Charisma and Surgery in the Middles Ages: The Example of Henri de Mondeville, Surgeon of Philip IV the Fair

Abstract

Based on Henri de Mondeville’s treatise on surgery, this article focuses on his practice and explores the surgeon’s awareness of the concept of charisma and its implications for his professional activities. It seeks to demonstrate the medieval textual continuity of the concept of charisma, its relevance to medieval medical vocation and training, and the fact that charisms remained central to the act of care for this surgeon, who acted for the common good and in fear of divine judgment. This essay looks at possible limiting factors in surgical practice, such as theological issues concerning the body and soul, or the consideration of the notion of moral responsibility. Do charisma, faith, and divine intervention absolve the surgeon from such responsibility? This article will examine whether de Mondeville’s surgical practice was based on predefined principles and non-intervention in the natural order of things or if, on the contrary, the medieval surgeon was accountable for his actions and their consequences independently of divine grace, due to his making a reasoned choice in the context of an ethical approach. This analysis shows that the elements involved in medical decision-making rely on a moral basis, influenced by the Christian religion and normed by religious texts, but do not exclude recourse to an applied code of ethics for specific cases, reserving all freedom of action.

1. Introduction

The notion of charisma was defined by St Paul, one of the most influential figures in early Christianity, as a divine gift of the Holy Spirit; it was then associated by thirteenth-century theologians with the notion of grace (Aurell 2022). The lexeme charismata appeared in the Latin translation of the First Epistle to the Corinthians (1 Cor 12:31, Vulgate) and was clearly defined by what preceded it in the epistle, in the form of the terms spiritualibus (1 Cor 12:1), gratiarum (1 Cor 12:4), and datur manifestatio Spiritus (1 Cor 12:7), its meaning as a divine gift thus being well established. Charisma originates from the classical Greek χάρισμα: grace, favor, and benefit, and from χάρις: benevolence and favor. The number of its occurrences is rather few in the Vulgate: 17 instances are in the Greek text of the New Testament, mainly in the Pauline writings or those of his disciples and in the First Epistle of Peter.1 In the Latin text, when the word charisma is not used, the translators have preferred to use the terms donum, donatio, and gratia. In the Greek text, there seems to be a difference between χαρισμα, which is placed on the side of the receiver (a divine gift being received), and God’s action of grace, χαρις του θεου, which is placed on the side of the giver (a divine gift granted).2 It is quite natural that χαρισμα was translated by the Latin donum or donatio, while χαρις was more likely translated by gratia (action of grace).

Paul saw charisma as a manifestation of God’s grace and believed that it was not acquired through personal effort but was instead freely given by God as a manifestation of His grace and for the benefit of the entire community, rather than for personal benefit. From the nineteenth century onward, a more modern approach has been developed in a sociological context, opening the way to further interpretation as the notion of leadership. However, in the thirteenth and fourteenth centuries, debates about charisma remained quite faithful to the Pauline definition. This topic of charisma has already been addressed by medievalist scholars. Many of the articles discussing the question in medieval culture have used Weberian definitions and concepts (Even-Ezra 2013). Some authors have been interested in the charismatic effect of historical figures such as Francis of Assisi, Hildegard of Bingen, and Bernard of Clairvaux, while others have focused on institutions and still others on governance, whether religious or political, including charismatic symbols of power (Finlay 2002; Andenna et al. 2005; Jansen and Rubin 2010; Felten et al. 2009; Jaeger 2018, pp. 181–204; Vedeler 2018, pp. 9–30). Some works have discussed a medieval approach to charisma with a return to its Pauline origins, most often in a religious context (Even-Ezra 2013; Gignac 2009; Gustafson 2018; Rossi Monti 2018), but never in a medical and professional context.

For this purpose, I focused on Henri de Mondeville (1260–1320), a French surgeon and physician, who was born in Normandy. Not much is known in terms of his biography. He studied in Montpellier and Paris, where he completed his training in surgery with Lanfranc of Milan (who was exiled from his city at that time).3 De Mondeville wrote that he taught surgery in these two cities, as well as medicine in Montpellier (Pouchelle 1983, p. 15). He was a cleric and a fine scholar. Surgeon to King Philip IV the Fair from 1298 onward, he was renowned during his own lifetime. His obligations toward the king and the royal armies, his teaching duties, and the exercise of his profession left him little time to write his Surgery, which meant a great deal to him. He gave lectures from its pages for students wishing to “learn, quietly, free of charge, and as if by a gift of charity, all that we moderns and all our predecessors […] have learned”.4 De Mondeville greatly contributed to the field of surgery by his method for treating wounds, which relied on cleanliness, and by performing brain surgery. He died around 1320, leaving an unfinished work that was translated into many vernacular languages, even during his lifetime, and copied until the fifteenth century, thus demonstrating its popularity. This text allows us to glimpse how the famous surgeon conceived of his profession.

