The representation of palliative care as a modern ars moriendi

Abstract

In the Middle Ages, the onset of an illness was almost similar to facing death, so relatives and the Catholic church initiated the appropriate care. Caring for the ill and dying was an essential part of the Christian doctrine. By following this model of ars moriendi, patients and their loved ones had the opportunity to share their spiritual needs and deepen relationships at the end of life. A way of caring for the ill at the end of life. Nowadays, palliative care can be understood as a similar to this model. Palliative care refers to end-of-life care, where we can place the ars moriendi on the same level in the study. This study attempts to capture the similarities between the two models in order to bring together different ways of understanding death.

Keywords
Death; Palliative care; History; Humanism

Resumen

En la época medieval la aparición de la enfermedad era casi equivalente a enfrentarse a la muerte, de manera que la familia y la iglesia iniciaban la conveniente ayuda asistencial. El cuidado de los enfermos, y de los moribundos, era parte esencial de la doctrina cristiana. Con este modelo del ars moriendi, los pacientes y sus seres queridos tenían la oportunidad de compartir sus necesidades espirituales y profundizar en las relaciones al final de la vida, por lo tanto, era una forma de cuidar de los enfermos al final de la vida. En estos días podemos trasladar este tipo de modelo a los que conocemos actualmente como cuidados paliativos, referentes del cuidado de los enfermos al final de la vida, en que podemos colocar en el estudio al mismo nivel del ars moriendi. Este estudio trata plasmar las similitudes de ambos con el fin de acercar formas distintas de entender la muerte.

Palabras clave
Muerte; Cuidados paliativos; Historia; Humanismo

Resumo

Nos tempos medievais, o surgimento de uma doença era quase equivalente a enfrentar a morte, de modo que a família e a igreja iniciavam a assistência adequada. A assistência aos doentes e moribundos era uma parte essencial da doutrina cristã. Com esse modelo de ars moriendi, os pacientes e seus familiares tinham a oportunidade de compartilhar suas necessidades espirituais e estreitar as relações na terminalidade da vida, sendo, portanto, uma forma de cuidar dos doentes terminais. Atualmente, podemos aplicar esse tipo de modelo ao que conhecemos como cuidados paliativos, que se referem aos cuidados promovidos na terminalidade da vida, e podemos equipará-lo a ars moriendi. Este estudo busca compreender as semelhanças entre ambos para aproximar diferentes formas de entender a morte.

Palavras-chave
Morte; Cuidados paliativos; História; Humanismo

Historical background

The Ars moriendi comprises texts written in the 15th century to encourage the traditional care that should be provided to a dying person. Such care was important due to the Christian belief that, at the moment of agony, the devil took advantage of the sufferers’ weakness to torment them with the last temptations, leading to the condemnation of their soul. However, in this final struggle between good and evil, of the sacred and the divine against the wicked, humans are not alone, as the angels and saints, invoked by the prayers of those by their side, can help them overcome those temptations ¹.

Both the Dance of death and Ars moriendi would be aimed at raising self-awareness of death. Despite having very different emphases, they are not opposing manifestations. Fear of death or of the representation of death has been a constant element in pastoral care in the Catholic Church. Throughout history, this religious manipulation has been more or less intense according to the period, and such spiritual maneuver gained prominence during crises ².

As in other European countries, Ars moriendi was also known in Spain, in both Castilian and Catalan translations. The oldest version, published in Castilian, was printed by Hurus and published in Zaragoza between 1479 and 1484, while the Catalan edition of Art de be morir, also printed by the aforementioned Hurus and in Zaragoza, only appeared in 1493 ³.

Although it is not clear who the author was, there is no doubt that Jean Gerson was the main inspiration through his work Opusculum tripartitum. The text, known as Tractatus or Speculum artis bene moriendi ⁴, was widely circulated. It consisted of six chapters in which the following questions were addressed:

1. Praise of death.

2. Temptations that beset the dying and how to overcome them.

3. Questions that should be asked to patients so they may reaffirm their faith and repent from their sins.

4. The need to emulate the life of Christ.

5. Behavior to be followed by lay people caring for a dying person: presentation of sacred images; exhortation to receive the last rites; and encouragement to make a will.

6. Uttering prayers by those present in favor of the dying person.

Thanks to the popularity of this treatise, a copy of the work was made available to the faithful, summarizing its main elements, especially from the second chapter of the original text. Thus was born Ars moriendi (The Art of dying).

