Are the Wages of Sin Really Death?: Moral and Epidemiologic Observations

In this article we document correlations between practices once regarded as sinful, both personal and social, and medical evidence of increased morbidity and decreased longevity. We suggest that more attention needs to be given to such correlations, especially considering the escalation of costs associated with maintaining good public health, and further, that ancient and medieval virtue ethics offer still pertinent insight into the importance of moral health for wholistic preventative medicine. David Lyle Jeffrey is Distinguished Professor of Literature and the Humanities at Baylor University. Jeff Levin is University Professor of Epidemiology and Population Health at Baylor University.

Those whose memory includes Sophocles’ great tragedy Oedipus Rex will recall that it opens with a priest giving somber news to the king: a great sickness had come over the land, striking crops, decreasing fertility, hastening death:

A blight is on our harvest in the ear,

a blight upon the grazing flocks and herds,

a blight on wives in travail, and withal

armed with his blazing torch the God of Plagues

has swooped upon our city…¹

The root cause turned out to be a breach in the moral order, for which physical disorder was a consequence.

Similarly, the ancient Jewish prophets thought that a well-ordered moral life resulted in physical health and fruitful fields and vineyards,² while departure from the moral order would engender disease, crop failure, and other environmental destruction.³ As with the Greeks, personal physical morbidity was seen as a consequence as well as an instance of the general malaise affecting the environment; in the memorable language of Isaiah, as a result of widespread willful departure from the Law:

The whole head is sick,

and the whole heart faints.

From the sole of the foot even to the head,

there is no soundness…⁴

This theme runs through the entire book of Isaiah, but its roots are in the Law of Moses, whether with respect to regulations governing sexual behavior,⁵ obligations to strangers,⁶ or care for the poor as well as other neighbors.⁷ Even dietary and purity laws, though cultic, have some obvious preventative health aspects.⁸ Just as egregious transgressors are to be “cut off from among their people” so as to avoid pollution of the people, so also whole nations that transgress, Israel not excluded, suffer consequences consistent with their corruption or pollution of the natural order:

You shall therefore keep my statutes and my judgments, and shall not commit any of these abominations, either any of your own nation or any stranger who dwells among you. For all those abominations the men of the land have done, who were before you, and thus the land is defiled, lest the land vomit you out also, when you defile it, as it vomited out the nations that were before you. For whoever commits any of these abominations, the persons who commit them shall be cut off from their people.⁹

Anthropologically, such a view of the interrelation of moral order and community biological health is known as a chthonic worldview. When the Apostle Paul attempted to summarize this Greek and Jewish view for his Roman hearers, he put it more succinctly: “the wages of sin is death.”¹⁰

Many in our contemporary culture think of such views as quaint, archaic to the point of needing little reflection, even distasteful. But in fact we have analogues to these chthonic observations in our era, even if they tend to be grounded more in materialistic than moral correlations. In the light of sound medical evidence, we label tobacco products with health warnings and, in the interest of public health, try to curtail their use. We do the same with alcohol, not to mention disposal of toxic wastes, such as lead in old paint, mercury, and pesticides. With much less success, we also try to discourage poor nutrition and warn about the consequences of obesity, and rightly so, given the large percentage of public health expenditure that is required to ameliorate the morbidity associated with it. And who among us is not concerned about biochemical pollution of the environment by agribusiness and petroleum-based enterprises?¹¹

There are still other factors that arguably cause even greater damage to public health, behaviors in which, from traditional perspectives, the moral dimension is still more evidently at play, yet which we have been largely reluctant to diagnose as a public health danger, primarily for social and political reasons. Among these most obviously are various sexual behaviors, but they are not all obvious. For example, changes in sexual behavior since the 1960s entail pharmaceutical consequences for the environment, such as the feminization and reduced fertility of both fish and amphibian aquatic species because of the way many drugs, including notably birth control pill and antibiotic residues, are flushed from the human body into the water supply.¹² These are bidding to be no less a factor in public health expense than the consequences of other intemperate appetites, for example those associated with excessive carbon emissions and plastics pollution. Even couch-potato indolence such as would once have been called laziness or sloth are now known to incur life-long diminishment of health through resulting conditions such as cardiovascular disease and diabetes.

On such grounds, it has occurred to us to wonder what, if anything, older, more explicitly moral analyses of the causes of morbidity might provide in the way of perspective as we struggle to constrain the rapidly rising costs of public health, including components such as health insurance and the growing bureaucracy of healthcare both private and public. At the least, we have come to think, a diachronic reflection might provide some interesting points for discussion. Some obvious questions hardly need to be asked. Are all behaviors value-neutral in the context of healthcare? Obviously not, and there is evidently nothing new or controversial in thinking so. Yet it may be that consideration of the costs associated with particular behaviors should be re-assessed in the light of current social as well as epidemiologic factors.

Older Paradigms of Vices and Virtues

For our predecessors in Greek, Jewish, and medieval European cultures, personal and public health were closely related, and in both spheres the pursuit of health required the practice of behaviors regarded as virtuous and the avoidance of their contrary vices. There are, of course, differences among these ancient, medieval, and early modern views, but their core virtues turn out to be remarkably constant.

For the ancient Greeks, pursuit of virtue in a whole life was thought to lead, at least for those successful in achieving a very high standard, to arête, essentially an enduring reputation for nobility of character.¹³ Homeric virtue, it must be acknowledged, was not much concerned about incidental excesses of carnal appetite or violence, as a recollection of the Iliad and Odyssey will serve to illustrate. However, by Aristotle’s account, four centuries later, there had occurred considerable refinement.¹⁴ Virtues now appear as character traits associated with social maturity, including not only such features as courage, temperance, liberality, and “magnificence” (a kind of public grandeur or gravitas), but also pride, honor, equanimity, friendliness, candor, and a sense of humor. These are “virtues” which, for Aristotle, should be sought after by the “exceptional man,” and constitute a prudential list for any socially aspirant person. Moral laws, on the other hand, primarily regard the socius or neighbor (in its largest application, the polis or state), and have essentially to do with what we might now think of as civic virtue and what Aristotle considered as justice.