This article is concerned with the notion of charisma as defined by St Paul, referring to a divine gift. In this context, I focus on de Mondeville’s surgical practice and his treatise, exploring the surgeon’s awareness of this concept and its implications for his professional activities. In the first part, I will introduce the historical context. I will then show the textual continuity of the concept of charisma throughout the Middle Ages, including the literary domain, which allowed scholars to integrate the concept into their daily practice. I will then discuss the appropriation of the concept by de Mondeville in his treatise on surgery, showing how the surgeon considered his practice to be charismatic. Among the various charisms, I will consider the charisms of healing, knowledge, faith (1 Cor 12:8–9), and charity and humility. Finally, I will show that this appropriation by the surgeon allowed him to define moral norms for a professional code of ethics, one in which making therapeutic choices and accepting moral responsibility are not antagonistic to the notion of grace.

2. Historical Context

The Middle Ages was a period of evolution for the medical profession. Monastic medicine played an important role in the development of medicine until the twelfth century. The emergence of universities from the thirteenth century onward gave laymen access to medical training. Scholastic medicine, heavily influenced by the teachings of ancient Greek and Roman physicians such as Galen and Hippocrates, used logical reasoning and empirical observation to develop an understanding of the human body. At the beginning of the fourteenth century, when de Mondeville was teaching in Paris and began to write his treatise on surgery, three universities had a near-monopoly on medical training: Bologna, Montpellier, and Paris (Jacquart 1995, p. 186). Surgery was regarded until the twelfth century as a branch of medicine forming part of therapeutic procedures. Surgery was considered to be a healing procedure. It was the surgeon’s task to treat, with the help of instruments, those ailments that a doctor could not cure with herbs or diet. Surgery was considered a manual operation. While doctors received theoretical training in medical school, those doctors involved in manual operations were trained via an apprenticeship. Surgery and medicine eventually separated and became two separate disciplines (Mc Vaugh 1995, p. 244). The creation of the brotherhood of St Cosmas and St Damian in the thirteenth century in Paris sealed the recognition of the profession of surgeon, while the ordinance of Philip the Fair in 1311, which obliged surgeons to pass an examination with a master before practicing, separated educated surgeons from barber surgeons (Pouchelle 1983, pp. 170–73). Indeed, alongside the few literate surgeons who had followed a medical course and knew Latin, there were all kinds of practitioners: not only non-literate surgeons and barbers, whose training was based on apprenticeship, but also a considerable number of tooth-pullers and quacks (Nutton 1995, pp. 164–65). In addition to shaving and undertaking cosmetic body care, barbers were allowed to perform procedures that surgeons disdained—bloodletting and the treatment of small wounds, boils, or bruises—while it fell to surgeons to treat “injuries such as broken limbs, sprains, dislocations, burns, scalds, cuts, bites and bruises” (Bullough 1959; Dumas 1995, p. 89; Siraisi 1990, p. 154). It was only at the end of the Middle Ages that barbers became more important, their activity then extending to the treatment of open wounds (Jacquart 1981, p. 35). This division between doctors, learned surgeons, and barbers was a source of constant conflict.

De Mondeville was one of the few educated surgeons in Paris at the beginning of the fourteenth century. He, therefore, carried out his activity at a time of transition when the health professions were being structured and university medical teaching, based on textual resources, was developing (Jacquart 1998). Medieval surgical literature constituted by repetitive compilations of previous texts until the twelfth century, was enriched with new texts during the thirteenth and fourteenth centuries (Mc Vaugh 1995, pp. 244–49). These treatises became more original and more didactic when new Arabo-Latin translations were first assimilated and then commented upon in the light of personal experience. Although certain texts, such as Roger Frugardi’s Cyrurgia, undeniably influenced medieval surgeons, it was not until the publication of William of Saliceto’s Cyrurgia and Lanfranc’s Chirurgia Magna, from which de Mondeville drew inspiration in his treatise, that rational texts based on argumentation became available, with the authors citing their sources and justifying their therapeutic choices (Ibid.). These works contrasted with earlier texts in terms of their conception: a chapter on anatomy was included, which is very detailed in de Mondeville’s work; pathologies were discussed according to disease and not from head to toe; finally, for Lanfranc and de Mondeville, an antidotarium, a book of antidotes and recipes, was introduced at the end of the treatise. De Mondeville was in favor of the reunification of surgery and medicine: two inseparable disciplines with the same base of theoretical knowledge. This was the same attitude adopted by Guy de Chauliac in his Cyrurgia, a text that later surpassed de Mondeville’s treatise in terms of fame (Tittel 2004). However, Mondeville’s treatise on surgery remains an original and passionate text. He also added a very personal and interesting reflection on the practice of his calling, which allows us to explore his perception of his profession through the concept of charisma.

