INTRODUCTION
Premature death was much more common in the Late Middle Ages than it is today. Awareness of an unexpected death was widespread. Mortality was ubiquitous through constant plagues and epidemics in scales that are hard to imagine from a current perspective. The highest rate of mortality took place with the arrival of the Black Death in 1348, which exterminated between half and two thirds of the population of Europe. After catastrophic epidemics and wars, death became omnipresent in the culture and mentality of the time. In religious medieval society, such events were perceived as a punishment sent by God as a result of moral depravation (Binski, Reference Binski1996; Geary, Reference Geary1994). Unfortunately, minorities were often accused of being responsible for the disasters—mainly Jews and lepers—who were frequently accused of poisoning wells (Camille, Reference Camille1992; Ginzburg, Reference Ginzburg1989; Nirenberg, Reference Nirenberg1998; Mellinkoff, Reference Mellinkoff1993). Other coping strategies involved self-flagellation and suffering as a way to imitate the tortures of Jesus during the Passion—the so-called Imitatio Christi. Self-inflicted pain was perceived as a path to purify one's soul and thereby be forgiven (Beringer, Reference Beringer2014; Bynum, Reference Bynum1988, Derbes, Reference Derbes1996; Marrow, Reference Marrow1979; Viladeseau, Reference Viladeseau2006). Despite a lack of knowledge of infectious pathology, there were certain notions of how diseases could be transmitted. The sick were commonly isolated in hospitals, whose main function was to save the soul. It was forbidden for them to touch food that was going to be consumed by the rest of the population, as was drinking from public wells (Richards, Reference Richards1990).
Coping with Death in Late Medieval Culture
Art and literature were used to relieve anxiety about imminent death. Poems concerned with death were being written between 1193 and 1198 by the monk Hélinant of Froidmont. His Les Vers de la Mort (Verses of Death) deal with a visit of Death to individuals of different age and status to warn them of the necessity of living a pious life in order to avoid eternal damnation (Kurtz, Reference Kurtz1934; Rosenfeld, Reference Rosenfeld1995). Similarly, the legend of “The Three Living and The Three Dead” became popular both in art and literature during the 13th and 14th centuries. A good deal of late medieval French and Italian depictions present three beautiful young men hunting in a moment when they encounter three corpses in different states of putrefaction. The corpses admonish the hunters that they were once like the young men are today, but that one day the young will share the same miserable fate. This type of memento mori (reminder of death) had the goal of making society conscious of the importance of living a righteous life. This sort of iconography was later developed in the richer depictions of “The Triumph of Death”—mainly in Italy during the 14th century—and “The Dance of Death”—a recurrent theme of European art and literature during the Late Middle Ages and the Early Modern period (Binski, Reference Binski1996; Espí Forcén, Reference Espí Forcén2013; Infantes, Reference Infantes1997; Oosterwijk, Reference Oosterwijk2011). With the appearance of mendicant orders (religious orders that combined monastic life with outside religious activity) during the 12th century, mainly Dominicans and Franciscans, friars began to preach in the newly developed urban centers. They were thus in constant contact with society, transmitted the values of Christianity, and controlled possible emerging heretical doctrines. One of their major roles involved spiritual guidance for the terminally ill just before facing death. Some members of the mendicant orders were increasingly concerned with helping people deal with their eventual death. These included the writing of manuals that would help friars assist the moribunds. An early example of this kind of manual would be La Somme des Vices et Vertus (The Sum of Vices and Virtues), written in 1279 by Dominican friar Lawrence of Orleans for King Philip III the Bold of France. In 1334, the Dominican friar Henry Suso wrote the Horologium Sapientiae (Clock of Wisdom), a book that taught one how to die (Bayard, Reference Bayard1999; Feros Ruys, Reference Feros Ruys2014; O'Connor, Reference O'Connor1942; Rolfes, Reference Rolfes and Wagner1989; Rozenski, Reference Rozenski2008; Rudolf, Reference Rudolf1957).