There is surprisingly little sense in Aristotle or Homer of interconnection between prudential virtues of the individual and either general moral laws or the laws of nature. By contrast, however, all three are deeply intertwined in the tragedies of Sophocles and Aeschylus, where consciousness of particular vices—virtue opposites—are connected with what Frazier, Freud, and others have called “taboo,” violations of primal chthonic moral order such as incest, failure to bury the dead, or eating one’s own children.¹⁵ In this connection it is worth noting that the plays of Sophocles and Aeschylus were written for religious festivals.¹⁶

The literary canon of Hebrew-speaking ancients does not distinguish between philosophical and religious principles in the way the Athenian Greeks did, yet a conviction that human miscreance corrupts the ecosystem and personal health alike is everywhere apparent. In Judaism, as the first citations in this essay well illustrate, the chthonic intertwining of natural and moral law is close to seamless; health in respect of one entails health in respect of the other (shalom). A reading of Exodus, Leviticus, and Deuteronomy reveal many more types of transgression than in Greek chthonic moral order to have the odium of taboo, inviting deleterious consequences not only for the individual miscreant, but for the entire community of which the individual is seen as an integral part. Moral laws are articulated in terms which have the force of divine oracle, and, as Levitical laws in particular make clear, crossing the line of transgression may well require exclusion of the offender, making him or her a pollutant per ipse, in extreme cases even requiring capital punishment in order to preserve community shalom.¹⁷ That this was true at least to some extent in the case of taboo among the Greeks may be seen in the plays of Sophocles and the Oresteia of Aeschylus.

Western Christian culture inherited and developed both Greek and Jewish chthonic concepts of community health, if not all their specific practices. But the Jewish ideas which connect shalom, or, as it is sometimes thought of in Christian contexts, “human flourishing,” with kedushah (holiness) more substantially shaped early and medieval Christian thought, a linguistic residue of which in English seems to be the linkage between “holy” and “wholly” as well as “wholistic.” For medieval Christians, conscious transgression against both the moral and natural law was seen as something inherently damaging not only to the self, but to other persons, and indeed, to the health of the community at large.¹⁸

Opposing the habitual sins were spiritual virtues typically cited as fortifications against succumbing to vice. In the Psychomachia of Prudentius (410 CE) the more or less standard list of countervailing psychopharmical virtues appears as chastity, temperance, charity, diligence, patience, liberality, and humility. Since then these virtues have been regularly cited by Catholic Christians (confirmed at the Council of Trent, in 1546) as antidotes to the “seven deadly sins.” This still fairly widely-known catalogue for common transgressions of moral law was actually first introduced in its present form more than a millennium earlier by John Cassian, and it acquired the force of basic catechism.¹⁹ Beginning with the venial sins of lust and gluttony, the more spiritually destructive mortal sins of envy, sloth, wrath, greed (or covetousness), and pride round out the venerable diagnostic spectrum.

We thought it might be most useful to our purposes here to limit ourselves to considering, in however general a way, the social cost of just these traditional seven deadly sins. We recognize that there are great consequences for public health which are not easily monetizable, and we do not attempt an economic analysis. Yet, in respect of at least one measure of their communal consequence, namely in those spheres of public health expenditure which can reasonably be associated with these habitual behaviors, thinking about epidemiologic analysis in a way which pairs it with the older moral analysis proves to be interesting, and it is within the realm of the imaginable to guess what proportion of general public health costs they consume.

Some Epidemiologic Observations

To determine whether and to what extent the wages of sin are indeed an “etiologic” antecedent of death we apply the concepts and methods of epidemiology, the science of the distribution and determinants of disease across populations. In simpler terms, epidemiologists identify factors—constructs, variables, exposures—whose presence is associated with elevated or diminished frequency of some respective outcome, such as a particular disease or illness state or level of health, as calculated across a population or sample of people. Of course, for research scientists in this field it is all quite a bit more complicated than that. But for the purpose of this essay, our task is to determine whether empirical evidence exists for the proposition that the seven deadlies—or reasonable proxy measures—are associated with significantly higher rates of death or disease than would be observed in the absence of each respective sin. This is by necessity an inexact experiment: no NIH-funded study that we know of has set out to investigate the mortality-related consequences of sloth or lust or gluttony, at least in those terms. However, substantial evidence exists implicating, for example, exercise, sexual behavior, and diet and obesity as risk or protective factors for overall or outcome-specific rates of mortality (death) or morbidity (disease). For some of these sins, the data are clear; for others, evidence is equivocal.

Lust

In Dante’s famous vision, the seventh circle or ring of his Purgatorio is lust (in his Inferno, the term used is luxúria). Its residents include souls guilty of sexual liaisons that were either inappropriate or excessive. The sin here, they admitted, in Esolen’s translation, was that they had “failed to hold to human law,/like beasts that follow but the appetite (l’appetito).”²⁰ Even in their damnation, they would “make haste/to greet the others with a kiss, each one/…rubbing nose to nose,”²¹ unable to control themselves, while at the same time bemoaning with regret that they had failed their “wives and husbands who were chaste and lived/as virtue’s laws and marriage both demanded.”²² While visiting this terrible place, Dante’s guide suggests, “you’d better keep a tight rein on the eyes./One small misstep and you’ll have gone astray.”²³ This sounds like advice one might receive today regarding the ubiquity and ease of stumbling upon internet pornography or prurient images in the mass media.

In Inferno, the battle has been eternally lost and the suffering souls are beyond redemption. Having been given over completely to their sexual appetites, the guilty now reside forever in a place whose “hellish cyclone that can never rest/snatches the spirits up in its driving whirl,/whisks them about and beats and buffets them,/and when they fall before the ruined slope,/ah then the shrieking, the laments, the cries!/Then they hurl curses at the power of God.”²⁴ Is there a more terrifying depiction of the torturous consequences of sexual addiction in the literary canon?