3. Charisma and Medieval Textual Continuity

Even if the concept of charisma had been “revitalized in the thirteenth century in the debates of nascent scholasticism around the theological concept of grace” (Aurell 2022, p. 613), its use showed a textual continuity. Although rare and specific, the term charismata was used by many early Christian authors. Tertullian (160–220), an important early Christian theologian, wrote theological texts in Latin in which the lexeme can be found (Cazenave 2010, p. 314; Dunn 2004, p. 83).5 He described the Holy Spirit as the source of spiritual gifts and abilities.6 His theological texts were widely spread across the West, not only in the Paleochristian period but also in the Middle Ages, when a manuscript tradition is attested as early as the eighth century (Meyers 2015). Laurence Mellerin (2015) has shown, for example, that Augustine borrowed the notion of unforgivable sins from Tertullian’s exegesis of the gospels of St John and St Matthew.7 About 800 occurrences of the term charismata can be found in the Latin texts of early and medieval Christianity in the Latin West between the third and the fifteenth centuries, by 117 authors and in 203 texts.8 Among the authors who have contributed to this textual continuity, we can mention St Jerome (347–420), Bede the Venerable (673–735), Alcuin (735–804), Raban Maur (780–856), Rupert of Deutz (1070–1129), Peter Lombard (1096–1160), Thomas Aquinas (1225–1274), and more. The term was used in this theological context to indicate a gift of the Holy Spirit, in correlation to its Pauline origins, and was related to grace.9 Among these debates, different aspects of the charisms were evoked, such as charity, love, prophecy, and the notion of non-gratifying grace (non gratia gratis non gratum faciens), which is given freely for the service of the community (Aurell 2022, pp. 613–15).

Apart from strictly theological texts, this term can also be found in poetry, as in the work of Prudentius, a poet of Iberian origin and contemporary of Saint Jerome, who composed theological poems with didactic value (Thomson 1949, p. 117).10 Given the number of surviving manuscripts, Prudentius was also widely read in the Middle Ages. Finally, consultation of the Acta Sanctorum Database (1999–2017) allows us to validate the existence of the lexeme in literary texts.11

Indeed, the Latin word was used in the Middle Ages, but what about its use in vernacular languages? The dictionary of Middle French does not reveal any occurrence of the Latin term. The semantic field of the term being restricted to the theological domain, the use of Latin in theology for a very long time probably explains the absence of a need for a French word, especially since the terms donum, donatio, and gratia, which are used mainly in Latin translations, must have been sufficient to cover their linguistic needs. The earliest recorded use of charisma in French occurs only in 1879, in the Histoire des origines du christianisme (Renan 1879, p. 471), and, from 1960 onward, in dictionaries. The same is true in Italian and Russian (Cohen 2016). While the English term charism was thought to appear only in the seventeenth century, it in fact occurred much earlier. Indeed, the Middle English Dictionary (MED 2000–2018) reveals the existence of karism, in the sense of divine grace or spiritual gift, in a manuscript dating from the end of the fifteenth century.12

The medieval textual continuity of charisma has been established in the theological and literary domains; its passage into the vernacular is attested in the English language before 1500. Medieval physicians were educated in the faculty of arts, including logic and natural philosophy (Jacquart 1995). De Mondeville was a cleric. He had a perfect command of Latin and a good knowledge of religious texts (some of these physicians had received minor orders). He had read the works of important theologians, such as Bede or Thomas Aquinas, and he knew the theological concept of charisma and the “alii gratia sanitatum in uno Spiritu”, i.e., the gift of healing (1 Cor 12:9, Vulgate). De Mondeville devoted his whole life to the practice of surgery. Integrating this spiritual concept into the heart of his healing practice may have seemed quite natural to him.