The general consensus is that the text was written by a member of the mendicant orders, probably a Dominican, and it was through them that the text spread so quickly throughout Europe. The text was originally written in Latin, latter translated into the various vernacular languages. Ars moriendi was translated in almost all important European languages ⁵.

On the other hand, there is no doubt that, throughout history, the social and health environment surrounding the dying has changed, mainly due to technical advances and new research into the end of life. This perspective that relates Ars moriendi to palliative care has been a constant in the author’s studies ⁶.

The article by Alberto Tenenti entitled Ars moriendi: algunas notas sobre el problema de la muerte a finales del siglo XV ⁷ clearly stresses that death and its scope will depend on the period in which it occurs. For this author, it can be approached from two unmixable levels: ethnic and historical. Ceremonies, monuments and worship, everything that involves the symbolism of death, most of the time tends to escape History; but its language is in harmony with the language of human activities. There seems to be a symbiosis between symbolism and human action. The author analyzes the non-Christian or popular origin of macabre representations in relation to the iconography that emerged from the mid-14th century to dances of death and other types such as the “Trionfi” and the difference with ars moriendi ⁸.

As stressed by Castelbón Fernández, the confraternities played a key role, since supporting the dying to help them “die well” was a common practice. Therefore, we can conclude that they existed to care for the dying in their agony, as well as during their burial and after death. Death thus becomes a point of reference for solidarity among the living and also between the living and the dead ⁹. Suffice it to say that the medieval confraternities evolved with the interests of society, in which they emerged spontaneously.

The 18th century was the golden age of confraternities for souls throughout Spain ¹⁰. Nowadays, certain independent religious organizations, such as Jehovah’s Witnesses, delve into this idea, supporting their parishioners both in hospitals and in the households of the dying. These are organizations that watch over and support them in their final days, as is currently the case with several religious or secular organizations.

Throughout history, European countries have had great cultural, religious, and political differences. There are differences between northern and southern countries; the idea of death is also a differentiating aspect. Helping the dying in their final days, alongside their caregivers, is an essential part of the work of healthcare staff in oncology and palliative care units. And this is not only a contemporary practice; it has been part of Western culture since the Middle Ages, when it was known as ars moriendi (the art of dying). For some authors, this way of interpreting death should be revived to overcome the limitations of palliative medicine, as it addresses issues that play a key role in all situations of medical intervention and treatment ¹¹.

Danses macabres are, together with triumphs of death, an artistic-literary expression that emerged in the 14th century, representing personified death. But unlike triumphs, the action in the dances is more personalized because they are not a threatening monster that traps its helpless victims. However, Spanish dances have their own characteristics that differentiate them from other European dances. That is how Martínez Gil sees it, highlighting the fact that the former are more moderate, less terrifying and more coherent with the Christian tradition, in addition to encouraging a serene attitude towards death.

Nowadays, we find references to ars moriendi in several scientific articles, especially those dedicated to bioethics. In his article “Claves para una ética de la ancianidad ¹²,” Moratalla defends an ars moriendi to live life to the fullest, stressing that an ethics of good dying cannot resign itself to unjustified, premature or avoidable death. Thus, the struggle of medicine against those ways of dying is not only a medical imperative, but a requirement of social ethics for which we cannot spare resources.

Indeed, this way of reaching the last days of a dying person may cause benefit or discomfort, especially spiritual. It is worth asking whether this ars is a true art of dying. Añua Tejedor hesitates and reflects in the conclusions of her work El Ars moriendi: ¿Un manual del buen morir? ¹³ about whether at the end of life, in complete solitude, in the absence of family and surrounded by clergy or representatives of the Church; with the feeling of abandonment and the impossibility of talking to loved ones, this does not lead us to a peaceful or desired death. Quite the opposite of what a good death should be, where the family’s role is prominent, essentially to bid a final farewell. Religious beliefs may or may not be present in the final days, but human support should be unquestionable. Delving deeper into the dying person and their experience, she resorts to Elisabeth Kübler-Ross to signify the generality of the act of dying, regardless of religion, social condition or age ¹⁴.

The book Dying into grace features an intimate and detailed experience of a person grieving their mother and their own role as caregiver, going beyond old patterns and actions to heal wounds and losses ¹⁵. Furthermore, it represents a contemporary Western ars moriendi, providing detailed instructions on how to help someone prepare and bring their life to a satisfying end.