Considerable epidemiologic evidence implicates mortality or morbidity arising from excesses associated with sexual behavior considered, for one reason or another, to be non-normative—that is, excessive or deviant in the sociological sense. Large-scale studies and/or reviews across nations and cultures link multiple sexual partners and early onset of first intercourse to increased cervical cancer and human papilloma virus infection,²⁵ marital infidelity to greater anxiety and depressive symptomatology²⁶ and greater suicide risk,²⁷ premarital sex to sexually transmitted diseases,²⁸ and non-heterosexual behavior to HIV/AIDS risk.²⁹ Whether or not these associations, especially the latter, are truly etiologic or “causal,” or rather an example of the familiar dictum of correlation-but-not-causation, remains a contentious and politically charged issue. We take no editorial side here, but simply note the presence of excess risk associated with sexual behavior or identity outside of traditional Western moral norms. This could be due to direct and substantive consequences of sinfulness, or to downstream psychosocial effects of society having politically sanctioned certain behavior on the basis of restrictions or judgments that some consider outdated or oppressive. No matter, Dante’s luxúria, unrestrained, does appear to have serious health-related ramifications.

Not only health-related, but healthcare- and social-expenditure-related: consider the costs of failed marriages,³⁰ single-parent households,³¹ and teenaged motherhood³²—and more recently noted sequelae of these excesses in the U.S., such as the plague of human trafficking.³³ These include increasing disinterest in sex among married or cohabiting millennials³⁴ and an unprecedented sub-replacement-level fertility rate.³⁵ Intriguingly, in a culture obsessed with sex which has de-emphasized the primacy of sex for the sake of reproduction, sexual coupling seems to have lost some of its allure, or perhaps normal desires have become annulled due to the ubiquity of pornographic images. No matter, it seems that lust, taken to an unbridled extreme, may be productive of its antithesis—atrophy of the sexual instinct and of the desire to propagate.³⁶ In either expression—lust raging out of control, or lust that burns itself out—this sin is a destructive and life-negating force.

Gluttony

The link here between sin and its health consequences seems apparent and obvious, and not particularly controversial. Who is not aware that intemperance in the act of eating is not good for our health? For Dante, the fate of the gluttonous in purgatory is practically karmic in its working out of divine justice: each sufferer “was dark and hollow in the eye,/pale in the face, and worn away so thin/the flesh assumed the contours of the bones.”³⁷ For the overindulgent in food, the wages of sin, in death, is “[famishment] down to the dreary scales.”³⁸ In hell, things are even worse, the guilty beset upon by ravenous demons “[a]s a dog/Yammering in an agony of greed,/straining to eat and nothing else, shuts up/soon as he sinks his fangs into his feed.”³⁹ As a final reward for gluttony (gula), the consumer is consumed, but then consigned to “reassume his flesh and form,” over and over again for eternity, leaving behind a “polluted mix of soul and slush.”⁴⁰ This should be warning enough to persuade even modern readers not to reach for that second piece of pie. More tellingly perhaps, consciousness of the burden obesity adds to the cost of public health should prompt a more thoughtful reckoning with gluttony as a societal sin with fiscal consequences.

In Marlowe’s Doctor Faustus, the character of the glutton is so obviously dissolute that even Faustus himself, a notoriously willing servant of Lucifer, is taken aback, as seen in their heated exchange:

GLUTTONY. Now, Faustus, thou hast heard all my progeny; wilt thou bid me to supper?

FAUSTUS. No, I’ll see thee hanged: thou wilt eat up all my victuals.

GLUTTONY. Then the devil choke thee!

FAUSTUS. Choke thyself, glutton!⁴¹

In the medical, nutritional, and public health literatures, ample evidence exists for a connection between overeating and indulging in poor food and nutrient choices, on the one hand, and serious health consequences, on the other. These include obesity and other health risks,⁴² coronary heart disease and chronic kidney disease,⁴³ hypertension and stroke,⁴⁴ and Type 2 diabetes.⁴⁵ Changing one’s dietary behavior and thus diminishing one’s risk can contribute to reversing these conditions.⁴⁶

The link here between the sin, or behavior, of gluttony and its adverse outcomes may be mediated by various factors. These include pathophysiological cascades triggered by the substances ingested, or their quantity or combination; and resultant physical changes consequent to such behavior, notably obesity, itself a significant risk factor for decreased longevity and premature mortality.⁴⁷ Recent evidence of non-volitional factors in the incidence of obesity, such as a heritable genetic predisposition⁴⁸ or differential susceptibility to environmental or chemical exposures,⁴⁹ including endocrine-disrupting chemical toxins in the food supply,⁵⁰ remind us to be gentle and nonjudgmental in describing the health consequences for people suffering with obesity. Not all overweight people are guilty of gluttony.

Sloth

This sin would appear to go hand in hand with gluttony, much as laziness and lax attention to exercise are often coincident with overeating and obesity. Accordingly, the health effects are plain. But sloth, as classically defined, is about much more. For Dante, sloth is acedia (negligence), and this applies to all of life’s endeavors, not just the physical, and especially to the exercise of spiritual and intellectual reflection. In purgatory, those guilty of this sin are described as “men who care to rest, and nothing else.”⁵¹ In the Summa, Aquinas describes sloth as one of “the vices opposed to the joy of charity” and contrary to “the Divine good.”⁵² It is “an oppressive sorrow, which, to wit, so weighs upon man’s mind, that he wants to do nothing.”⁵³ It “so oppresses man as to draw him away entirely from good deeds,”⁵⁴ and is thus a moral fault.

