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Performing the Good Death: the Medieval Ars Moriendi and Contemporary Doctors K Thornton,1 C B Phillips2

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Performing the Good Death: the Medieval Ars Moriendi and Contemporary Doctors K Thornton,1 C B Phillips2 View metadata, citation and similar papers at core.ac.uk brought to you by CORE mh1693 Module 1 Medical Humanities 25/9/09 19:41:36 Topics: provided by The Australian National University Ethics Performing the good death: the medieval Ars moriendi and contemporary doctors K Thornton,1 C B Phillips2 1 Medical School, Australian ABSTRACT The medieval Ars moriendi is structured around National University, Canberra, 2 Death is inevitable, but dying well is not. Despite the role inspirations (illustrations of the good death) and Australia; Social Foundations of 8 Medicine, Medical School, of medical professionals as overseers of dying in temptations (illustrations of the bad death). Leget Australian National University, contemporary society, there is comparatively little has suggested that a modern Ars moriendi would Canberra, Australia discourse among doctors about the constituents of a include consideration of key concepts such as death good death. In the 15th century, by contrast, the Ars and the afterlife, autonomy and self, pain control Correspondence to: moriendi portrayed normative medieval ideas about good and medical intervention, attachment and rela- Christine B Phillips, Social Foundations of Medicine, and bad deaths. At a time when dying could be viewed as tions, and guilt and life balance. These do not map Medical School, Australian a performed battle against damnation, the Ars moriendi exactly onto the inspiration/temptation approach National University, Canberra codified a set of moral precepts that governed the of the medieval Ars moriendi, though they do 2602, Australia; Christine. [email protected] expression of autonomy, relations between the dying and represent modern preoccupations. In this paper the living and orientation towards God. In these images, we focus particularly on the visual dialectic used in Received 16 March 2009 dying well is a moral activity that results from active the medieval Ars moriendi, arguing that this decisions by the dying person to turn from earthly reflective learning method may be of contemporary preoccupations to contemplation of, and submission to, use in clarifying doctors’ own notions of the good the divine. It is likely in contemporary society that there is death through simultaneous contemplation of the a range of understandings of the ‘‘good death’’. While bad death. We begin by reviewing research on attitudes to personal autonomy may differ, reflectiveness historical constructions of the good death. We then and dying at home in the presence of family (expressed in closely analyse a pair of images from the Ars the Ars moriendi), remain part of many modern notions of moriendi. Finally, we discuss the implications of the the good death. We argue that medical institutions structure and focus of the Ars moriendi for continue to construct death as a performed battle against developing medical awareness of, and support for, physical debility, even when patients may have different contemporary cultural notions of the good death. views of their preferred deaths. The dialectic approach of the Ars moriendi may offer a way for contemporary ARS MORIENDI doctors to reflect critically on the potential dissonance The Ars moriendi belongs to a corpus of texts in the between their own approach to death and the variety of late Middle Ages that codified the integration of culturally valorised ‘‘good deaths’’. Church teaching and religious reflection into everyday life. At the turn of the 15th century, papal authority had been reasserted when a dispute In wealthy countries in the 21st century, questions about the democratisation of religious texts had of dying well tend not to be part of everyday been settled with the banning of Wycliffe’s English discourse. Many young people have encountered language Bible and a papal bull proscribing 1 death only on film or in television programmes. scripture not in Latin.9 At the Council of Currently around 70% of residents of England and Constance in 1414–1418, the Council ordered the 2 Wales die in hospital, and it is likely that the production of a book about how to die well.10 Two 3 proportion is similar in Australia. Although principal versions of this book have survived. The doctors are often the overseers of dying in the longer version entitled Tractatus artis bene moriendi West, studies suggest that they may misunder- (A Treatise on the Art of the Good Death) includes stand the real wishes of the dying while focusing six sections of Latin text addressing death as an on the physiological aspects of death.45 inevitable part of living, the five temptations By contrast, in medieval Europe, death was part (attachment to worldly goods, infidelity, despair, of the fabric of existence. It is estimated that in the impatience