4. Charisma at the Center of de Mondeville’s Act of Care

4.1. A Charismatic Medieval Conception of the Profession

De Mondeville was, above all, a Christian. However, this assertion is not unchallenged. Pouchelle (1983, pp. 68–70) questioned the depth of de Mondeville’s faith, suggesting that his reflections on religion were “too succinct to be able to pronounce definitively on his profound attitude”, pointing out some of the surgeon’s ironic remarks and the use of “obligatory style clauses”. Although the surgeon’s true intention cannot really be known, there is nothing to prevent us from believing the sincerity of de Mondeville’s writings. Thus, another reading of the text remains possible. As the work had a medical and not a theological purpose, it seems quite natural that religious considerations are not in the foreground. However, because they do appear in his work, they allow us to approach the surgeon’s charismatic values and beliefs. De Mondeville was not content with a single “dedication in due form” at the beginning of his treatise; instead, he regularly invoked the help of God throughout his work. He concluded his first two treatises “with God’s help only, from whose grace all knowledge and all other good flow”.13 With these words, de Mondeville linked his abilities to those of divine grace, as in the First Epistle to the Corinthians: “To one there is given through the Spirit a message of wisdom, to antoher a message of knowledge by means of the same Spirit”.14 In the writing of his work, he also invoked also the help of Christ, that “He may enlighten, perfect and correct my obscure, insufficient and ill-disposed mind, that it may support the burden and labour of such a task, so that in His light and power all the present work can be easily accomplished”.15 For him, God guided the hand of the hard-working surgeon in his inspiration and theoretical knowledge: “Without God no one can sufficiently write the history of remedies that is the subject of this doctrine”.16 To be educated, to become literate, to practice learned medicine and surgery, is to cultivate and honor this gift. Indeed, God had given him a gift, but it was necessary for him to make it flourish and turn it into a skill. De Mondeville had to learn this science that he “does not possess”, he said.17 Warning against the credulity of people or against ignorant surgeons, who claim “that they know surgery without art, and that they have infused science like an infused spring through the Creator” does not call into question the surgeon’s faith; if these remarks sometimes take an ironic turn, the irony is directed rather against those who are lacking in discernment, or those who have not taken the trouble to choose the more arduous path of knowledge, than against religion itself.18 For de Mondeville, God’s help appears to be fundamental in practice, in the manual act of surgery, “and without whose help the surgeon who takes care of human bodies does not achieve his goal. […] Let the surgeon in his acts of care have God before him, and God will manifest himself to him, and he would operate anywhere without trouble”.19

Alongside the charism of knowledge and faith, and the charism of healing, humility appears to be a fundamental virtue for Paul, who exhorted Christians to: “Be completely humble and gentle; be patient, bearing with one another in love. Make every effort to keep the unity of the Spirit through the bond of peace” (Eph 4: 5–8, NIV). The charism of humility, which is inseparable from love and charity, is necessary to serve the interests of the community. The common good is an important concept expressed in the First Epistle to the Corinthians (1 Cor 12:7, Vulgate). It encourages believers to work together in love and compassion to meet the needs of their community. De Mondeville put himself at the service of his community by writing his treatise for “the common good” and “the common good of present and future generations”, as he expressed it in his introductory sections.20 Paul points out that if charity is lacking, even the highest level of charisma is of no use to him to whom it is given (cf. 1 Cor 13:1–3). It is also these virtues that de Mondeville placed at the heart of his profession. Exemplary conduct and moral rectitude are manifested in a constant desire for humility in de Mondeville, who sought the best of graces. The surgeon obeyed the precept, saying: “I served the Lord with great humility” (Acts 20:19, Vulgate), writing that “the proud doctors will be put to shame for eternity”.21 It is also out of charity and to meet the needs of all that he undertakes the writing of his work: “But the learned disciples of surgery […] must rejoice, and all the people with them, if they take care, since they are put here in a position to learn quickly, quietly, for free, as if by a gift of charity, all that we […] have learned”.22 De Mondeville also mentioned surgeons’ fees. If it seems normal to charge the rich for their services, it is, nevertheless, necessary to treat the poor for free, out of charity, because “the reward is great in Heaven, as necessarily follows from the words of the Saviour, who says in the psalm, through the mouth of the prophet: ‘blessed is the one who has pity on the needy and the poor, for on the evil day the Lord will deliver him’”.23 On the subject of preventive treatments, he added that these must be administered free of charge “to those who are truly poor, for God’s sake” and that deceiving the poor would be dishonest.24 Finally, de Mondeville also followed the precept: ”A cheerful heart is good medicine, but a crushed spirit dries up the bones” (Pr. 17:22, NIV), by encouraging patients who “must be comforted”. He encouraged friends and relatives to visit the sick, to bring them joy, distraction, and laughter (Nicaise 1893, p. 144). He advised the avoidance of anger, hatred, and sadness, which make the body lose weight (Nicaise 1893, p. 145).

The Holy Scriptures were a constant guide for the surgeon, as shown by the numerous explicit or, more often, implicit quotations from and references to biblical texts (including proverbs, psalms, and the epistles of Paul and Peter). He compared, for example, theory and practice to the two gates of the fold that the surgeon must open, so as not to approach the discipline in the manner of a scoundrel. “He who does not enter the fold by the door is a thief or a robber”, he wrote, referring to John 10:12.25 He also warned surgeons to fear God: “Since the fear of the Lord is the beginning of wisdom and nothing is lacking in those who fear the Lord, [let the surgeon] trust in the largesse of mercy and the fullness of his power” in an analogy to the proverb that “the fear of the Lord is the beginning of knowledge, but fools despise wisdom and instruction” (Pr. 1:7, NIV).26

The charisms as virtues and the precepts of the Holy Scriptures allowed de Mondeville to define a moral framework with normative purposes for shaping the good practice of surgery.