In its purely physical context, sedentary behavior contributes through willful inertia and lethargy to all sorts of ills: poor mental health,⁵⁵ symptoms of depression,⁵⁶ cardiovascular risk,⁵⁷ deterioration in neurocognitive function,⁵⁸ and a general failure to cope with stressful circumstances.⁵⁹ By contrast, ample evidence supports consistent exercise as a factor promoting physical and mental health and well-being. Accordingly, a federal program, “Let’s Move!,” was established by the Department of Health and Human Services in 2010 to bring faith-based and community organizations together to promote exercise and healthy living, especially in children.⁶⁰ Regular exercise when cultivated as a life-long habit is associated with longevity. Fit and active people, on average, live longer.⁶¹ Its opposite—and, here, acedia is a fitting descriptor still today—is associated with decreased life expectancy; sedentary people, again on average, live shorter lives and have higher rates of all-causes mortality.⁶²

Wrath

Wrath should be distinguished here from simple, transient expressions of anger. Sometimes anger may be justified or provoked, and, in and of itself, is not necessarily a “deadly sin.” But the word “wrath” implies something more, involving vengeance and retribution, or ongoing hostility, even hatred, and extremes of emotion such as rage. For Dante, wrath is ira (literally “ire”) and purgatory is required of the one who “seething under suffered harm,/gluts himself with vindictiveness and brings/evil upon another by his arm.”⁶³ For “those whom wrath has overcome,” who wear “faces torn with rage,”⁶⁴ redemption is impossible and the fifth circle of hell is their reward, an eternity spent as “a spirit full of slime”⁶⁵ sloshing about a “black bog”⁶⁶ and perpetually torn to pieces.

Wrath is a common theme in Western narrative. The Iliad begins with the Greek word mênin, usually rendered as wrath, anger, or rage, depending upon the translation, and Homer’s epic is nothing if not a story of wrath, of violent quarrels in the midst of war. Indeed, Robert Graves’ famous translation is retitled, The Anger of Achilles. In Melville’s Moby Dick, wrath is also essentially thematic: the story of a wrathful beast’s pursuit by an increasingly wrathful pursuer, whose ira drives him mad and seals his doom.

These literary sources reveal a great truth about such vengeful hatred: wrath may destroy the object of anger or hatred, but will destroy the source, the agent of wrath. There is no escaping. Evidence from clinical and epidemiologic research bear this out in a medical context, revealing the high cost paid for living in perpetual outrage. Studies have connected wrath or anger or hostility with hypertension,⁶⁷ risk of stroke,⁶⁸ gastrointestinal symptoms,⁶⁹ and other detrimental health outcomes including coronary heart disease.⁷⁰ Regarding heart disease, there are longstanding research literatures connecting hostility, Type A behavior, and risk of future incidence and mortality⁷¹ underscoring the detrimental effects both of expressing wrath⁷² and of holding it in.⁷³ Wrathfulness, once felt or experienced, is damaging, whether outwardly expressed or not.

Greed and Envy

These are related sins, if not true flipsides of each other. Dante speaks of avaritia (greed) and invidia (envy), the former akin to jealousy. One who is jealous seeks to hoard what he has and not share with others; the envious one hopes to obtain what belongs to others. The eternal fate of neither is pleasant. In purgatory, reports Dante, the avaricious “lament and moan their errors pitiably”;⁷⁴ the envious, “Whose eyelids were all sutured through and sewn/shut with an iron wire,”⁷⁵ wail “words of woe”⁷⁶ while their “cheeks were glistening with the tears they pressed/through the horrible seams.”⁷⁷ In hell, the avaricious face a bizarre fate: the condemned joust with one another, slamming enormous stones against each other’s chests while jeering at one another, “bellowing out their poetry of shame.”⁷⁸ In “The Parson’s Tale,” Chaucer, too, writes of avarice and covetousness: woe is the “avaricious man, that loveth his tresur beforn God”;⁷⁹ likewise, the “synful mannes soule is bitrayed of the devel by coveitise of temporeel prosperitee.”⁸⁰ There are personal and societal consequences of both greed and envy. Borrowing a phrase from Ovid, Augustine spoke of amor habendi, in which some will become neurotically obsessed with getting and preserving material wealth to the point of overwork, neglecting their personal life.⁸¹ This greed or avarice may also feed into communal sins, such as a refusal to contribute to the greater welfare through supporting public health expenditure and infrastructure, focusing instead on preserving one’s own flesh and bounty. Such behavior enables and reinforces suffering on a population-wide scale.

As for covetousness or envy, the consequences in the end are similar, although the pathway is different. Consider the sociopath Iago, in Shakespeare’s Othello, who through manipulation and deceit plots and schemes to take down the target of his envy. The envious harbors a brooding resentment because someone else has something that he does not have. This destroys any hope for happiness. There is much evidence to suggest that gratitude and well-being are closely linked.⁸² To put it in terms of folk wisdom, “Happiness is not getting what you want; it is being grateful for what you already have.”

Pride

For medieval and early modern writers, pride manifests itself in hauteur, a disdain for others. In the same passage cited above in which Faustus is entertained by a private performance of a morality play on the seven deadly sins, Pride identifies herself by saying, “I disdain to own any parents!”—that is, she denies that she owes anything to anyone but herself.⁸³

According to Dante’s Purgatorio, those guilty of pride, or superbia, must go forth carrying a burden on their back, a variation on the myth of Sisyphus, a rock weighing them down until penance is received. Self-awareness is manifest here: one victim laments “the boulder/that tames my arrogant and stiff-held neck/and forces me to keep my look the humbler,”⁸⁴ and recognizes that having “held all men in such a high disdain,/I died of it.”⁸⁵ Another prideful soul admits, “Here for such pride we pay the fee…./O empty glorifying in human power!”⁸⁶ Pride is a serious transgression, but penitence is ensured to the remorseful once their sin is purged. For those most vain denizens of purgatory (hence unsuccessfully repentant), the lowest circle of hell awaits along with those others guilty of tradimento (Italian for “treachery”), including Lucifer, embedded in a lake of ice. In Paradise Lost, Milton depicts Satan as the greatest exemplar of pride, “whom now transcendent glory raised/Above his fellows, with monarchal pride/Conscious of highest worth,” yet, significantly, “unmoved.”⁸⁷ Satan’s fate is thus sealed—eternal damnation in hell.

