Literature Evaluation TableStudent Name Summary of Clinic.docx

Literature Evaluation Table
Student Name:
Summary of Clinical Issue (200-250 words):
The number of HIV- positive adults has become an increasing
the issue due to the increasing the number of patients.
According to the UNICEF,1.8 million adolescents are living
with HIV worldwide, and more 1.5 million number of cases
lives in Africa. More Analysis of this number revealed HIV-
positive adolescents girls accounted for two-thirds of new
adolescents’ infection. Young adults between the age of 15-19
made up 16% of new adult infections worldwide.in Africa,
adolescents’ girls are the most prone adolescents to be infected
with the virus.as compared to boys, adolescent girls were twice
as likely to get HIV.
Th main mode of infection among adolescents is
unprotected sex.in Africa,85% of all new infection were as a
result of having unprotected sex.Adolescents don’t use
contraception they don’t have enough knowledge about the sex
how to do healthy sex and protect their self from the infection
due how people going to judge them and specially in Africa
because people still follow the other culture you should not
have sex in certain age because they follow the strict the
culture preference. The financial and technological status of the
countries specially in the poor and Asian courtiers is
responsible for the HIV in the adolescents. The lack of the
proper technology in the health care institution is responsible
for the making gap between the planning, treatment, and
distribution of antiviral drugs difficult.in Africa there is lack of
the budget due to the poor management purchase and
distribution of the antiretroviral drugs leaving HIV positive
adolescents to the drugs themselves. Also, the poor living
standards of low income of adults lead them to resort using sex

for the daily earning. The poor financial conditions of most
regions in Africa need to be addressed to cater to medical gaps
and to enhance the provision of antiretroviral drug among
infected youth. This paper analysis six articles to find out the
HIV perception, social support and protection, and medical gaps
which exists in adolescents over the last decade.
PICOT Question: How do adolescents diagnosed with HIV
perceive social support, promotion, and medical gaps during the
decade?
Criteria
Article 1
Article 2
Article 3
APA-Formatted Article Citation with Permalink
Okawa, S., Mwanza-Kabaghe, S., Mwiya, M., Kikuchi, K.,
Jimba, M., Kankasa, C., & Ishikawa, N. (2017). Adolescents’
experiences and their suggestions for HIV serostatus Disclosure
in Zambia: a Mixed-Methods study. Frontiers in public health,
5, 326 Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736526/
Bloch, S., (2018). HIV in Ukraine: An Everlasting Epidemic?
Assessment of knowledge, behaviour change, tolerance towards
people living with HIV, and accessibility of healthcare services
for HIV among adolescent girls and young women in Ukraine.
Retrieved from
https://academic.oup.com/her/article/14/4/473/693716
Li, R. J., Jaspan, H. B., O'Brien, V., Rabie, H., Cotton, M. F.,
&Nattrass, N. (2010). Positive futures: a qualitative study on
the needs of adolescents on antiretroviral therapy in South
Africa. AIDS Care, 22(6), 751-758.Retrieved from
https://www.tandfonline.com/doi/abs/10.1080/09540120903431
363
How Does the Article Relate to the PICOT Question?

Quantitative, Qualitative (How do you know?)
Purpose Statement
Research Question
Outcome
Setting
(Where did the study take place?)
Sample
Method
Key Findings of the Study

Recommendations of the Researcher
Criteria
Article 4
Article 5
Article 6
APA-Formatted Article Citation with Permalink
Wong, V. J., Murray, K. R., Phelps, B. R., Vermund, S. H.,
&McCarraher, D. R. (2017). Adolescents, young people, and the
90–90–90 goals: a call to improve HIV testing and linkage to
treatment. AIDS (London, England), 31 (Suppl 3), S191.
Retrieved from www.aidsmap.com/Study-identifies-serious-
gaps-in-treatment-and-care-of-HIV-positive-adolescents-in-sub-
Saharan-Africa/page/3151096/
Toth, G., Mburu, G., Tuot, S., Khol, V., Ngin, C., Chhoun, P.,
& Yi, S. (2018). Social-support needs among adolescents living
with HIV in the transition from pediatric to adult care in
Cambodia: findings from a cross-sectional study.AIDS research
and therapy, 15(1), 8 Retrieved from
https://aidsrestherapy.biomedcentral.com/articles/10.1186/s1298
1-018-0195-x
Armstrong, A., Nagata, J. M., Vicari, M., Irvine, C., Cluver, L.,
Sohn, A. H., ... & Ross, D. (2018). A global research agenda for
adolescents living with HIV. Journal of acquired immune
deficiency syndromes (1999), 78(1), S16. Retrieved from
https://journals.lww.com/jaids/FullText/2018/08151/A_Global_
Research_Agenda_for_Adolescents_Living.4.aspx
How Does the Article Relate to the PICOT Question?
Quantitative, Qualitative (How do you know?)

Purpose Statement
Research Question
Outcome
Setting
(Where did the study take place?)
Sample
Method
Key Findings of the Study
Recommendations of the Researcher

© 2019. Grand Canyon University. All Rights Reserved.
2
1
Before Ethics
Eric R. Severson
Chapter 1: How to Save a Life
Morality is dangerous.
Such a declaration is ironic, of course. Human beings turn
precisely to the realm of morality, to
the discipline of ethics, when we wish to address the danger or
injustice we see in the world. The
discipline of ethical reasoning sometimes arises from abstract
philosophical contemplation, and
sometimes from urgent and practical questions. However we
move into the discipline, the telos (purpose)
of ethics is clear: to know how to take the right action in

complicated situations. People rarely feel a
compulsion to read an ethics book, or take a college course, to
explore the morality of clubbing baby
seals. The study of ethics seeks to stabilize the world by
outlining virtuous ways of living, modes of
behavior, or perhaps moral laws, that might guide us out of
trouble. We turn to ethics to get out of danger.
But this discipline has its own strange peril, hiding well
between the musty pages of thick textbooks on
“ethical reasoning.”
This book is not a guide to ethics, or ethical theory. Though I
will spend a great deal of time in
conversation with various theories from around planet Earth and
across human history, ethical theory has
been well documented. Instead, this book is about the danger
that moves quietly in the margins of any
prescriptive discussion of human moral behavior. At the same
time, by identifying and wrestling with this
threat, I seek a more hopeful and helpful way to approach
ethics. To discuss the great risks of doing ethics
2
is not to advocate abandoning the academic study or practical

performance of ethics. Quite the opposite,
our task is to do this work well.
The television show The Good Place has a running line that
appears in several episodes: “This is
why everyone hates moral philosophers.” My wife, married to a
moral philosopher, finds this line
particularly amusing. There are, perhaps, many reasons why
moral philosophers are maligned the world
over. However, in The Good Place this line is mostly leveled
against a character whose key weakness is
the inability to decide between reasonable arguments. Moral
theories often disagree about what choice a
person should make in a given situation. Utilitarians and
Kantians, for instance, make earnest and
reasonable arguments about both everyday and extreme
situations. Should I lie to protect the feelings of a
friend? This is a moral decision, and Kantians and utilitarians
completely disagree about how the question
should be contemplated. Should drone pilots incinerate a home
containing known terrorist operatives,
even though there are children in the house? Depends on which
theorist you ask. Clearly we have a
fundamental problem in the discipline of ethics, and this issue
has become increasingly exposed in recent