In the meantime, Franciscans continued preaching in towns, reminding people of the necessity of preparing one's soul to go to heaven in case of an unexpected death. They warned that hell was much more fearful than death and that sin was to be avoided at all times to prevent eternal suffering. An illustrative example of this idea is the preaching of the Franciscan Saint Bernardino of Siena (1388–1444), who was especially worried about the message that people could avoid going to hell by repenting their sins at the very last moment of life. In his sermon De duodecim periculis quae insperatu superveniunt peccatoribus in ultimo fine (“The twelve dangers that unexpectedly come upon sinners at their lives' ends”), he declared that the last-minute salvation of the Good Thief on the Cross according to the Gospels was the only example of such an easy redemption. However, Bernardino asserted that, due to the terrible suffering of the body, the dying would be deprived of reason and would not be able to utter anything but “ba, bla, blo, ble, ah, oh, hen, hai, hoi, hui, hei!”—which in any case would be considered a proper penitence and would inexorably guarantee a place in hell (Mormando, Reference Mormando, DuBruck and Gusick1999). Based on his description of moribunds, it seems that Bernardino had some knowledge about the phenomenology of delirium that so often characterizes people with terminal illness.
Another very prominent book that deals with the preparation for a good death is the Opusculum Tripartitum (Three Part Treatise), by Jean de Gerson (1363–1429), chancellor of the University of Paris. The Council of Constance took place between 1414 and 1418, in which Gerson's ideas were heavily discussed. It is highly likely that a Dominican friar that attended the council wrote the Ars Moriendi (The Art of Dying) precisely between those years. The Ars Moriendi was originally printed and soon distributed in his Latin version throughout Europe. Slightly later, it was translated into the main European languages—German, Dutch, English, Swedish, Italian, Catalan, and Spanish—becoming a very popular manual for friars to help people cope with death (Bayard, Reference Bayard1999; Chartier, Reference Chartier1976; O'Connor, Reference O'Connor1942; Rolfes, Reference Rolfes and Wagner1989; Rudolf, Reference Rudolf1957).
Objective
The aim of our study was to perform a review of the literature concerning the Ars Moriendi in the medical field, to study the psychological mechanisms for coping with death anxiety in the Ars Moriendi; and, finally, to explore its parallels with contemporary literature about death and dying.
METHODS
We first performed a systematic review of the literature according to the PRISMA guidelines. We have used the Pubmed, EMBASE, JSTOR, and Project MUSE databases in search of articles concerning the medical and psychological aspects of the Ars Moriendi. All articles, no matter the language in which they were written, were considered. The search “Ars Moriendi” led to a total of 21 articles in Pubmed and 28 articles in EMBASE. The titles and available abstracts were reviewed. Some 17 articles were selected for full-length review. Of these, six were chosen and quoted because they fell within the scope of our study. The search “Ars Moriendi” in JSTOR allowed a maximum of 1,000 titles. All were reviewed, but none met the criteria for inclusion in our review. The entry “Ars Moriendi” in Project MUSE produced 10 articles, among them 1 that dealt with the topic. In total, seven articles were included and are discussed in the Results section.
The subject of our review—the Ars Moriendi in the Late Middle Ages and its usefulness in contemporary society—has been extensively analyzed in the literature of the humanities. The resources at the New York Public Library allowed us to find many books and manuals that deal with our subject. Among them, 24 books have been carefully reviewed. In addition, other articles pertinent to our introduction and discussion have been cited and included in the reference list.
After reviewing the secondary literature, we studied the primary source, the 15th century manuscript of Ars Moriendi, with special attention to the first and second chapters, which contain the main ideas of interest that fit the purposes of this manuscript. We have used a facsimile of a 1450 Latin edition from the British Museum (reprinted in London in 1881) (Rylands & Bullen, Reference Rylands and Bullen2010), two 15th-century Spanish translations (Álvarez Alonso, Reference Álvarez Alonso1990), and a 1497 English version printed in Westminster (electronically available at the New York Public Library). The strategies recommended in Ars Moriendi to help moribunds cope with death anxiety were analyzed. Finally, parallels with current therapies focused on dying patients were explored.