Unlike the historical ars moriendi, this book does not aim to ensure that the dying person is sufficiently prepared to meet their creator, but rather to help them die, as far as possible, in their own way ¹⁵ (a fundamental idea in palliative care). Pastoral theory and practice consisted, among other things, of educating the faithful in such a special art as ars moriendi. The priest was the educator. The ignorant physician, even if he is virtuous, harms more than benefits the patient. Thus, spiritual medical confessors must be wise to teach and heal the sick sinner ¹⁶.

Ars moriendi and palliative care

In recent times, ars moriendi has been used in the context of the hospice and palliative care movement ¹⁷. Ars moriendi and palliative care share the conviction that a good and appropriate death depends not only on the circumstances, but also, to a certain extent, on learning to live the end of life. Both ideas of a good death agree and are in tune; it is a process that requires taking time to make certain important decisions before the end of life (transcendental, among others), to bid the final farewell, that is, to solve personal pending issues.

In his essay La soledad de los moribundos ¹⁸, Norbert Elias offers us 16 scenes or brief excursus showing cultural ways of experiencing death that go beyond the 20th century. There is no doubt that loneliness is an alarming condition for the most vulnerable in this society, but it becomes more pronounced when the end of life approaches. Indeed, this essay is an analysis of the questions humans ask about their own existence and the extreme loneliness that people experience when facing death in contemporary society ¹⁹. No one can guarantee that we will not die in solitude.

Other authors insist on the idea that having to die alone is typical of a relatively late phase in the process of individualization and development of self-awareness. This manner of experiencing death in solitude coincides—at least in some aspects—with the creation of the space that we call “inner self ²⁰.” Delving deeper into the solitude of death, we learn in the study by Holly Nelson-Becker and Christina Victor ²¹ that cultural and social responses to lonely dying are important to ease the emotional burden of dying alone, help people prepare for this possibility and better integrate death with the life course.

For Elias, there are four ways to face the event of death: using the oldest way, which is thinking that there is life after death; repressing the idea of death; thinking about the death of others, but not one’s own death; and the last one, which the author put into practice in the last 40 years of his life, facing death head on.

To present the study of death by historians of the last century, it is worth highlighting those who are inspired—especially—by anthropology and French historiography, prominent in which are studies on attitudes towards death in classics such as Philippe Ariès and Michel Vovelle ²². Currently, to protect the wishes of patients at the end of life, certain similarities are observed with the leading role of the dying in the so-called “tamed death.”

Definitely, with this model, patients and their loved ones have the opportunity to share their spiritual needs and deepen relationships in palliative and end-of-life care. Based on the conclusions of Vermandere’s study, I revive the idea that in the ars moriendi model, healthcare providers can gather information about the context, life history and significant connections of patients, making it easier to provide patient-centered care ²³.

The dialectical approach of ars moriendi can offer both physicians and other healthcare providers a way to reflect, critically and in-depth, on the possible disagreement between their idea of death and the variety of culturally valued “good deaths ²⁴.” The dominant concept of dying at home in the presence of family, expressed in ars moriendi, is still part of many modern notions of a good death; palliative care is a link in this way of understanding the end of life.

For some authors, especially nowadays, a contemporary ars moriendi should be republished, as the historian Arthur E. Imhof points out in his conference on the art of dying. Perhaps palliative care is the necessary adjustment for a good death.

Final considerations

It is possible to compare ars moriendi, this way of dying or wanting to die, with palliative care including modern nuances to it, when the rites of suffering and dying may have some parallels with current palliative care. Is there any similarity in how suffering is alleviated between these two ways of understanding the transition to death? It is evident that the tools for supporting the end of life have changed. I believe that, in essence, from the late 15th century to the present, care for the dying has not changed that much. Physical and spiritual (religious) support continue to exist, with different components.

In the face of thanatophobia, which seems to be present today, palliative care may be the necessary link to promote a trance that eases the path to death.

Life expectancy is a clear triumph of medicine. Research, together with new technologies, has been crucial to such expansion of life expectancy. However, we must bear in mind that it is associated to certain diseases that increase suffering at the end of life.

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Publication Dates

• Publication in this collection
  05 Apr 2024
• Date of issue
  2023

History

• Received
  05 Mar 2023
• Reviewed
  31 Aug 2023
• Accepted
  13 Sept 2023