years. For every decision with moral weight, ethicists deliver a
swarm of suggested choices. If some of
the most brilliant, earnest and well-meaning philosophers of all
time cannot agree on moral decision-
making, how are everyday people to behave ethically?
The danger is most palpable when people turn to ethics to
justify choices they have already
decided to make. I was once asked to provide an “Ethics
Consultation” for a university, as they finalized
plans for a major construction project that had significant
impacts on local ecology. The university
provost invited me to meet with the committee charged with
planning, publicizing, funding, and justifying
the project. At first, I was pleased that the university wanted to
think ethically about their plans for
development. After I had spent an hour with the committee,
however, I realized that the decision to move
forward had been made before they decided to think about
ethics. My work was to help the university
convince a skeptical community that this path forward was
morally defensible, and to do so with fancy-
sounding arguments and appeals to ethical theory along the way.
This approach, which is perhaps more

common than we realize, turns ethics into a sham. In fact, this
approach weaponizes ethics, turning ethical
reasoning into an arbitrary game in which the goal is to justify
behavior determined before ethics is even
consulted. Ethical reasoning becomes a “choose your tool”
project, in which the tools of reasoning are
bent to meet priorities that precede and often supersede the
deliberations. The pressure to be successful,
profitable, or efficient is powerful, which makes it easier to ask
for forgiveness than permission when it
comes to ethical justification. This backdoor use of ethics is
unethical, even when it presents itself to the
world with all the fancy words and arguments of ethical theory.
From its varied origins all around the world, philosophy has
sought to stop people from doing
horrible things. Sometimes people do horrible things when they
know better, or are sinister enough in
3
their self-interest to intentionally inflict harm for their own
profit. It is worth hoping that such people are
a small minority, and worth noting that they are unlikely to pick
up a book such as this. This book is for

people who want to be thoughtful about the commitments that
are often frontloaded into ethical
reasoning, about the anthropological, sociological, theological,
and philosophical conditions for ethics.
People often turn to the study of ethics having been already
stung by suffering they’ve experienced
personally, or witnessed others experience, or seen devastate
animals or the environment. These are
inspiring reasons to engage in ethical reasoning, but also
influence future deliberations in ways that
frequently go undetected. We will never become fully aware of
all of the forces that influence our
attempts to think ethically. Still, it seems safe to wager that this
investigation is worthwhile. Another way
to put it is this: what would happen if ethics had the first word?
What if we were honest about what we
bring into questions of ethical significance? In this book I am
referring to that which we bring with us
into conversations about ethics leanings.
In pursuit of thinking about what comes before ethics, two
questions will recur throughout this
book: 1) what ideas are already underway when we turn to ask
the questions of ethics? And, 2) what ideas
should be underway before we consult the texts written by

ethical theorists? I raise these questions not
because I have answers to them, but because it seems imperative
that they be investigated. These
questions do not have an obvious end to them, and they require
an ongoing commitment to the
philosophical search for visible and invisible presuppositions.
Whatever the answers, and however
difficult it may be to seek them, we are better for asking these
questions.
There are two distinct ways of moving into the study of ethics.
We can begin with the
contemplation of philosophical ideas and attempt to connect
them to practical situations, or we can seek
direction within the complex quagmire of human experience.
Immanuel Kant provides a sterling example
of the first mode, seeking a rational foundation for the
“metaphysics of morals” that is not asked to be
practical until it has first been derived from “reason alone.”1
The second option is articulated by some
Feminist philosophers who seek ways of thinking about morality
that begin, and remain, embedded in the
complexity of social relations. Margaret Urban Walker “pictures
morality as a socially embodied medium
of understanding and adjustment in which people account to

each other for the identities, relationships,
values that define their responsibilities.”2 Whether or not our
leanings - cultural, gendered, personal,
1 Kant, Groundwork for the Metaphysics of Morals (New
Haven, CT: Yale University Press, 2002), 27. “[A] fully
isolated metaphysics of morals, mixed with no anthropology,
with no theology, with no physics or hyperphysics,
still less with occult qualities (which one might call
‘hypophysical’), is not only an indispensable substrate of all
theoretical cognition of duties which is securely determined, but
it is at the same time also a desideratum of the
highest importance for the actual fulfillment of its precepts.”
2 Margaret Urban Walker, Moral Understandings: A Feminist
Study in Ethics, 2nd Edition (Oxford: Oxford
University Press, 2007), 67-68.
4
religious, etc. – are toxins to be identified and removed from
ethical reasoning, or key components of
thinking ethically, they matter. Both modes are beset by
difficulties, and it may be the case that they can
be used together rather than in opposition. However one might
approach the philosophical discipline of

ethics, much is to be gained by looking closely at the world
from which we think about ethical ideas and
moral situations.
At the outset of this journey, to think about what comes before
ethics is a fundamental question
about the function of philosophy itself, and this drives us back
to philosophical foundations in the ancient
world. We launch this journey from ancient Greece, a fairly
common starting point for philosophical
adventures, though this book heads toward global and historical
destinations not typically visited in the
study of ethics. We begin with Socrates, partly because he
indicated with such clarity the profound need
to think ethically and self-critically. Most of what we know
about Socrates, who lived in Athens about
469-399 BCE, we receive from his student Plato.3 In each case,
I will be investigating ideas and
commitments that already hang in the air when ethical questions
are raised. This first chapter will work
with the Platonic dialogue the Meno.
Socrates and Meno: How to Save a Life
A brash, handsome, and rich gentleman of ancient Greece makes
his way to Athens, the center of

Greek cultural and political life. His name is Meno, and he
comes from both money and power. He is rich
enough to be followed by an entourage and though in his early
twenties, he is already well on his way to
the fame and fortune that he deeply desires. He has also devoted
some time and energy to the study of
philosophy, and believes himself to be wise. Plato, who tells the
story of Meno’s visit to Athens, doesn’t
explain why he came to town but we get some clues from the
dialogue between Meno and Plato’s famous
teacher, Socrates. Meno stays at the home of a rich friend in
Athens, a man named Anytus, who will later
become a mortal enemy of Socrates and one of the three
accusers who eventually bring Socrates to trial.
In all likelihood, the dialogue recorded between Socrates and
Meno never took place; Plato rarely wrote
for the purpose of recording historical events. The purpose of
this dialogue, instead, is to teach. Socrates, I
think, tries to use philosophy to save Meno’s life. Plato delivers
this tale in the hope of saving yours, and
mine.
When Meno approaches Socrates he does so with bravado and
confidence. A young man on a