4.2. Charisma and Surgical Practice: A Compatible Course

The idea that the soul resides in a specific part of the body seems to have had little impact on surgical practice in the Middle Ages. The question of the soul and its nature was primarily a matter for philosophers and theologians, in terms of its relationship to God. However, the issue of an anatomical substratum for the soul and charisma could have been both the object of anatomical research and also an obstacle to surgical acts. Reservations regarding touching the body, opening it up at the risk of injuring the soul or of annihilating a divine gift, could have restricted the freedom to operate. De Mondeville devoted little space to the soul in his text, while giving anatomy, which he described as “the foundation of surgery”, an essential place in it (Nicaise 1893, p. 2). That is why the surgeon chose to make his anatomy treatise the preamble for his Surgery, rather than placing it “in a rather scattered manner”, as he blamed Avicenna for doing.27 “Anatomy is the exact division and knowledge of the human body and of each of its members and parts, of this body which is the object of all medical science and also of surgery. […] For all these reasons, my intention is to treat anatomy at the beginning of this work”, he added.28 However, it was indeed the knowledge of the human body that interested him and not that of the “compound” of Saint Thomas, a being that is provided with its own soul: “Anatomy is […] the knowledge of the human body and of each of its members and parts, and this body is the object of all medical deeds and also of surgery” (Lamour 2017)29. It is through the study of the various members of the body that knowledge of the body can be achieved. The mention of an anatomical relationship between body and soul comes very late in de Mondeville’s treatise and is not in the part devoted to anatomy, which shows an absence of practical interest for the surgeon. The human body remains, however, an instrument at the service of the soul: this duality is ambiguous for the surgeon, for whom there is a very close interaction between the body and the soul. This link, therefore, has therapeutic implications: “The body and the soul are so closely linked to each other that as long as one is ill, whatever it may be, the other cannot act externally”, added de Mondeville. Physiology focuses on how the human body works. To practitioners in the Middle Ages, the liver generates nutritive blood during the second digestion. This nutritive blood is made more subtle by virtue of the heart, the principal organ that distributes vital blood, heat, and spirit, which, now purified, enters the left ventricle, where it gives rise to the spirit.30 The surgeon explained:

This spirit is clearer, lighter, purer and more shining than any other corporeal thing formed of the four elements, and is consequently closer to the nature of supercelestial things; it forms between the body and the soul a friendly and appropriate link, and is the immediate instrument of the soul, which makes spirits the bearers of faculties.31

Spirits are, therefore, not the soul, according to de Mondeville, but the carriers of faculties. Hence, the union of body and soul is not fusional in de Mondeville’s mind since it requires a third party to create the link. De Mondeville made a distinction between the “cardiac spirit”, which was born in the heart and was the instrument of all the faculties, and the “spirit of the soul”, which was born from a new digestion in the ventricles of the brain.32 In line with Avicenna, de Mondeville described the brain as being divided into three ventricles: the anterior ventricle, the seat of the imaginative faculty, which receives the appearances of sensible things transmitted by sensory organs; the middle ventricle, the seat of the faculty of appreciation, discernment, and judgment; and the third ventricle, seat of the faculty of memory, which stores thoughts and perceptions (Wiberg 1914; Van der Eijk 2008).33 Since de Mondeville described the brain as being the seat of cognitive functions and thoughts, could he have considered this spirit of the soul carrying faculties as the “arm” of the charism? It is impossible to analyze this because, according to him, “spirits can neither be seen nor touched” (Nicaise 1893, p. 134). Indeed, one cannot describe using anatomy what is invisible and untouchable. The inability to define the anatomical seat of a divine gift does not seem to be an obstacle to the opening of bodies, not in the case of living ones via the surgical act, but even less so in the case of the dead. For de Mondeville, surgery is more necessary than medicine because surgeons open up corpses. For him, death is merely a corruption that turns living organisms from beings to non-beings (Nicaise 1893, p. 119). To him, it is indeed a body without a soul, a non-being, that the surgeon faces, an argument faithful to the works of Aristotle, for whom a carnal envelope without a soul is nothing more than a corpse (Aristotle 2018, pp. 21–45). Thus, operations performed on dead bodies were not uncommon. Post-mortem conservation care, for which a special privilege had to be requested from the Church, post-mortem caesareans, and medico-legal autopsies were within the scope of medieval surgeons. As M-C. Pouchelle points out, it is in the treatise on surgery by Guy de Chauliac (1300–1308) that the obligation to extract the fetus before the burial of pregnant women (who had died before giving birth) is mentioned (Pouchelle 1976, p. 264).34 The fact that Guy de Chauliac was also the physician of the popes of Avignon was obviously not in contradiction with his surgical practices. In Islam, the preservation of bodies was also not problematic. Abū Bakr al-Rāzi (Rhazes 825–965) devoted a chapter to it in his work, Al-Mansur (Koetschet 2014). As for human dissections, the first of which we owe to Erasistratus (310–250 BCE) and Herophilus (330–260 BCE), these do not appear to have been forbidden either, even if they were only slowly resumed in the West from the fourteenth century onward (Von Staden 1975). Faith was no obstacle to the practice of dissection of a dead body for surgeons wishing to learn, either in the Catholic religion or in Islam, after the tenth century (Annajjar et al. 2022).