Here among the living, things are not as neatly resolved. The super-arrogation which presumes entitlement and elevated station can warp into malignant narcissism. The narcissist lacks both gratitude and generosity of spirit, his sense of injured merit prompting him to dominate others to bolster his fragile ego. Are there psychological liabilities to being a person with a habitus of such a vice, and can such people successfully reform themselves?

Narcissistic personality disorder, or NPD, may be thought of as self-pride in extremis. According to the DSM-5 diagnostic manual, NPD is characterized by symptoms such as grandiosity, fantasies of power, self-perception of superiority, and a sense of entitlement. Most characteristic are a constant need for praise and an inability to experience empathy.⁸⁸ Sadly, these symptoms are typically intractable, and a diagnosis of NPD is not easily amenable to therapy;⁸⁹ an outright “cure” for this personality trait is unlikely. Such unfortunate people are nearly impossible to live with, and when not receiving their required “narcissistic supply” may become dangerous to others as well as prone to fits of self-destruction.⁹⁰ This may be one reason the ancients and medieval thought it the most dangerous of habitual sins. Pride, or self-absorption, taken to the extreme renders one an unfit companion, coworker, or spouse and can leave one miserable and alone. But is there epidemiologic evidence that such people suffer an excess of morbidity or mortality due to their condition? Yes, but the evidence is nuanced.

Narcissism has been identified as a risk factor for certain health-related behaviors (alcohol and marijuana use and risky driving), but may actually be health-promoting for others (healthy eating and physical activity).⁹¹ Perhaps for the narcissist, appearances are everything and one is more inclined to want to look good than to be good. Narcissistic personality is also associated with greater risk of suicidality⁹² and a higher lethality among suicide attempters.⁹³ When a narcissist does not receive the requisite attention and admiration, his anger may be as likely to be turned inward as outward. A major national epidemiologic survey conducted in 2005 found that the lifetime prevalence of NPD in the U.S. is 6.2%,⁹⁴ a number that we should all find alarming.

Morality and Preventive Medicine

What of the flipside of the seven deadly sins, the medicinal virtues previously mentioned? Various listings of cardinal and theological virtues appeared in the first millennium, and only later were efforts made to propound lists of virtues corresponding precisely to the seven vices or sins. Nevertheless a pattern may be observed. According to Prudentius in his Psychomachia, as we have already noted, the antidotal seven virtues comprise fides (faith), pudecitia (modesty), patientia (patience), mens humilis (humility), sobrietas (temperance), operatio (charity), and concordia (harmony).⁹⁵ Later listings included humanitas (kindness), castitas (chastity), and industria (diligence), and used the terms caritas for charity, temperancia for temperance, and humilitas for humility. These virtues are holy and divinely given; the human soul ought to be married to virtue.⁹⁶ Is there evidence that just as the seven sins increase risk of disease or death, as noted above, these virtues serve a primary-preventive effect, protecting against subsequent illness and promoting positive physical or psychological well-being? In a word, yes.

This affirmation ought not be as provocative as it may first appear. The Nichomachean Ethics is a treatise on eudaimonia, usually translated as happiness or, lately, human flourishing. The text unpacks perspectives on “the question whether happiness is a thing that can be learnt, or acquired by training, or cultivated in some other manner.”⁹⁷ Aristotle concludes that it is best cultivated through “human goodness [which] means in our view excellence of soul,”⁹⁸ this in turn indicated by “moral virtues” and “moral character”⁹⁹ exemplified by self-restraint, temperance, bravery, and rationality.

Human flourishing has emerged in recent years as a construct for research on physical and mental health.¹⁰⁰ Empirical evidence for the salience of flourishing as a correlate or predictor of health and well-being is provided by research from the field of positive psychology, the study of positive human functioning and sources of strength. These have been defined as positive traits (for example, love, courage, forgiveness, spirituality, wisdom) and civic virtues (for example, responsibility, altruism, tolerance).¹⁰¹ This field was developed as a way to ensure that psychology not be “just the study of pathology, weakness, and damage; it is also the study of strength and virtue.”¹⁰² Research evidence links constructs including hope, self-control, forgiveness, gratitude, humility, wisdom, spirituality, and love to myriad salutary health outcomes: lower rates of mood disorders such as depression and anxiety and greater psychosocial benefits such as self-esteem and self-efficacy, positive affect and happiness, and greater life satisfaction,¹⁰³ and even, in the case of spirituality, to lower rates of morbidity and mortality.¹⁰⁴ Apparently, the wages of virtue is life. No wonder we are implored by the word of the Lord, spoken through His prophet Moses, to “choose life” (Deut. 30:19).

To summarize, as far as health is concerned, a simple truism suggests itself: on the whole, at the population-wide level and on average, caveats that hold true for any evidence produced by epidemiologic research, it is bad to be bad and it is good to be good. Of course, there is no guarantee that the sinful will suffer in this life, or that the virtuous will prosper here and be well. But the same could be said of any putative risk or protective factor: not all smokers get lung cancer—indeed most do not—nor do all runners live to a ripe old age—some like Jim Fixx drop dead at the age of 52. However, considering the evidence that exists across populations—the way that epidemiologic evidence is conventionally presented—morality and mortality appear to be inversely linked. The less of the former, the more of the latter, at the population-wide level.

So, are the wages of sin really death? As far as population-health research suggests, the answer is a guarded yes. With any observational research, by epidemiologists or anyone else, there are qualifications and caveats and reservations that limit us in making precise, declarative causal judgments that hold true for everyone. But, on the whole, yes, we would affirm that morality and mortality are substantially linked. Perhaps the most sage advice that one could offer in our own time, at least from a public health perspective, is to repeat the words of Jesus, from the gospel of John: “Go and sin no more” (John 8:11).