mission, he looks to prove himself politically and
philosophically. In those days, it was not uncommon for
people to come to Athens specifically to speak with Socrates.
Meno, however, is there on other business.
3 For the purposes of this chapter, “Socrates” refers to the
character in Plato’s dialogue the Meno, as well as other
works written by Plato. Socrates appears in other works,
especially those of Xenophon, so it is important to clarify
“which” Socrates appears in these deliberations.
5
He is raising funds, or perhaps gathering mercenary troops, for
an impending and lucrative battle in
Persia. While he is in town, though, Meno chooses to spend an
afternoon with the leading local
philosopher, Socrates. He comes to Socrates with a very
specific question, a pertinent question for young
people planning their life adventures. Meno wants to understand
virtue. What marks a person as
genuinely good? Already we encounter a complex problem in
translation, as the word virtue is asked to
span centuries and translations and a metamorphosis of

meanings. The word virtue rarely occurs in
everyday society today; I doubt it is used in many dating
profiles. As I type the modern English word
“virtue” I write in a language that would have been utterly
unrecognizable to everyone on Earth during
the years Socrates walked the planet. We must proceed with an
awareness of this distance; sometimes it
may matter little, but at other times the evolution of meaning
might lead to significant misunderstanding.
The word used for virtue in ancient Greece, and in this
conversation recorded by Plato, is arête
(ἀρετή). Whatever its connotations today, the word meant
something along the lines of “excellence of
any kind” or “fulfilling potential”4 when it was used in Plato
(and Aristotle’s) dialogues. Aristotle, whose
treatment of this word will occupy us in Chapter 9, develops his
entire ethical system on the basis of this
fruitful concept. In the older appearances of arête, such as the
work of Homer, the term is typically added
to another concept. Though it is a noun, virtue is usually
applied to excellence in some particular
application. The character Penelope, wife of the hero Odysseus
in the Homer’s Odyssey, is considered an
exemplar of “feminine virtue.”5 Agamemnon declares to

Odysseus:
Fortunate son of Laertes, Odysseus of many wiles!
You have surely got for yourself a wife of outstanding virtue,
Such is the good sense that is in the blameless Penelope,
daughter of Icarius!
How well she has kept the memory of Odysseus, her wedded
husband!
And so the fame of her virtue will never die,
And ever-living gods will make a beautiful song for men on
earth
in honor of the faithful Penelope.6
Penelope’s virtue is the excellence appropriate to her station;
she is left behind in Ithaca to fend off suitors
and stabilize the homeland while Odysseus fights and
adventures abroad. Her virtue is blamelessness,
steadiness, consistency, and – as Homer understood it –
feminine. And yet Homer does not hesitate to use
the same word to apply to the most excellent of javelin
throwers, and is especially fond of using it to
4 Henry George Liddell and Robert Scott, A Greek-English
Lexicon (London: Oxford University Press, 1968), 238.
5 For an interesting exploration of this theme in Homer, see:
Wendy E. Helleman, “Homer’s Penelope: A Tale of
Feminine Arête,” Echos du monde classique: Classical views

(University of Toronto Press, Volume XXXIX, no. 14,
1995), 227-250.
6 Homer, Odyssey, Anthony Verity, trans. (Oxford: Oxford
University Press, 2018), Book 24, lines 192-198, p. 317.
6
describe the bravery of warriors.7 In these cases the word
means something very different, but commonly
refers to the excellent and full expression of some particular
trait.
Meno does not enter this conversation as a blank slate. He
knows his Homer, in all likelihood,
and has even studied and taught virtue in his hometown. He
boasts, at the outset of their discourse, about
lectures he has given on virtue, to the delight of audiences
numbering in the thousands. They hung on his
every word, back home, and this should surely count for
something. He brings his wisdom to Socrates
and seems to hope that Socrates will confirm that he has indeed
been teaching the masses well. Meno
comes to philosophy, to the philosopher, already pretty sure that
he knows what needs to be known in
order for a person to live well. He has not, however, considered
with care the puzzle that Socrates is

about to put to him. What does virtue look like all by itself?
Penelope and Odysseus are exemplifications
of a particular type of virtue; but this just means they are being
celebrated as the pinnacle of something
their culture already idealized. Homeric virtue simply means
being excellent at something; we ought to
pause before assuming that this goodness or morality spans the
centuries between Penelope and females
today.
For his part, Meno comes to Socrates with his understanding of
virtue thoroughly and robustly
developed. Like the university that called me in for an “Ethical
Consultation,” Meno came to Socrates to
further consolidate his desire with some configuration of virtue.
Ethics is being done after the big
decisions have been made. For Meno, it seems, virtue is the
stamp of approval on the top of already
venerated, but often unquestioned, modes of living. In the
manner of a modern social media influencer,
Meno is carried into this conversation by the force of mass
approval. His momentum is significant; he is
physically attractive, rich and growing in power. For the ancient
Greeks, virtue in one arena, such as good
looks or wealth, gave the impression that a person would be

virtuous in other arenas as well. We may
very well share this assumption today: in the modern world,
people are often shocked to discover that
talented and beautiful actors or athletes lack virtue in other
areas of their lives. The wind at Meno’s back
is a powerful, cultural celebration of particular ways of being
human. No wonder Anytus declares that
virtue could be learned from any Athenian gentleman. For
Anytus, arête is merely the amplification of
Athenian values. Meno is merely telling Socrates what nearly
everyone thinks about virtue; he is
surprised that Socrates even needs to ask such questions.
Still, the disheveled, irreverent Socrates had never been
impressed by the opinions of crowds, so
he proceeds to put Meno through his paces. At first, Meno
declares that living virtuously, at least for a
man, means helping one’s friends, harming one’s enemies, and
properly administering society. Women,
children, and servants have different forms of virtue, according
to their roles in society. A woman, for

7 Finkelberg, Margalit. "Timē and Aretē in Homer." The
Classical Quarterly 48, no. 1 (1998): 14-28.
7
instance, when she becomes skilled at organizing the pantry and
obeying her husband; she must manage
“the household well, conserving what is inside, and being
obedient to her man.”8 A child shows virtue by
respect and learning. A servant shows virtue by obedience and
subservience. To be virtuous is to correctly
perform one’s role in society. Meno is preparing for war,
gathering resources and militia for the purpose
of wealth and glory. By framing virtue in support of this
mission, he is quite literally weaponizing ethics.
There is a palpable resonance between his initial position on
virtue and the dynamics of an effective
military. Soldiers are virtuous when they play their roles well.
At each level of the military, soldiers both
administer and obey according to their rank and position. Of
course, nothing about the mechanics of
functioning well in a household or military really establishes
what is virtuous, what it means to live well.
These are pragmatic performances in the interest of Meno’s
prior commitment to victory in war. Meno’s

position is that virtue is equivalent to leadership and obedience,
but to what end? Socrates is unimpressed.
So, Socrates presses him for a way of thinking about virtue
beneath these diverse (and troubling)
behavioral expectations. Meno stumbles for a while; the
questions that Socrates asks are at the same time
irritating and disarming. Meno then attempts another definition
for virtue, one that he hopes will
sufficiently describe how virtue functions for all people. He
claims that virtue is “desiring fine things and
being able to acquire them.”9 This may turn out to be a slightly
more honest version of his first definition.
Socrates is not impressed by the desire for “fine things” - does
anyone, after all, desire horrible things? Or
isn’t it true that even when one desires something harmful (say,
cigarettes) one does so thinking that it
will bring about some good (say, satisfying one’s craving)? This
leaves virtue defined as simply “being
able to acquire fine things.” When Socrates points out the rather
obvious weaknesses of this definition,
Meno feels stunned. The confident, brash, and dashing young
man is, perhaps for the first time in his life,
at a loss for words. He accuses Socrates of being like a Torpedo
Fish, an electric ray that defeats attackers