RESULTS
Though we have not found any articles that directly analyze the text within the manual Ars Moriendi, we have selected seven articles that comment on the importance of the Ars Moriendi in the medical field.
Bertman wrote an article on the way that a good death has been depicted in different cultures over the centuries. In her review, she refers to the Ars Moriendi and includes one of the woodcuts of the 1450 Latin edition (Bertman, Reference Bertman1998). Flynn compares the medieval “Book of Hours” with the Ars Moriendi and argues that the latter provides a deeper and more personal way of coping with death, emphasizing the importance of a good death in going to heaven (Flynn, Reference Flynn2014). Leget points out the necessity of retrieving the strategies of the Ars Moriendi in modern society to help patients cope with death anxiety (Leget, Reference Leget2007). After a brief summary of the content of the Ars Moriendi, Thornton and Phillips explore parallels between the medieval attitudes in Ars Moriendi and contemporary attitudes about a good death. In both, it is important to die surrounded by family members. They denote the need for physicians to become more mindful about helping patients have a good death (Thornton & Phillips, Reference Thornton and Phillips2009). Ballnus examines and proposes the idea that the creation of hospices for the terminally ill and dying patients was first introduced in the textbook of the Ars Moriendi (Ballnus, Reference Ballnus1995). Herkommer points out that nowadays we lack the kind of strategies to cope with death that the text of the Ars Moriendi contains. The author explains how these strategies are graphically illustrated by the xilographies of the 15th-century printed editions of the Ars Moriendi (Herkommer, Reference Herkommer2001). An article written by Feros Ruys explores how experience and emotion were strategies used in the late medieval and early modern traditions of the Ars Moriendi to help people prepare to die. She stresses the fact that fear could be used to guide Christians to acceptance of dogmas (Feros Ruys, Reference Feros Ruys2014).
Ars Moriendi: Interpretation of the Primary Source
Chapter I: Death Is a Good Thing
After a brief introduction, the anonymous author of the Ars Moriendi attempts to present death as a wonderful event. He acknowledges the fear provoked by death in mankind and even quotes a passage from Aristotle taken from the third book of his Nichomachean Ethics that describes death as the most terrible of all things. However, the book establishes a distinction between death of the body and death of the soul, and states that death of the soul is much more terrifying than death of the body, since the soul is more precious than the body. Even if death of the body implies physical suffering, death of the soul entails torture in hell. Therefore, the goal of the manual is to instruct people on how to properly die in order to save their souls. According to the author, death can be a release from the mundane burdens of life (e.g., debts, diseases, sorrows). In these terms, the day of death is described as even more joyful than the day of birth. Nonetheless, this would only apply to those who followed a pious life or had truly repented their sins. The inevitability of death is attributed to the good will of God; therefore, there should be nothing to be afraid of. In this sense, our author also mentions Seneca for his celebrated attitude toward refraining from complaints about the inevitable. Since the moment of our death is unpredictable, it is important to be prepared for it.
Chapter II: Fighting the Five Temptations for a Good Death
The second chapter of the Ars Moriendi deals with the temptations that the moribund is to overcome on his deathbed. Any doubt about the good will of God is attributed to the evil agency of demons. Five temptations can threaten the moribund in the last moments of life: lack of faith, despair, impatience, pride, and greed. The success of these arguments provoked a later publication of the chapter with graphic illustrations of the moribund overcoming the temptations at his deathbed to save his soul (Duclow, Reference Duclow, DuBruck and Gusick1999; Tenenti, Reference Tenenti1951; Vinken & Schlüter, Reference Vinken and Schlüter2000).