1. Sophocles, Oedipus the King, trans. F. Storr. http://classics.mit.edu/Sophocles/oedipus.html.
2. For example, Deuteronomy 28:4.
3. For example, Deuteronomy 28:15-24.
4. Isaiah 1:5-6; see also Isaiah 24:3-6 (KJV).
5. For example, Leviticus, chapters 17-18.
6. Leviticus 19:33-35.
7. Leviticus 19:9-16.
8. For example, Leviticus 17:10-16.
9. Leviticus 18:26-29 (NKJV).
10. Romans 6:23.
11. The literature here is massive, but a good starting point is the symposium on “Minimizing Agricultural Nonpoint Source Impacts,” held in 1992 by the American Society of Agronomy in its annual meeting in Minneapolis, subsequently published by the Journal of Environmental Quality 23.1 (1994).
12. The research is voluminous. See, for examples, Thomas G. Bean, Barnett A. Rattner, Rebecca S. Lazarus, Daniel D. Day, S. Rebekah Burket, Bryan W. Brooks, Samuel P. Haddad, and William W. Bowerman, “Pharmaceuticals in Water, Fish and Osprey Nestlings in Delaware River and Bay,” Environmental Pollution 232 (2018): 533- 545; and Minna Saaristo, Tomas Brodin, Sigal Balshine, Michael G. Bertram, Bryan W. Brooks, Sean M. Ehlman, Erin S. McCallum, Andrew Sih, Josefin Sundin, Bob B. M. Wong, and Kathryn E. Arnold, “Direct and Indirect Effects of Chemical Contaminants on the Behaviour, Ecology and Evolution of Wildlife,” Proceedings of the Royal Society B: Biological Sciences 285 (2018): 20181297. dx.doi.org/10.1098/rspb.2018.1297.
13. The classic study is by Werner Jaeger, Paideia: the Ideals of Greek Culture, 3 vols., trans. Gilbert Highet (Oxford: Basil Blackwell, 1939), esp. 1. 1-12. In his later Early Christianity and Greek Paideia (Cambridge, MA: The Belknap Press of Harvard University, 1961), he shows how these ideals merged with Jewish notions of vice and virtue in early Christianity.
14. Aristotle, The Nichomachean Ethics, trans. Harris Rackham (Hertfordshire, U.K.: Wordsworth, 1996).
15. For example, Lukas van den Berge, “Sophocles Antigone and the Promise of Ethical Life: Tragic Ambiguity and the Pathologies of Reason,” Law and Humanities 11 (2017): 205-227.
16. A stimulating reflection on the implications is afforded by Martha Nussbaum, The Fragility of Goodness: Luck and Ethics in Greek Tragedy and Philosophy (Cambridge, U.K.: Cambridge University Press, 1986).
17. For example, Leviticus 18-20. The scrupulosity of Mishnaic deliberations indicates further the concern for community health or shalom, as a brief review in the translation by Herbert Danby will confirm: The Mishnah (Oxford, U.K.: Oxford University Press, 1933/1991).
18. Mary Flowers Braswell, The Medieval Sinner: Characterization and Confession in the Literature of the Middle Ages (Teaneck, NJ: Fairleigh Dickinson Press, 1983).
19. John Cassian, The Institutes, trans. Boniface Ramsey (New York: The Newman Press of the Paulist Press, 2000).
20. Dante, Purgatorio, trans. Anthony Esolen (NY: Modern Library, 2003), Canto XXVI, lines 82-84.
21. Ibid., Canto XXVI, lines 31-32, 35.
22. Ibid., Canto XXV, lines 134-135.
23. Ibid., Canto XXV, lines 118-120.
24. Dante, Inferno, trans. Anthony Esolen (NY: The Modern Library, 2002), Canto V, lines 31-36.
25. Zhi-Chang Liu, Wei-Dong Liu, Yan-Hui Liu, Xiao-Hua Ye, and Si-Dong Chen, “Multiple Sexual Partners as a Potential Independent Risk Factor for Cervical Cancer: a Meta-analysis of Epidemiological Studies,” Asian Pacific Journal of Cancer Prevention 16 (2015): 3893-3900.
26. Annmarie Cano and K. Daniel O’Leary, “Infidelity and Separations Precipitate Major Depressive Episodes and Symptoms of Nonspecific Depression and Anxiety,” Journal of Consulting and Clinical Psychology 68 (2000): 774-781.
27. B. Joyce Stephens, “Suicidal Women and Their Relationships with Husbands, Boyfriends, and Lovers,” Suicide and Life-Threatening Behavior 15 (1985): 77-90.
28. Musie S. Ghebrimichael and Matthew D. Finkelman, “The Effect of Premarital Sex on Sexually Transmitted Infections (STIs) and High Risk Behaviors in Women,” Journal of AIDS and HIV Research 5.2 (2013): 59-64.
29. J. W. Curran, H. W. Jaffe, A. M. Hardy, W. M. Morgan, R. M. Selik, and T. J. Dondero, “Epidemiology of HIV Infection and AIDS in the United States,” Science 239 (1988): 610-616.
30. Benjamin Scafidi, The Taxpayer Costs of Divorce and Unwed Childbearing: First-Ever Estimates for the Nation and All Fifty States (New York: Institute for American Values, 2008).
31. Stephen G. Bronars and Jeff Grogger, “The Economic Consequences of Unwed Motherhood: Using Twin Births as a Natural Experiment,” American Economic Review 84 (1994): 1141-1156.
32. Payal H. Patel and Bisakha Sen, “Teen Motherhood and Long-Term Health Consequences,” Maternal and Child Health Journal 16 (2012): 1063-1071.
33. Seo-Young Cho, Ariel Dreher, Eric Neumayer, “Does Legalized Prostitution Increase Human Trafficking?” World Development 41 (2013): 67-82; and Ronald Weitzer, “New Directions in Research on Human Trafficking,” Annals of the American Academy of Political and Social Science 653 (2014): 6-24.