The daily practice of surgeons in the Middle Ages seems to have put the theological issues of the body and soul aside. Finding an anatomical place of divine grace was not a necessity for de Mondeville, who could neither see nor touch spirits, as he wrote, yet he accepted the brain as the seat of cognitive faculties, including thought, judgment, and discernment. For a man who always tried to reconcile theory and practice in a pragmatic vision of the profession, these questions were probably considered to belong to the philosophical or theological field and, thus, far removed from daily surgical concerns; indeed, he made no mention of them in his chapter on anatomy, which he said was fundamental and the basis of the practice. Just as for Ibn Rushd (Averroes 1126–1298), who stated that: “Anyone who practices anatomy will increase his faith in Allah”, the knowledge of anatomy was also, for de Mondeville, a way to approach or understand the miracle and the perfection of the Creation; that the soul, spirits, and charisma are invisible and untouchable is part of its mystery (Annajjar et al. 2022).35

Alongside the charisms as virtues and the theory of medical science, de Mondeville’s religious convictions and his desire for irreproachable conduct led the surgeon to constant reflections on his practice. Religion and medicine are two disciplines that address the questions of life: its origin, its meaning, and its end. Faith, in all periods of history, determines the ways in which health and illness are approached. As a believer, seeking to develop a professional attitude from the Scriptures, interpreting them, and adapting them to resolve potential value conflicts, is an essential step that defines an ethical approach.

5. From Charisma to the Ethics of Responsibility

The ethical approach concerns the way in which medical decisions are taken, in particular, therapeutic choices. Ethics differ from pure morality, which is exercised in a binary mode (it is permitted to/it is forbidden to) and reflects the values of a particular society at a given moment, and also from deontology, a code of good practice governing the patient–carer relationship. These issues are not new; they had already been raised in Greek and Roman antiquity (Gourévitch 1984; Flashar and Jouanna 1997). Some previous research has dealt with medical “ethics” in the Middle Ages, focusing on deontology in the patient–doctor relationship, the conduct of a consultation, or relations between colleagues (Nicoud 2004; Mc Vaugh 1997; Crisciani 2004). The issue of moral responsibility, as perceived by the medical community itself, has never been explored. This issue is fundamental because, since it relies on the carers themselves, it raises the question of the values that guide choices and the issue of free will. Ethics, says A. Guggenheim (Guggenheim 2019), “is the art of questioning one’s responsibilities. Responsibilities for others, for humanity.” The ethics of responsibility emphasize that individuals are responsible for their actions and any consequences and imply a certain freedom of choice. In the context of Christianity, religious beliefs and values play an important role in decision-making. The ethics of responsibility and faith, two different approaches to ethical decision-making, may seem incompatible. Believing in a healing charisma, believing that God is supremely responsible for every act, could have a great influence on the way that individuals assume or discharge their responsibilities. This view of ethics applies to the physician’s responsibility in making therapeutic choices. It is applicable to decision-making in the Middle Ages and resonates with Thomas Aquinas, for whom “God is the first cause of every being and of each of its operations” (Blankenhorn 2014). From charisma and the notion of divine grace to the surgeon’s responsibility, it was indeed the question of determinism and free will that came to the forefront and that de Mondeville discussed throughout his work. At first sight, it seems that de Mondeville considered the surgeon’s acts as being determined by the action of an almighty God and the divine gift: “It is indeed God who created Nature, who governs all bodies and who, more powerful than it, governs it in turn.” “Nature acts at all times, the physician is only its servant”, he wrote, in accordance with Aquinas’ statement, “God holds all things in being, gives them their capacity to act, and he acts with them in every operation as first cause, while the creature acts as secondary cause” (Blankenhorn 2014). Thus, the surgeon may appear as the “hands” of God. However, the question of the moral responsibility of actions and their judgment remained relevant for the medieval surgeon who also defended free will. Hoffmann and Michon (2017) have shown that these questions were central to medieval thinking. They argue that for Aquinas, free will requires the existence of alternative possibilities, and that it is only on this condition that the moral responsibility of the agent can be exercised as causality does not call into question the ultimate source. An action is, thus, considered free if it is not contingent, implying that the agent of the action has the power to either carry it out or not do so. Indeed, for Aquinas, “since God does not operate exactly as creatures do […] he acts in and with creatures without violating the freedom of rational secondary causes” (Blankenhorn 2014). De Mondeville regarded charisms as forces that work in conjunction with human freedom, providing inspiration. Freedom of action, defined as the possibility of choosing one’s own path with the support of divine help, is thus considered compatible with a belief in the hand of God. It is at this exact point of intersection that applied ethics is situated. The field of applied ethics is concerned with issues of practical concern in a professional field (Almond 1998). While this term is quite recent, applied ethics or applied philosophy was already recognized in antiquity and in the Middle Ages (Almond 1998).36 Ethics as a concept can be described as an uninterrupted path from theory to practice, i.e., from metaethics to applied ethics. Ethical theory is concerned with the analysis of moral concepts such as “right”, “good”, and “virtue”, and normative ethics, which occupies an intermediate position on our path, is concerned with the norms and rules that apply to moral concepts. Metaethics and normative ethics are, thus, based on the values and beliefs of an individual or a society. For de Mondeville, his faith in God, charisma, and divine grace are the basis of his moral values; the Holy Scriptures he quotes throughout his book represent the normative ethics he wishes to apply in the practice of his profession. Thus, he is the hand of God because he obeys His precepts. What is remarkable about de Mondeville is the use of applied ethics in the context of his case reports. Applied ethics means applying normative rules to specific situations: “What should I do?” It requires decision-making, the possibility of alternative and rational choices, and free will. Therefore, applied ethics can be a source of dilemmas, for the choice between two courses of action may be extremely difficult, a matter of adjudication between two situations (Moros et al. 1987). The actor’s choices will be made in relation to his moral values in the particular context, depending on the options available.