with electric shock. He has been rendered torpid, stunned by the
questions of Socrates. The name of this
fish is nárke,10 the root of the contemporary term “narcotic.” In
Modern Greek usage, the word nárke
(νάρκες) means landmine, a weapon designed to stop war
vehicles in their tracks. The words of Socrates
stun Meno because they quickly strip away the thin façade of
morality that Meno has glazed over his self-
interested warmongering. Meno uses the Torpedo Fish metaphor
to complain that Socrates has rendered
him motionless, numb, and immobile.
Plato has Meno respond with these lines:
8 Plato, Plato’s Meno, George Anastaplo and Laurence Berns,
trans. (Newburyport, MA: Focus Publishing, 2004), 3.
9 Hamilton, Edith, and Huntington Cairns, eds. The Collected
Dialogues of Plato (Princeton, NJ: Princeton
University Press, 1990), 360, line 77b.
10 Geoffrey Steadman, Plato’s Meno: Greek Text with Facing
Vocabulary and Commentary (Geoffrey Steadman,
2017), 79e.

8
Socrates, I certainly used to hear, even before meeting you, that
you never do anything else than
exist in a state of perplexity yourself and put others in a state of
perplexity. And now you seem to
me to be bewitching me and drugging me and simply subduing
me with incantations, so that I
come to be full of perplexity. And you seem to me, if it is even
appropriate to make something of
a joke, to be altogether, both in looks and in other respects, like
the flat torpedo-fish of the sea.
For, indeed, it always makes anyone who approaches and
touches it grow numb, and you seem to
me now to have done that very sort of thing to me, making me
numb. For truly, both in soul and
in mouth, I am numb and have nothing with which I can answer
you. And yet thousands of times
I have made a great many speeches about virtue, and before
many people, and done very well, in
my own opinion anyway; yet now I’m altogether unable to say
what it is.11
Part of Meno’s frustration is the recent memory of throngs of
people celebrating his lectures on virtue.
With that much positive social reinforcement, that many “likes”
on his public profile, how could he be
wrong?12
Meno is a busy man, and he makes it clear that he only has time
for quick answers before getting
busy with his business and military commitments. Throughout

the dialogue, it becomes clear that learning
to think will take time and patience, and Meno has neither.
Thinking takes time, certainly more than one
brief conversation. But Meno had apparently informed Socrates
before this conversation that his visit to
Athens was on a tight timeline, and he would need to leave
soon. Too busy for philosophy, he turns his
attention toward the pressing business of his life.
There are innumerable texts that professors can use to introduce
philosophy to students. I often
start with the Meno precisely for this reason. Meno was too
busy for philosophy, too distracted by the
more pressing duties of life to waste his time figuring out how
to think and therefore live carefully,
clearly, virtuously. “If only you could stay and be initiated,”
bemoans Socrates, to which Meno replies: “I
would stay, Socrates, if you could tell me many such things.”13
Initiated! Meno began this conversation
with pompous assurance that he was already an expert in
philosophy; now it is clear that he has never
even started. Socrates was given one short afternoon to prove to
Meno that philosophy is worthwhile. The
adventure of philosophy, which Meno declines, might have
disappointed him anyway, for it leads not to

certainties but to a humble and open-minded approach to
questions of virtue. And this means the clever
line from The Good Place is not just an indictment on bad moral
philosophers but also good ones.
Thinking ethically must help us make decisions, even if it does
so without collapsing the need for
ongoing questions and uncertainty.
Meno, however, demands answers from Socrates, and firm ones
at that. He wishes for Socrates
to tell him something, indeed “many such things.” Meno has
little interest in being guided into thinking.
11 Plato, Plato’s Meno, Anastaplo and Berns, trans., 15.
12 I am thankful to my colleague Jonah Ford for suggesting the
connection between Meno’s social popularity and
contemporary social media.
13 Plato, Meno, G.M.A. Grube, trans. (Indianapolis: Hackett,
1976), 9.
9
Put in this position, Socrates moves quickly to his method,
asking pressing and probing questions that

deconstruct Meno’s simplistic view of the world. The stunned
and confused Meno does not stay to be
initiated. He shrugs off the nárke’s sting, and goes back to his
business.
Two years later? Meno is dead.
This dialogue is a marvelous work, a philosophical “gem” in the
words of John Stuart Mill.14
Meno contains fascinating explorations of a range of themes
that are expanded in later works of Plato,
including the famous Doctrine of Recollection and the crucial
question regarding whether virtue can be
taught. And though the overall subject of the dialogue concerns
virtue, this relatively short text wanders
across diverse topics and themes. In his recent commentary on
the book, Dominic Scott points out that
Plato “could rarely broach one topic without stumbling upon a
multitude of others. But this feature of the
dialogue also raises acute challenges for the interpreter. For one
thing, what is the work about?”15 Without
excluding other answers to this question, I think this dialogue
was at least partly issued as a warning. Dire
consequences await those who fail to pause for reflection before

charging into action. The education that
Meno turns down would not have led him to the certainty he
sought anyway, but the wager of philosophy
is that he would nevertheless have been better for the adventure.
That is, in fact, the wager of this book.
After it becomes clear that Meno is only auditing a philosophy
course and not willing to take it
seriously, the dialogue ends without much ceremony or
satisfaction. But the name “Meno,” to the first
audience of Plato’s dialogue, would have been synonymous with
what happened next. Plato makes very
intentional use of characters, in this dialogue, whose names and
stories would have been known to his
first readers. With the exception of a nameless servant boy, with
whom Socrates has a conversation about
geometrical knowledge, every character in this dialogue is
known to history. According to Plato scholar
Jane Day, these characters “are not merely vivid stage
characters,” for though we “cannot compare the
portraits with the originals as Plato’s contemporaries could…all
the evidence suggests that they were
strikingly telling as likenesses, as well as in their own right.”16
The name Meno would have, for early
readers of this dialogue, called to mind the events that

immediately follow the dialogue. And for Meno,
these events are disastrous and humiliating.
14 Mill also claims that in the Meno “more that is characteristic
of Plato is brought together in a smaller space than in
any other dialogue.” John Stuart Mill, Dissertations and
Discussions, Vol. III, (New York: Cosimo Classics, 2013),
350.
15 Dominic Scott, Plato’s Meno, (Cambridge: Cambridge
University Press, 2006), 3.
16 Jane M. Day, ed., Plato’s Meno in Focus (Routledge: New
York, 1994), 14.
10
Meno’s trip to Athens had been motivated by money; he was
there to raise money for his family
and their interests up north in Thessaly, which were under some
threat. The young Meno, perhaps twenty
years old when he speaks with Socrates, had been sent – along
with his entourage – to cash in favors,
raise funds to pay mercenaries, and fund a military campaign.
Meno, headstrong and ambitious, moves
from Athens into a series of military engagements. Xenophon, a