The author starts out by making a strong statement about faith as the basic foundation for having a good death. Doubts about the veracity of every Christian dogma are attributed to the influence of demons. This concept is graphically illustrated in the engravings that the so-called Master E.S. executed for the (ca.) 1450 edition of the chapter. The image presents a cachectic moribund lying on his deathbed with signs of debilitation, wasting, muscle atrophy, and malnutrition, appearing drowsy and unaware of his surroundings (Figure 1). Demons tempt the sick with sins like idolatry—represented by two pagan kings adoring a sensual half-naked statue on a column—and suicide to avoid suffering from God's will instead of a proper acceptance of the pains involved in any terminal disease. This is depicted in the foreground with the figure of a man slitting his throat beside a self-flagellating person. In support of the moribund to maintain his faith, there are three doctors of the church on his right-hand side and the representation of the Father, Son, and the Virgin Mary behind the bed, which are nonetheless being hidden with a shroud by a gruesome hairy demon.
Fig. 1. Master E.S. 15th-century engraving. Temptation through lack of faith. Source wikimedia commons.
The second temptation has to do with the despair caused by potential loss of salvation due to sins committed earlier in life by the moribund. The author emphasizes that, no matter how bad or frequent the sins may have been, redemption is still possible through truly honest repentance. Hope is the main weapon against despair.
The third temptation refers to the impatience that may lead the moribund to curse God as the result of the pain and suffering that can come with the death process. Such terrible pains the moribund may have, that he may be deprived of reason, which could result in agitation and impatience. The engraving describing the temptation of impatience shows an apparently confused and agitated man, who has overturned the bedside table and is kicking his physician (Figure 2). A grimacing bat-winged demon tries to tempt him in order to make him remain in such a miserable state. Two women assist and attempt to calm the moribund with support, food, and water.
Fig. 2. Master E.S. 15th-century engraving. Temptation through impatience. Source: wikimedia commons.
The fourth temptation is concerned with the sin of pride. The author warns that the Devil has a very subtle strategy to achieve damnation of the soul. This involves praising those moribunds who have successfully overcome the previous three temptations. The goal of the Devil is to make the moribund feel proud of himself, and this would entail a last-moment sin that conversely would earn him a place in hell. Finally, the fifth and last temptation is greed, understood as the inability to abandon earthly possessions and family members and the nonacceptance of death itself.
Chapters III–V: Salvation for Those Deprived of Reason, Imitatio Christi, and Prayers for Family
The third chapter is concerned with situations that arise due to the consequences of poor health, and the moribund is unable to utter a proper statement of their penitence and repentance to save their soul. The author includes a thorough and extensive list of questions, which includes the acceptance of every Christian dogma. Thus, the moribund only needs to somehow respond affirmatively to questions (Wicks, Reference Wicks1998).
The fourth chapter presents the life of Jesus as a model for every Christian, a very common attitude in the Late Middle Ages, and designated Imitatio Christi (Beringer, Reference Beringer2014; Bynum, Reference Bynum1988, Derbes, Reference Derbes1996; Marrow, Reference Marrow1979; Viladeseau, Reference Viladeseau2006). The fifth provides behavioral guidance for the family and friends of the moribund at his deathbed. The sixth and final chapter deals with pertinent prayers for the dying.
DISCUSSION
The Ars Moriendi provides guidance for friars to help people cope with death anxiety during the Late Middle Ages. Keeping in mind that society was controlled by the Christian church, no doubt about the existence of eternal paradise was tolerated. Any ambivalence with regard to Christian dogmas was considered a form of heresy. Thus, the text provides an external locus of control—the evil influence of demons—for this sinful vacillation. On the one hand, relief from guilt can be achieved, and, on the other, a mission is offered to the moribund. He must fight the temptations of the demons in order to be transported into heaven. These strategies resemble those used in acceptance and commitment therapy, a treatment that has been found to be helpful in patients with prostate cancer. In the latter, the patient's anxieties are referred to as the monsters he or she must fight or control for symptomatic relief (Nelson, Reference Nelson, Lacey and Kenowitz2015). Furthermore, the book offers a meaning to physical and existential suffering, which is ultimately according to God's good intentions, and the moribund has no other choice but to accept God's will—following the model of Jesus during the Passion (Imitatio Christi). For our author, a good death offers the reward of heaven; therefore, the day of death is perceived as even more joyful than the day of birth, since the latter implies the sufferings of earthly life.