and spiritual pride), questions to ask late Middle Ages (generally regarded as the period the dying man, admonitions to imitate Christ’s from 1300 to 1500), three out of every 10 babies life, advice for families on managing death, and died in infancy.6 Against this background were prayers for the dying.10 famines, the Hundred Years War and plagues, all The second surviving version is commonly resulting in widespread death. The outbreak of the referred to as the Ars moriendi. This version Black Death from 1347 to 1350, for example, is comprises five paired woodcuts, one single wood- estimated to have killed 30–50% of Europe’s cut and some accompanying text. Each pair population.7 One consequence of this omnipre- consists of one woodcut depicting temptation sence of death in the Middle Ages is that questions and one depicting inspiration for the dying person. of death and dying well became everyday pre- The devil uses these temptations to inveigle occupations, assisted by the widely disseminated humans into committing one of the seven deadly book of woodcuts, the Ars moriendi (literally, the sins (avarice, lust, gluttony, pride, anger, envy, art of dying). sloth). The use of images enabled the messages to J Med Ethics; Medical Humanities 2009;000:0–4. doi:10.1136/jmh.2009.001693 1 mh1693 Module 1 Medical Humanities 25/9/09 19:41:36 Topics: Ethics be understood and accessed by members of the general populace particular, appears to be accompanied by medical anxieties who were illiterate.10 The Ars moriendi become an enormously about the ambiguous role of technology in end-of-life activities popular work, read well into the 1700s.11 Its messages were that may appear to be engaging in ‘‘medical futility’’.19 adapted by the author(s) of the popular Everyman morality Aries does not give a simple definition of what comprises a play, in which Death informs Everyman he is about to die, good death in a particular era. He does, however, stipulate that starting a process where Everyman must overcome the five as a general principle, when individuals feel that they are temptations if he is to die well.12 approaching the end of their life, it is important they prepare adequately. The historian Paul Binski also emphasises the role of 20 HISTORICAL CONSTRUCTIONS OF DYING WELL preparation in a good death. He suggests that a good death is Cultural attitudes towards death are not historically constant. one that ensures satisfactory continuity with life. To ensure In his seminal work Hour of our death, Philippe Aries proposes appropriate spiritual preparation, people in the Middle Ages five attitudes towards death adopted by people from Western needed to understand the basic principles of sin, confession and countries.13 These attitudes are arranged in rough sequence, penance. Binski argues that documents such as the Ars moriendi though Aries recognises they do not follow a simple linear were vital to the education of the public about dying well. trajectory, with several sometimes being held simultaneously. The first of these attitudes is a oneness between living and dead, GOOD AND BAD DEATH IN THE IMAGES OF THE ARS MORIENDI in which dying was accepted as part of everyday life. With this The Ars moriendi encapsulates the second attitude outlined by attitude, death was tame, something that everyone must yield Aries, in which death is viewed as a performance framed by to almost as if they were going to sleep.14 Aries elaborates this religious belief. For the viewers of the Ars moriendi, the existence idea with numerous examples of how death can be tame, of life after death was a social fact, with the text functioning as including in the 20th century. a guide to maximising chances of entering heaven and The second attitude articulated by Aries is the ‘‘death of the minimising the sojourn in purgatory. self’’, in which death was regarded as the enemy. People were To illustrate the encoded messages of the Ars moriendi,we terrified of eternal damnation and relied upon religion to help focus in detail on two images in the Ars moriendi stored in the them get through the process of dying. Dying was reframed as a British Museum.21 This version is believed to have been liturgical melodrama (using texts such as the Ars moriendi or the produced around 1450, possibly in Cologne. Each image Everyman morality play) with a dramatic performance by the contains a banderole on which Latin admonitions or injunctions priesthood at the deathbed. Aries argues that in the Middle were written. The two images we describe in this section are Ages, generally the gentry saw death as an enemy (consistent images 5a and 5b, which show the temptation of ‘‘attachment to with the second attitude), while peasants still regarded death as worldly goods’’ and the inspiration of ‘‘detachment’’ (figs1, 2). < natural (consistent with the first attitude). In the woodcut depicting the temptation of attachment to Aries’s third attitude is a virtual denial of death, dating from worldly goods, the dying man lies in bed.
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