soldier and philosopher who was also a
student of Socrates, recorded a detailed history of Meno’s
behavior. His moves, in the military, were
ambitious but self-interested; he became a mercenary leader of
paid Greek troops. Meno and his hired
army were employed by a man named Cyrus, who hoped to
overthrow his brother, Artaxerxes, King of
Persia. …
A reading for Eric Severson’s Ethics course 1
The Leviathan
Thomas Hobbes1
1651
CHAPTER XIII OF THE NATURAL CONDITION OF
MANKIND AS
CONCERNING THEIR FELICITY AND MISERY
NATURE hath made men so equal in the faculties of body and
mind as that, though there be
found one man sometimes manifestly stronger in body or of
quicker mind than another, yet
when all is reckoned together the difference between man and
man is not so considerable as
that one man can thereupon claim to himself any benefit to
which another may not pretend as
well as he. For as to the strength of body, the weakest has

strength enough to kill the strongest,
either by secret machination or by confederacy with others that
are in the same danger with
himself.
And as to the faculties of the mind, setting aside the arts
grounded upon words, and especially
that skill of proceeding upon general and infallible rules, called
science, which very few have
and but in few things, as being not a native faculty born with
us, nor attained, as prudence,
while we look after somewhat else, I find yet a greater equality
amongst men than that of
strength. For prudence is but experience, which equal time
equally bestows on all men in
those things they equally apply themselves unto. That which
may perhaps make such equality
incredible is but a vain conceit of one's own wisdom, which
almost all men think they have in
a greater degree than the vulgar; that is, than all men but
themselves, and a few others, whom
by fame, or for concurring with themselves, they approve. For
such is the nature of men that
howsoever they may acknowledge many others to be more witty,
or more eloquent or more
learned, yet they will hardly believe there be many so wise as
themselves; for they see their
own wit at hand, and other men's at a distance. But this proveth
rather that men are in that
point equal, than unequal. For there is not ordinarily a greater
sign of the equal distribution of
anything than that every man is contented with his share.
From this equality of ability ariseth equality of hope in the
attaining of our ends. And
therefore if any two men desire the same thing, which

nevertheless they cannot both enjoy,
they become enemies; and in the way to their end (which is
principally their own
conservation, and sometimes their delectation only) endeavour
to destroy or subdue one
another. And from hence it comes to pass that where an invader
hath no more to fear than
another man's single power, if one plant, sow, build, or possess
a convenient seat, others may
probably be expected to come prepared with forces united to
dispossess and deprive him, not
only of the fruit of his labour, but also of his life or liberty.
And the invader again is in the like
danger of another.
And from this diffidence of one another, there is no way for any
man to secure himself so
reasonable as anticipation; that is, by force, or wiles, to master
the persons of all men he can
1 Text in the public domain.
so long till he see no other power great enough to endanger him:
and this is no more than his
own conservation requireth, and is generally allowed. Also,
because there be some that, taking
pleasure in contemplating their own power in the acts of
conquest, which they pursue farther
than their security requires, if others, that otherwise would be
glad to be at ease within modest
bounds, should not by invasion increase their power, they would
not be able, long time, by

standing only on their defence, to subsist. And by consequence,
such augmentation of
dominion over men being necessary to a man's conservation, it
ought to be allowed him.
Again, men have no pleasure (but on the contrary a great deal of
grief) in keeping company
where there is no power able to overawe them all. For every
man looketh that his companion
should value him at the same rate he sets upon himself, and
upon all signs of contempt or
undervaluing naturally endeavours, as far as he dares (which
amongst them that have no
common power to keep them in quiet is far enough to make
them destroy each other), to extort
a greater value from his contemners, by damage; and from
others, by the example.
So that in the nature of man, we find three principal causes of
quarrel. First, competition;
secondly, diffidence; thirdly, glory.
The first maketh men invade for gain; the second, for safety;
and the third, for reputation. The
first use violence, to make themselves masters of other men's
persons, wives, children, and
cattle; the second, to defend them; the third, for trifles, as a
word, a smile, a different opinion,
and any other sign of undervalue, either direct in their persons
or by reflection in their kindred,
their friends, their nation, their profession, or their name.
Hereby it is manifest that during the time men live without a
common power to keep them all
in awe, they are in that condition which is called war; and such
a war as is of every man

against every man. For war consisteth not in battle only, or the
act of fighting, but in a tract of
time, wherein the will to contend by battle is sufficiently
known: and therefore the notion of
time is to be considered in the nature of war, as it is in the
nature of weather. For as the nature
of foul weather lieth not in a shower or two of rain, but in an
inclination thereto of many days
together: so the nature of war consisteth not in actual fighting,
but in the known disposition
thereto during all the time there is no assurance to the contrary.
All other time is peace.
Whatsoever therefore is consequent to a time of war, where
every man is enemy to every man,
the same consequent to the time wherein men live without other
security than what their own
strength and their own invention shall furnish them withal. In
such condition there is no place
for industry, because the fruit thereof is uncertain: and
consequently no culture of the earth; no
navigation, nor use of the commodities that may be imported by
sea; no commodious
building; no instruments of moving and removing such things as
require much force; no
knowledge of the face of the earth; no account of time; no arts;
no letters; no society; and
which is worst of all, continual fear, and danger of violent
death; and the life of man, solitary,
poor, nasty, brutish, and short.
It may seem strange to some man that has not well weighed
these things that Nature should
thus dissociate and render men apt to invade and destroy one
another: and he may therefore,

not trusting to this inference, made from the passions, desire
perhaps to have the same
confirmed by experience. Let him therefore consider with
himself: when taking a journey, he
arms himself and seeks to go well accompanied; when going to
sleep, he locks his doors;
when even in his house he locks his chests; and this when he
knows there be laws and public
officers, armed, to revenge all injuries shall be done him; what
opinion he has of his fellow
subjects, when he rides armed; of his fellow citizens, when he
locks his doors; and of his
children, and servants, when he locks his chests. Does he not
there as much accuse mankind
by his actions as I do by my words? But neither of us accuse
man's nature in it. The desires,
and other passions of man, are in themselves no sin. No more
are the actions that proceed
from those passions till they know a law that forbids them;
which till laws be made they
cannot know, nor can any law be made till they have agreed
upon the person that shall make
it.
It may peradventure be thought there was never such a time nor
condition of war as this; and I
believe it was never generally so, over all the world: but there
are many places where they live
so now. For the savage people in many places of America,
except the government of small
families, the concord whereof dependeth on natural lust, have
no government at all, and live at