Charisma and divine grace do not exclude the free will of the actor, who remains, in the eyes of de Mondeville, responsible for his actions. He wanted the surgeon to be responsible for his actions but not for events that he did not cause. Thus, he warned against conditions external to the surgeon’s action that could compromise the success of the operation. Relying on Galen’s precepts, he stated that “since the cure of a disease depends on the surgeon, the patient, the assistants, and external accidents, the surgeon, who is only responsible for a quarter of the cure, should not guarantee it in advance.” “It is important to take into account not only oneself but also the patient, the assistants, and the external circumstances”, he commented in his introduction (Nicaise 1893, p. 6). “A contingency results from certain external accidents, such as sudden and accidental changes in the weather, sudden heat, cold, or wind”, he wrote (Nicaise 1893, p. 6). De Mondeville argued that the surgeon’s responsibility is conceivable and measurable, in the light of contingent factors that then appear to be excuses for the therapeutic escape for which he cannot be blamed. De Mondeville does not, however, absolve the surgeon of his obligations with regard to external circumstances: “Even things that come from outside […] must be the object of the surgeon’s attention” (Nicaise 1893, p. 6). Indeed, “sudden changes in the weather”, he said, or “astronomical accidents” such as the disposition of celestial bodies must be taken into account, for, even if these events are independent of the practitioner, he may have alternatives in terms of operative procedures, i.e., he could act differently. Sometimes, however, the incurability of the disease and the inevitability of death will make non-intervention the only reasonable option: “I advise not to treat serious diseases for which we do not foresee a happy outcome and cure”, refusing to be made responsible for the inevitable death of these patients for fear of being accused of accidental homicide (Nicaise 1893, pp. 5–6). It is here that the question of the judgment of the act is raised: “Do not take on the treatment of bad diseases, lest you be called bad doctors, and the envious or the vulgar find words of blame against you”, he advised (Nicaise 1893, p. 6).

Philosophical theories about determinism and moral responsibility tell us that when an individual is responsible for an event by omission, he does not cause that event in the same way as if he had performed an action, but he is still responsible if he might have been able to prevent it (Michon 2018). Charisms, faith, and divine inspiration are not excuses for a surgeon’s non-intervention. “He who sees his neighbor dying of hunger and does not feed him, although he can, is responsible for his death”, said de Mondeville to justify the surgeon’s obligation (Nicaise 1893, p. 493). In cases of omission, moral responsibility seems to be linked to the existence of an alternative possibility. This question is addressed by de Mondeville in the hemostatic treatment of wounds. He offers the example of a wound, made by a lance in the thorax and near to the heart, in which a large piece of iron remains stuck. The wound is bleeding and hemostatic treatment is necessary. If the piece of iron cannot be removed safely—without risk of injury to the heart—then “you must either leave or remove the iron. If you abandon it, the patient will die. It is impossible for a man to live long with a large object stuck in or near his major organs”, wrote the surgeon, before quoting the therapeutic possibilities for its extraction. In this case, the surgeon is not responsible for the patient’s wound, but to what extent, if he does not intervene, is he responsible for a death that could have been avoided if he had intervened? This question remains in the realm of the hypothetical, as there is no proof that intervening would save the injured person. De Mondeville was, therefore, well aware of the alternative possibilities and left the decision up to the surgeon’s liberum arbitrium. The whole of de Mondeville’s work is marked by the idea of responsibility, making this surgeon a precursor of professional ethics. This responsibility is not in opposition to either his faith or his belief in divine grace, and he always relies on the Scriptures to justify his statements as moral rules.