34. Jean M. Twenge, Ryne A. Sherman, and Brooke E. Wells, “Declines in Sexual Frequency among American Adults, 1989–2014,” Archives of Sexual Behavior 46 (2017): 2389-2401.
35. Jason S. Carroll and Walter Schumm, “The Fall of Fertility: How Same-Sex Marriage Will Further Declining Birthrates in the United States,” Ave Maria Law Review 14 (2016): 123-139.
36. Interestingly, this has become thematic in contemporary literature, best illustrated in P. D. James’ novel, Children of Men (London: Faber and Faber, 1992).
37. Dante, Purgatorio, Canto XXIII, lines 22-24.
38. Ibid., Canto XXIII, line 39.
39. Dante, Inferno, Canto VI, lines 27-30.
40. Ibid., Canto VI, lines 98, 100-101.
41. Christopher Marlowe, The Tragical History of the Life and Death of Doctor Faustus [1604], Scene VI, in Marlowe’s Doctor Faustus 1604-1616, ed. W. W. Greg (Oxford: Clarendon Press, 1968), 206. This is the A-Text translation.
42. Andrew M. Prentice, “Overeating: The Health Risks,” Obesity Research 9, Suppl. 4 (2001): 234S-238S.
43. Freij Gobal, Abhishek Deshmukh, Sudhir Shah, and Jawahar L. Mehta, “Triad of Metabolic Syndrome, Chronic Kidney Disease, and Coronary Heart Disease With a Focus on Microalbuminuria: Death by Overeating,” Journal of the American College of Cardiology 57 (2011): 2303-2308.
44. Susanna C. Larsson, Alice Wallin, and Alicja Wolk, “Dietary Approaches to Stop Hypertension Diet and Incidence of Stroke: Results From 2 Prospective Cohorts,” Stroke 47 (2016): 986-990.
45. Simin Liu, “Intake of Refined Carbohydrates and Whole Grain Foods in Relation to Risk of Type 2 Diabetes Mellitus and Coronary Heart Disease,” Journal of the American College of Nutrition 21 (2002): 298-306.
46. Gundu H. R. Rao, “Prevention or Reversal of Cardiometabolic Diseases,” Journal of Clinical and Preventive Cardiology 7 (2018): 22-28.
47. Ryan K. Masters, Eric N. Reither, Daniel A. Powers, Y. Claire Yang, Andrew E. Burger, and Bruce G. Link, “The Impact of Obesity on US Mortality Levels: The Importance of Age and Cohort Factors in Population Estimates,” American Journal of Public Health 103 (2013): 1895-1901.
48. C. Stryjecki, A. Alyass, and D. Meyre, “Ethnic and Population Differences in the Genetic Predisposition to Human Obesity,” Genetics 19 (2018): 62-80.
49. Sarah S. Park, David A. Skaar, Randy L. Jirtle, and Cathrine Hoyo, “Epigenetics, Obesity and Early-Life Cadmium or Lead Exposure,” Epigenomics 9 (2017): 57-75.
50. Amber L. Simmons, Jennifer J. Schlezinger, and Barbara E. Corkey, “What Are We Putting in Our Food That Is Making Us Fat?: Food Additives, Contaminants, and Other Putative Contributors to Obesity,” Current Obesity Reports 3 (2014): 273-285.
51. Dante, Purgatorio, Canto IV, line 105.
52. Thomas Aquinas, Summa Theologica, Part 2-2, Question 35.
53. Ibid.
54. Ibid.
55. Stuart Biddle, “Physical Activity and Mental Health: Evidence is Growing,” World Psychiatry 15 (2016): 176-177.
56. Long Zhai, Yi Zhang, and Dongfeng Zhang, “Sedentary Behaviour and the Risk of Depression: A Meta-Analysis,” British Journal of Sports Medicine 49 (2015): 705-709.
57. J. Nauman, D. Stensvold, J. S. Coombes, and U. Wisløff, “Cardiorespiratory Fitness, Sedentary Time, and Cardiovascular Risk Factor Clustering,” Medicine and Science in Sports and Exercise 48 (2016): 625-632.
58. Stan J. Colcombe, Arthur F. Kramer, Edward McAuley, Kirk I. Erickson, and Paige Scalf, “Neurocognitive Aging and Cardiovascular Fitness,” Journal of Molecular Neuroscience 24 (2004): 9-14.
59. Markus Gerber and Uwe Pühse, “Do Exercise and Fitness Protect Against Stress-Induced Health Complaints?: A Review of the Literature,” Scandinavian Journal of Public Health 37 (2009): 801-819.
60. David L. Katz, “Let’s Move!: Progress, Promise, and the Miles Left to Go,” Childhood Obesity 8 (2012): 2-3.
61. Andreas Holtermann, Jacob Louis Marott, Finn Gyntelberg, Karen Søgaard, Ole Steen Mortensen, Eva Prescott, and Peter Schnohr, “Self-Reported Cardiorespiratory Fitness: Prediction and Classification of Risk of Cardiovascular Disease Mortality and Longevity—A Prospective Investigation in the Copenhagen City Heart Study,” Journal of the American Heart Association 4.1 (2015). doi.org/10.1161/JAHA.114.001495.
62. Peter Katzmarzyk, Timothy Church, Cora Craig, and Claude Bouchard, “Sitting Time and Mortality from All Causes, Cardiovascular Disease, and Cancer,” Medicine and Science in Sports and Exercise 41 (2009): 998-1005.
63. Dante, Purgatorio, Canto XVII, lines 121-123.
64. Dante, Inferno, Canto VII, lines 116, 111.
65. Ibid., Canto VIII, line 32.
66. Ibid., Canto VII, line 124.
67. M. S. Kaplan and A. Nunes, “The Psychosocial Determinants of Hypertension,” Nutrition, Metabolism, and Cardiovascular Diseases 13 (2003): 52-59.
68. Janice E. Williams, F. Javier Nieto, Catherine P. Sanford, David J. Cooper, and Herman A. Tyroler, “The Association Between Trait Anger and Incident Stroke Risk: The Atherosclerosis Risk in Communities (ARIC) Study,” Stroke 33 (2002): 13-20.