this day in that brutish manner, as I said before. Howsoever, it
may be perceived what manner
of life there would be, where there were no common power to
fear, by the manner of life
which men that have formerly lived under a peaceful
government use to degenerate into a civil
war.
But though there had never been any time wherein particular
men were in a condition of war
one against another, yet in all times kings and persons of
sovereign authority, because of their
independency, are in continual jealousies, and in the state and
posture of gladiators, having
their weapons pointing, and their eyes fixed on one another; that
is, their forts, garrisons, and
guns upon the frontiers of their kingdoms, and continual spies
upon their neighbours, which is
a posture of war. But because they uphold thereby the industry
of their subjects, there does not
follow from it that misery which accompanies the liberty of
particular men.
To this war of every man against every man, this also is
consequent; that nothing can be
unjust. The notions of right and wrong, justice and injustice,
have there no place. Where there
is no common power, there is no law; where no law, no
injustice. Force and fraud are in war
the two cardinal virtues. Justice and injustice are none of the
faculties neither of the body nor
mind. If they were, they might be in a man that were alone in
the world, as well as his senses
and passions. They are qualities that relate to men in society,
not in solitude. It is consequent
also to the same condition that there be no propriety, no

dominion, no mine and thine distinct;
but only that to be every man's that he can get, and for so long
as he can keep it. And thus
much for the ill condition which man by mere nature is actually
placed in; though with a
possibility to come out of it, consisting partly in the passions,
partly in his reason.
The passions that incline men to peace are: fear of death; desire
of such things as are
necessary to commodious living; and a hope by their industry to
obtain them. And reason
suggesteth convenient articles of peace upon which men may be
drawn to agreement. These
articles are they which otherwise are called the laws of nature,
whereof I shall speak more
particularly in the two following chapters.
CHAPTER XIV
OF THE FIRST AND SECOND NATURAL LAWS, AND OF
CONTRACTS
THE right of nature, which writers commonly call jus naturale,
is the liberty each man hath to
use his own power as he will himself for the preservation of his
own nature; that is to say, of
his own life; and consequently, of doing anything which, in his
own judgement and reason, he
shall conceive to be the aptest means thereunto.
By liberty is understood, according to the proper signification

of the word, the absence of
external impediments; which impediments may oft take away
part of a man's power to do
what he would, but cannot hinder him from using the power left
him according as his
judgement and reason shall dictate to him.
A law of nature, lex naturalis, is a precept, or general rule,
found out by reason, by which a
man is forbidden to do that which is destructive of his life, or
taketh away the means of
preserving the same, and to omit that by which he thinketh it
may be best preserved. For
though they that speak of this subject use to confound jus and
lex, right and law, yet they
ought to be distinguished, because right consisteth in liberty to
do, or to forbear; whereas law
determineth and bindeth to one of them: so that law and right
differ as much as obligation and
liberty, which in one and the same matter are inconsistent.
And because the condition of man (as hath been declared in the
precedent chapter) is a
condition of war of every one against every one, in which case
every one is governed by his
own reason, and there is nothing he can make use of that may
not be a help unto him in
preserving his life against his enemies; it followeth that in such
a condition every man has a
right to every thing, even to one another's body. And therefore,
as long as this natural right of
every man to every thing endureth, there can be no security to
any man, how strong or wise
soever he be, of living out the time which nature ordinarily
alloweth men to live. And
consequently it is a precept, or general rule of reason: that

every man ought to endeavour
peace, as far as he has hope of obtaining it; and when he cannot
obtain it, that he may seek and
use all helps and advantages of war. The first branch of which
rule containeth the first and
fundamental law of nature, which is: to seek peace and follow
it. The second, the sum of the
right of nature, which is: by all means we can to defend
ourselves.
From this fundamental law of nature, by which men are
commanded to endeavour peace, is
derived this second law: that a man be willing, when others are
so too, as far forth as for peace
and defence of himself he shall think it necessary, to lay down
this right to all things; and be
contented with so much liberty against other men as he would
allow other men against
himself. For as long as every man holdeth this right, of doing
anything he liketh; so long are
all men in the condition of war. But if other men will not lay
down their right, as well as he,
then there is no reason for anyone to divest himself of his: for
that were to expose himself to
prey, which no man is bound to, rather than to dispose himself
to peace. This is that law of the
gospel: Whatsoever you require that others should do to you,
that do ye to them. And that law
of all men, quod tibi fieri non vis, alteri ne feceris.
To lay down a man's right to anything is to divest himself of the

liberty of hindering another
of the benefit of his own right to the same. For he that
renounceth or passeth away his right
giveth not to any other man a right which he had not before,
because there is nothing to which
every man had not right by nature, but only standeth out of his
way that he may enjoy his own
original right without hindrance from him, not without
hindrance from another. So that the
effect which redoundeth to one man by another man's defect of
right is but so much
diminution of impediments to the use of his own right original.
Right is laid aside, either by simply renouncing it, or by
transferring it to another. By simply
renouncing, when he cares not to whom the benefit thereof
redoundeth. By transferring, when
he intendeth the benefit thereof to some certain person or
persons. And when a man hath in
either manner abandoned or granted away his right, then is he
said to be obliged, or bound, not
to hinder those to whom such right is granted, or abandoned,
from the benefit of it: and that he
ought, and it is duty, not to make void that voluntary act of his
own: and that such hindrance is
injustice, and injury, as being sine jure; the right being before
renounced or transferred. So
that injury or injustice, in the controversies of the world, is
somewhat like to that which in the
disputations of scholars is called absurdity. For as it is there
called an absurdity to contradict
what one maintained in the beginning; so in the world it is
called injustice, and injury
voluntarily to undo that which from the beginning he had
voluntarily done. The way by which
a man either simply renounceth or transferreth his right is a

declaration, or signification, by
some voluntary and sufficient sign, or signs, that he doth so
renounce or transfer, or hath so
renounced or transferred the same, to him that accepteth it. And
these signs are either words
only, or actions only; or, as it happeneth most often, both words
and actions. And the same are
the bonds, by which men are bound and obliged: bonds that
have their strength, not from their
own nature (for nothing is more easily broken than a man's
word), but from fear of some evil
consequence upon the rupture.
Whensoever a man transferreth his right, or renounceth it, it is
either in consideration of some
right reciprocally transferred to himself, or for some other good
he hopeth for thereby. For it is
a voluntary act: and of the voluntary acts of every man, the
object is some good to himself.
And therefore there be some rights which no man can be
understood by any words, or other
signs, to have abandoned or transferred. As first a man cannot
lay down the right of resisting
them that assault him by force to take away his life, because he
cannot be understood to aim
thereby at any good to himself. The same may be said of
wounds, and chains, and
imprisonment, both because there is no benefit consequent to
such patience, as there is to the
patience of suffering another to be wounded or imprisoned, as
also because a man cannot tell
when he seeth men proceed against him by violence whether
they intend his death or not. And
lastly the motive and end for which this renouncing and
transferring of right is introduced is
nothing else but the security of a man's person, in his life, and

in the means of so preserving
life as not to be weary of it. And therefore if a man by words, or
other signs, seem to despoil
himself of the end for which those signs were intended, he is
not to be understood as if he
meant it, or that it was his will, but that he was ignorant of how
such words and actions were
to be interpreted.
The mutual transferring of right is that which men call contract.
There is difference between transferring of right to the thing,
the thing, and transferring or
tradition, that is, delivery of the thing itself. For the thing may
be delivered together with the
translation of the right, as in buying and selling with ready
money, or exchange of goods or
lands, and it may be delivered some time after.
Again, one of the contractors may deliver the thing contracted
for on his part, and leave the
other to perform his part at some determinate time after, and in
the meantime be trusted; and
then the contract on his part is called pact, or covenant: or both
parts may contract now to
perform hereafter, in which cases he that is to perform in time
to come, being trusted, his
performance is called keeping of promise, or faith, and the
failing of performance, if it be
voluntary, violation of faith.