6. Conclusions

The notion of charisma, since the term first appeared in the writings of St. Paul, continued to exist throughout the Middle Ages in the works of numerous authors, in a theological and literary context, associated with the notion of a divine gift. Henri de Mondeville wrote his treatise on surgery at a time when the health professions were being structured and when surgery, previously considered a therapeutic procedure that was dependent on medicine, was finding its autonomy. Opposed to this separation between the two disciplines for reasons of theoretical training, de Mondeville set his heart on writing a text that also established the rules of conduct that a good surgeon should follow. As a cleric, physician, and surgeon, he assimilated the concept of charisma in a professional context, placing divine grace, the gift of healing, the charisms of humility, and charity at the heart of his acts of care. He linked the surgeon’s abilities to divine grace, without omitting the necessity to cultivate and honor this gift, i.e., to learn and study by taking a theoretical and practical approach. The charism of humility, inseparable from that of charity, appears, as in the writings of Paul, as a fundamental virtue in the service of the community. De Mondeville insisted on treating the poor freely, remaining humble, and working for the common good. These virtues should guide the surgeon toward exemplary conduct. These charisms are found in the notions of charity, assistance, and care, which were the values of the original hospitals and whose history overlaps with that of monasteries. A large number of hospitals were founded at the instigation of ecclesiastics (Durand et al. 2000). The ways in which monks and nuns looked after the sick, pilgrims, or the poor reflected these virtues, based on charisms. The Hospitallers, a female branch of the order of St John of Jerusalem, founded in the eleventh century, were dedicated to the service of the sick poor. It was these sisters who introduced the notion of service not only into medieval spirituality but also into nursing. It would be interesting to explore how these values may have changed over time, both in general practice and in hospitals, in relation to distancing nursing from religion.

In his treatise, de Mondeville was interested in general practice. The surgeon’s real intention or his attitude toward religion can, of course, always be questioned. Some of his reflections have been seen as negative or as ironic attacks. They have been considered to represent the emergence of a form of medicine detached from religion in parallel with the beginning of scholasticism. However, the regular references to the Holy Scriptures leave no doubt about de Mondeville’s belief in God.

It is obviously impossible to judge the surgeon’s conduct with certainty from his work. Indeed, there is certainly a gap between the literary genre of the treatise and the surgeon’s empirical practice, and we must remain humble in whatever interpretation can be made of it. The diversification of medical writings that accompanied the development of medicine in the Middle Ages resulted in the production of texts dedicated to teaching, rather than in the form of commentaries, and of practical and varied texts in the form of treatises, collections of experimenta, recipes, or antidotaries. However, de Mondeville’s work is resolutely practical and is organized in the form of treatises, including personal experiences and a section devoted to an antidote. Moreover, the surgeon himself approached his text with a didactic aim, citing sources and approving the authors. The first Latin versions of his work (see Paris, B.N. lat. 7131) show a central text that is accessible to the simplest of surgeons, as he himself stated, along with a more elaborate, peripheral text dedicated to learned surgeons who wished to explore the theory further. The copyists of the successive versions did not consider it useful to reproduce these first formulations, incorporating the peripheral text into the main text to create a single reading level. Research on these differential versions considering the placement of religious values might be interesting to conduct. Reading this difficult text has been made easier by these scribes, perhaps to the detriment of the author’s original intention. If there is a gap between the writings and the practice, if de Mondeville undoubtedly used consecrated or expected literary forms, or if he sought to convince his reader, his text remains an original text that is dedicated to a practice enlightened by theory, based on his religious values.

De Mondeville did not restrict his surgical practice, the learning and teaching of anatomy, or interventions on living or dead bodies for theological reasons. Searching for an anatomical substratum for the soul was not his priority as a surgeon; the relationship between body and soul did not merit explanation in his chapter on anatomy, which he regarded as the foundation of medical and surgical science. While he located the spirit of the soul in the brain, de Mondeville still practiced skull and brain surgery, performing trepanation.

De Mondeville did not invoke charisma, faith, and divine intervention to excuse the surgeon from his moral responsibility, whether in the acts performed or those that are omitted. He regarded charisms as forces working in conjunction with human freedom, providing help and inspiration. Therefore, moral responsibility and faith become compatible in decision-making, subject to the existence of alternative possibilities. Christianity influenced medieval society as a whole by establishing a moral foundation that guided people’s thinking and actions during this period. This influence also applied to the fields of medicine and decision-making. De Mondeville’s faith and religious beliefs defined the moral concepts to which the surgeon adhered, while the Holy Scriptures fulfilled their normative role by establishing the rules and norms that applied to the moral concepts, and the patients represented specific situations for which de Mondeville resorted to an applied code of ethics.

In the work of Henri de Mondeville, one can see the dilemma between a practice based on predefined principles or duties, non-intervention in the natural order of things for incurable diseases, and an ethic of responsibility wherein the surgeon takes on his actions and their consequences independently of divine grace. The choices he makes are not automatic but are instead reasoned according to a consequentialist approach and adapted to the specific case. This practice of the medieval surgeon thus anticipates modern medical ethics in many ways.