69. Daria Piacentino, Rosanna Cantarini, Marianna Alfonsi, Danilo Badiali, Nadia Pallotta, Massimo Biondi, and Enrico S. Corazziari, “Psychopathological Features of Irritable Bowel Syndrome Patients with and without Functional Dyspepsia: A Cross Sectional Study,” BMC Gastroenterology 11 (2011): 94. doi.org/10.1186/1471-230X-11-94.
70. Todd Q. Miller, Timothy W. Smith, Charles W. Turner, Margarita L Guijarro, and Amanda J. Hallet, “Meta-Analytic Review of Research on Hostility and Physical Health,” Psychological Bulletin 119 (1996): 322-348.
71. Yoichi Chida and Andrew Steptoe, “The Association of Anger and Hostility With Future Coronary Heart Disease: A Meta-Analytic Review of Prospective Evidence,” Journal of the American College of Cardiology 53 (2009): 936-946.
72. Elizabeth Mostofsky, Elizabeth Anne Penner, and Murray A. Mittleman, “Outbursts of Anger as a Trigger of Acute Cardiovascular Events: A Systematic Review and Meta-Analysis,” European Heart Journal 35 (2014): 1404-1410.
73. Hara Estroff Marano, “The Downside of Anger,” Psychology Today 36 (2003). https://www.psychologytoday.com/us/articles/200307/the-downside-anger.
74. Dante, Purgatorio, Canto XX, line 18.
75. Ibid., Canto XIII, lines 70-71.
76. Ibid., line 65.
77. Ibid., lines 83-84.
78. Dante, Inferno, Canto VII, line 33.
79. Geoffrey Chaucer, “The Parson’s Tale,” in The Poetical Works of Chaucer, ed. F. N. Robinson (Boston: Houghton Mifflin, 1933), line 750, p. 300.
80. Ibid., line 276, p. 280.
81. The phrase “amor sceleratus habendi” appears in his City of God, Book III, as one of the ills leading to Rome’s decay. For a contemporary scientific analysis of possible consequences, see Andrew T. Jebb. Louis Tay, Ed Diener, and Shigehiro Oishi, “Happiness, Income Satiation, and Turning Points Around the World,” Nature Human Behaviour 2 (2018): 33-38.
82. For example, Philip C. Watkins, Kathrane Woodward, Tamara Stone, and Russell L. Kolts, “Gratitude and Happiness: Development of a Measure of Gratitude, and Relationships with Subjective Well-Being,” Social Behavior and Personality 31 (2003): 431-451.
83. Marlowe, op. cit., A-text 741, 206.
84. Dante, Purgatorio, Canto XI, lines 52-54.
85. Ibid., lines 64-65.
86. Ibid., lines 88, 91.
87. John Milton, Paradise Lost [1667], ed. John Leonard (New York: Penguin Classics, 2000), Book II, lines 427-429.
88. Donald W. Black and Jon E. Grant, DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Washington, DC: American Psychiatric Publishing, 2014), 400.
89. Eva Caligor, Kenneth N. Levy, and Frank E. Yeomans, “Narcissistic Personality Disorder: Diagnostic and Clinical Challenges,” American Journal of Psychiatry 172 (2015): 415-422.
90. Sam Vaknin, “Narcissistic Disorders of the Self as Addictions,” Journal of Addiction Research 2, 2 (2018): 1-5.
91. Erin M. Hill, “The Role of Narcissism in Health-Risk and Health-Protective Behaviors,” Journal of Health Psychology 21 (2016): 2021-2032.
92. Marnin J. Heisel, Paul S. Links, David Conn, Robert van Reekum, and Gordon L. Flett, “Narcissistic Personality and Vulnerability to Late-Life Suicidality,” American Journal of Geriatric Psychiatry 15 (2007): 734-741.
93. Hilario Blasco-Fontecilla, Enrique Baca-Garcia, Kanita Dervic, M. Mercedes Perez-Rodriguez, Jorge Lopez-Castroman, Jeronimo Saiz-Ruiz, and Maria A. Oquendo, “Specific Features of Suicidal Behavior in Patients With Narcissistic Personality Disorder,” Journal of Clinical Psychiatry 70 (2009): 1583-1587.
94. Frederick S. Stinson, Deborah A. Dawson, Rise B. Goldstein, S. Patricia Chou, Boji Huang, Sharon M. Smith, W. June Ruan, Attila J. Pulay, Tulshi D. Saha, Roger P. Pickering, and Bridget F. Grant, “Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Narcissistic Personality Disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions,” Journal of Clinical Psychiatry 69 (2008): 1033-1045.
95. Gernot R. Wieland, “The Anglo-Saxon Manuscripts of Prudentius’ Psychomachia,” in Anglo-Saxon England 16, eds. Peter Clemoes, Simon Keynes, and Michael Lapidge (Cambridge, U.K.: Cambridge University Press, 1987), 213-231.
96. Prudentius, “The Fight for Mansoul,” in Prudentius, Volume 1, trans. H. J. Thomson (Cambridge, MA: Harvard University Press, 1949), line 12, p. 275.
97. Aristotle, The Nichomachean Ethics, Book One, ix, 2.
98. Ibid., Book One, xiii, 6.
99. Ibid., Book One, xiii, 20.
100. Tyler J. VanderWeele, “On the Promotion of Human Flourishing,” Proceedings of the National Academy of Sciences 114 (2017): 8148-8156.
101. Martin E. P. Seligman and Mihaly Csikszentmihalyi, “Positive Psychology: An Introduction,” American Psychologist 55 (2000): 5-14.
102. Ibid., 7.
103. C. R. Snyder and Michael E. McCullough, eds., “Classical Sources of Human Strength: A Psychological Analysis,” Special issue of Journal of Social and Clinical Psychology 19.1 (2000).
104. Jeff Levin, “The Epidemiology of Religion,” in Religion and the Social Sciences: Basic and Applied Research Perspectives, ed. Jeff Levin (West Conshohocken, PA: Templeton Press, 2018), 259-286.