When the transferring of right is not mutual, but one of the
parties transferreth in hope to gain
thereby friendship or service from another, or from his friends;
or in hope to gain the
reputation of charity, or magnanimity; or to deliver his mind
from the pain of compassion; or
in hope of reward in heaven; this is not contract, but gift, free
gift, grace: which words signify
one and the same thing.
Signs of contract are either express or by inference. Express are
words spoken with
understanding of what they signify: and such words are either of
the time present or past; as, I
give, I grant, I have given, I have granted, I will that this be
yours: or of the future; as, I will
give, I will grant, which words of the future are called promise.
Signs by inference are sometimes the consequence of words;
sometimes the consequence of
silence; sometimes the consequence of actions; sometimes the
consequence of forbearing an
action: and generally a sign by inference, of any contract, is
whatsoever sufficiently argues the
will of the contractor.
Words alone, if they be of the time to come, and contain a bare
promise, are an insufficient
sign of a free gift and therefore not obligatory. For if they be of
the time to come, as,
tomorrow I will give, they are a sign I have not given yet, and
consequently that my right is
not transferred, but remaineth till I transfer it by some other act.
But if the words be of the
time present, or past, as, I have given, or do give to be
delivered tomorrow, then is my

tomorrow's right given away today; and that by the virtue of the
words, though there were no
other argument of my will. And there is a great difference in the
signification of these words,
volo hoc tuum esse cras, and cras dabo; that is, between I will
that this be thine tomorrow,
and, I will give it thee tomorrow: for the word I will, in the
former manner of speech, signifies
an act of the will present; but in the latter, it signifies a promise
of an act of the will to come:
and therefore the former words, being of the present, transfer a
future right; the latter, that be
of the future, transfer nothing. But if there be other signs of the
will to transfer a right besides
words; then, though the gift be free, yet may the right be
understood to pass by words of the
future: as if a man propound a prize to him that comes first to
the end of a race, the gift is free;
and though the words be of the future, yet the right passeth: for
if he would not have his words
so be understood, he should not have let them run.
In contracts the right passeth, not only where the words are of
the time present or past, but also
where they are of the future, because all contract is mutual
translation, or change of right; and
therefore he that promiseth only, because he hath already
received the benefit for which he
promiseth, is to be understood as if he intended the right should
pass: for unless he had been
content to have his words so understood, the other would not

have performed his part first.
And for that cause, in buying, and selling, and other acts of
contract, a promise is equivalent to
a covenant, and therefore obligatory.
He that performeth first in the case of a contract is said to merit
that which he is to receive by
the performance of the other, and he hath it as due. Also when a
prize is propounded to many,
which is to be given to him only that winneth, or money is
thrown amongst many to be
enjoyed by them that catch it; though this be a free gift, yet so
to win, or so to catch, is to
merit, and to have it as due. For the right is transferred in the
propounding of the prize, and in
throwing down the money, though it be not determined to
whom, but by the event of the
contention. But there is between these two sorts of merit this
difference, that in contract I
merit by virtue of my own power and the contractor's need, but
in this case of free gift I am
enabled to merit only by the benignity of the giver: in contract I
merit at the contractor's hand
that he should depart with his right; in this case of gift, I merit
not that the giver should part
with his right, but that when he has parted with it, it should be
mine rather than another's. And
this I think to be the meaning of that distinction of the Schools
between meritum congrui and
meritum condigni. For God Almighty, having promised paradise
to those men, hoodwinked
with carnal desires, that can walk through this world according
to the precepts and limits
prescribed by him, they say he that shall so walk shall merit
paradise ex congruo. But because
no man can demand a right to it by his own righteousness, or

any other power in himself, but
by the free grace of God only, they say no man can merit
paradise ex condigno. This, I say, I
think is the meaning of that distinction; but because disputers
do not agree upon the
signification of their own terms of art longer than it serves their
turn, I will not affirm anything
of their meaning: only this I say; when a gift is given
indefinitely, as a prize to be contended
for, he that winneth meriteth, and may claim the prize as due.
If a covenant be made wherein neither of the parties perform
presently, but trust one another,
in the condition of mere nature (which is a condition of war of
every man against every man)
upon any reasonable suspicion, it is void: but if there be a
common power set over them both,
with right and force sufficient to compel performance, it is not
void. For he that performeth
first has no assurance the other will perform after, because the
bonds of words are too weak to
bridle men's ambition, avarice, anger, and other passions,
without the fear of some coercive
power; which in the condition of mere nature, where all men are
equal, and judges of the
justness of their own fears, cannot possibly be supposed. And
therefore he which performeth
first does but betray himself to his enemy, contrary to the right
he can never abandon of
defending his life and means of living.
But in a civil estate, where there a power set up to constrain

those that would otherwise violate
their faith, that fear is no more reasonable; and for that cause,
he which by the covenant is to
perform first is obliged so to do.
The cause of fear, which maketh such a covenant invalid, must
be always something arising
after the covenant made, as some new fact or other sign of the
will not to perform, else it
cannot make the covenant void. For that which could not hinder
a man from promising ought
not to be admitted as a hindrance of performing.
He that transferreth any right transferreth the means of enjoying
it, as far as lieth in his power.
As he that selleth land is understood to transfer the herbage and
whatsoever grows upon it; nor
can he that sells a mill turn away the stream that drives it. And
they that give to a man the
right of government in sovereignty are understood to give him
the right of levying money to
maintain soldiers, and of appointing magistrates for the
administration of justice.
To make covenants with brute beasts is impossible, because not
understanding our speech,
they understand not, nor accept of any translation of right, nor
can translate any right to
another: and without mutual acceptation, there is no covenant.
To make covenant with God is impossible but by mediation of
such as God speaketh to, either
by revelation supernatural or by His lieutenants that govern
under Him and in His name: for
otherwise we know not whether our covenants be accepted or
not. And therefore they that vow

anything contrary to any law of nature, vow in vain, as being a
thing unjust to pay such vow.
And if it be a thing commanded by the law of nature, it is not
the vow, but the law that binds
them.
The matter or subject of a covenant is always something that
falleth under deliberation, for to
covenant is an act of the will; that is to say, an act, and the last
act, of deliberation; and is
therefore always understood to be something to come, and
which judged possible for him that
covenanteth to perform.
And therefore, to promise that which is known to be impossible
is no covenant. But if that
prove impossible afterwards, which before was thought
possible, the covenant is valid and
bindeth, though not to the thing itself, yet to the value; or, if
that also be impossible, to the
unfeigned endeavour of performing as much as is possible, for
to more no man can be obliged.
Men are freed of their covenants two ways; by performing, or
by being forgiven. For
performance is the natural end of obligation, and forgiveness
the restitution of liberty, as being
a retransferring of that right in which the obligation consisted.
Covenants entered into by fear, in the condition of mere nature,
are obligatory. For example, if
I covenant to pay a ransom, or service for my life, to an enemy,
I am bound by it. For it is a
contract, wherein one receiveth the benefit of life; the other is
to receive money, or service for
it, and consequently, where no other law (as in the condition of