Despair, the second temptation described in chapter two, refers to the overwhelming number of sins the moribund may have committed. This may make the alleged sinner think that he has no chance for salvation. Against despair, the author defends the virtue of hope and provides good examples in which God's mercy affected prominent sinners of the New Testament: the Good Thief, Saint Peter, Saint Paul, and Mary Magdalene. Interestingly, even today, the instillation of hope is a very powerful tool in the care of patients with terminal illnesses.
Impatience, the third temptation, describes the emotions and behaviors that may arise with the pain and suffering involved in the disease process. Symptoms of irritability, agitation, and disorientation, and the loss of the ability to speak, think, and reason in proper fashion are described in those about to die. If approached with a current medical nomenclature, these manifestations would be compatible with symptoms of what we today designate as delirium—an overall dysfunction of the brain resulting from disease. The engraving that depicts a drowsy, inactive person unaware of his surroundings would be compatible with the hypoactive type of delirium (Figure 1), whereas the image representing an agitated man kicking the physician (Figure 2) would be more consistent with the hyperactive form of delirium. An acceptable alternative may include anxiety or a mood disorder due to general medical condition. These behaviors loosely resemble the anger and depression stages described by Elisabeth Kübler-Ross in her On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families (Kübler-Ross, Reference Kübler-Ross1969).
The Ars Moriendi was written in the context of a society coping with the devastation that followed the Black Death. It quotes two of the most influential pagan philosophers of the Late Middle Ages—Aristotle and Seneca. In the case of the Roman, his presence in the text serves the purpose of introducing the stoic concept of comfortable acceptance of the inevitable. In contemporary society, World War II was the most recent catastrophe that could in a way resemble the disasters that happened during the Late Middle Ages. However, our society has responded to calamity with an agnostic rather than religious response. Men instead of God were made responsible for the disasters. As a result, existentialism—a philosophical approach that emphasizes the importance of man's freedom and responsibility for his actions—became the theme in Western countries. This suggests that a secular society may lack the proper elements to cope with death anxiety, which results in denial of death at an almost delusional level (Becker, Reference Becker1973). Today, even with dying patients, it is certainly difficult to talk directly about death. Even if psychiatrists and other professionals involved in palliative care must propose therapies congruent with the values of secular society, the strategies for coping with death anxiety in the Ars Moriendi could still be helpful for spiritual leaders in assisting the terminally ill. Nevertheless, dignity therapy and meaning-centered psychotherapy are valid therapies in our secular society. Dignity therapy proposes the creation of a narrative of the patient's life and values known as the “generativity document” (Chochinov, Reference Chochinov2012). The second was developed by William Breitbart, inspired by Viktor Frankl's experiences and coping skills after surviving a Nazi concentration camp. Meaning-centered psychotherapy proposes strategies directed at finding meaning despite terminal illness. Good examples are finding a new identity, exploring one's legacy, and developing a sense of transcendence (Breitbart & Poppito, Reference Breitbart and Poppito2014a ; Reference Breitbart and Poppito2014b ; Frankl, Reference Frankl1959).
CONCLUSION
In summary, the Ars Moriendi was a helpful manual for friars of the mendicant orders in the Late Middle Ages to help moribunds and their families cope with death anxiety. It provided relief and hope for everyone, even for those who had committed terrible sins. The manual also offered a chance for salvation to those deprived of cognitive abilities due to their afflictions. The strategies proposed in the Ars Moriendi can also be analyzed from a modern psychological perspective and in the modern context.
ACKNOWLEDGMENTS
The authors would like to thank Susan Hatters Friedman and Konstantina Matsoukas for help in developing this manuscript.
