly, he is critical of the medical system, lamenting that 'the patient gets tossed from "specialist" to "specialist" like a basketball' which prevents them from being treated as a 'single subject' (457). It is clear that Oreschenkov is acutely aware that doctors should be treating patients as a whole, instead of reducing them to a particular organ or disease, and that specialism perpetuates the dehumanising aspect of medicine. His stance on reviving the role of the family doctor is particularly admirable, as he touts the importance of having someone to whom one can '"pour out [their deeply concealed or shameful] fears"' and who will '"look after you personally"' (454). Unlike Dontsova, he desires to form connections with his patients, born of respect. To him, they are not just ill people but individuals with their own independence and subjective experiences. By getting to know them and understanding their needs, he can tailor their treatment holistically so that both parties are satisfied; he promotes beneficence while allowing room for the patient's voice.
Through Dontsova as doctor then patient, Kostoglotov as the patient who does not want to be defined by his cancer and Oreschenkov the doctor of an ideal world, Solzhenitsyn engages in sharp observation of the dynamics in a medical setting. The characterisation reveals the balance that is required and the importance of understanding the goals and intentions of both sides in the doctor-patient relationship. While paternalism prevailed in his time and was largely justified by the medical profession, Solzhenitsyn explores its downfalls and alternatives, almost predicting the shift towards valuing patient autonomy in modern medical ethics.