mere nature) forbiddeth the
performance, the covenant is valid. Therefore prisoners of war,
if trusted with the payment of
their ransom, are obliged to pay it: and if a weaker prince make
a disadvantageous peace with
a stronger, for fear, he is bound to keep it; unless (as hath been
said before) there ariseth some
new and just cause of fear to renew the war. And even in
Commonwealths, if I be forced to
redeem myself from a thief by promising him money, I am
bound to pay it, till the civil law
discharge me. For whatsoever I may lawfully do without
obligation, the same I may lawfully
covenant to do through fear: and what I lawfully covenant, I
cannot lawfully break.
A former covenant makes void a later. For a man that hath
passed away his right to one man
today hath it not to pass tomorrow to another: and therefore the
later promise passeth no right,
but is null.
A covenant not to defend myself from force, by force, is always
void. For (as I have shown
before) no man can transfer or lay down his right to save
himself from death, wounds, and
imprisonment, the avoiding whereof is the only end of laying
down any right; and therefore
the promise of not resisting force, in no covenant transferreth
any right, nor is obliging. For
though a man may covenant thus, unless I do so, or so, kill me;

he cannot covenant thus,
unless I do so, or so, I will not resist you when you come to kill
me. For man by nature
chooseth the lesser evil, which is danger of death in resisting,
rather than the greater, which is
certain and present death in not resisting. And this is granted to
be true by all men, in that they
lead criminals to execution, and prison, with armed men,
notwithstanding that such criminals
have consented to the law by which they are condemned.
A covenant to accuse oneself, without assurance of pardon, is
likewise invalid. For in the
condition of nature where every man is judge, there is no place
for accusation: and in the civil
state the accusation is followed with punishment, which, …
Animal Liberation
Peter Singer
A few excerpts:
“Animal Liberation” may sound more like a parody of other
liberation movements than a
serious objective. The idea of “The Rights of Animals” actually
was once used to parody the
case for women’s rights. When Mary Wollstonecraft published
her Vindication of the Rights

of Women in 1792, her views were widely regarded as absurd,
and before long, an anonymous
publication appeared entitled A Vindication of the Rights of
Brutes. The author of this satirical
work (now known to have been Thomas Taylor, a distinguished
Cambridge philosopher) tried
to refute Mary Wollstonecraft’s arguments by showing that they
could be carried one stage
further. If the argument for equality was sound when applied to
women, why should it not be
applied to dogs, cats, and horses? …
When we say that all human beings, whatever their race, creed,
or sex, are equal, what is it
that we are asserting? Like it or not, we must face the fact that
humans come in different
shapes and sizes; they come with different moral capacities,
different intellectual abilities,
different amounts of benevolent feeling and sensitivity to the
needs of others, different
abilities to communicate effectively, and different capacities to
experience pleasure and pain.

In short, if the demand for equality were based on the actual
equality of all human beings, we
would have to stop demanding equality. …
The existence of individual variations that cut across the lines
of race or sex, however,
provides us with no defense at all against a more sophisticated
opponent of equality, one who
proposes that, say, the interests of all those with IQ scores
below 100 be given less
consideration than the interests of those with ratings over 100.
Perhaps those scoring below
the mark would, in this society, be made the slaves of those
scoring higher. Would a
hierarchical society of this sort really be so much better than
one based on race or sex? I think
not. But if we tie the moral principle of equality to the factual
equality of the different races or
sexes, taken as a whole, our opposition to racism and sexism
does not provide us with any
basis for objecting to this kind of inegalitarianism. …
Fortunately, there is no need to pin the case for equality to one
particular outcome of a
scientific investigation. … There is no logically compelling

reason for assuming that a factual
difference in ability between two people justifies any difference
in the amount of
consideration we give to their needs and interests. The principle
of the equality of human
beings is not a description of an alleged actual equality among
humans: It is a prescription of
how we should treat human beings.
Jeremy Bentham, the founder of the reforming utilitarian school
of moral philosophy,
incorporated the essential basis of moral equality into his
system of ethics by means of the
formula: “Each to count for one and none for more than one.” In
other words, the interests of
every being affected by an action are to be taken into account
and given the same weight as
the like interests of any other being. …
It is an implication of this principle of equality that our concern
for others and our readiness to
consider their interests ought not to depend on what they are
like or on what abilities they may

possess. Precisely what our concern or consideration requires us
to do may vary according to
the characteristics of those affected by what we do: concern for
the well-being of children
growing up in America would require that we teach them to
read; concern for the well-being
of pigs may require no more than that we leave them with other
pigs in a place where there is
adequate food and room to run freely. But the basic element—
the taking into account of the
interests of the being, whatever those interests may be—must,
according to the principle of
equality, be extended to all beings, black or white, masculine or
feminine, human or
nonhuman.
Thomas Jefferson, who was responsible for writing the principle
of the equality of men into
the American Declaration of Independence, saw this point. It
led him to oppose slavery even
though he was unable to free himself fully from his
slaveholding background. He wrote in a
letter to the author of a book that emphasized the notable
intellectual achievements of Negroes

in order to refute the then common view that they have limited
intellectual capacities: “Be
assured that no person living wishes more sincerely than I do, to
see a complete refutation of
the doubts I myself have entertained and expressed on the grade
of understanding allotted to
them by nature, and to find that they are on a par with ourselves
… but whatever be their
degree of talent it is no measure of their rights. Because Sir
Isaac Newton was superior to
others in understanding, he was not therefore lord of the
property or person of others.”
Similarly, when in the 1850s the call for women’s rights was
raised in the United States, a
remarkable black feminist named Sojourner Truth made the
same point in more robust terms
at a feminist convention: “They talk about this thing in the
head; what do they call it?
[“Intellect,” whispered someone nearby.] That’s it. What’s that
got to do with women’s rights
or Negroes’ rights? If my cup won’t hold but a pint and yours
holds a quart, wouldn’t you be

mean not to let me have my little half-measure full?”
It is on this basis that the case against racism and the case
against sexism must both ultimately
rest; and it is in accordance with this principle that the attitude
that we may call “speciesism,”
by analogy with racism, must also be condemned. Speciesism—
the word is not an attractive
one, but I can think of no better term—is a prejudice or attitude
of bias in favor of the interests
of members of one’s own species and against those of members
of other species. It should be
obvious that the fundamental objections to racism and sexism
made by Thomas Jefferson and
Sojourner Truth apply equally to speciesism. If possessing a
higher degree of intelligence does
not entitle one human to use another for his or her own ends,
how can it entitle humans to
exploit nonhumans for the same purpose?
Many philosophers and other writers have proposed the
principle of equal consideration of
interests, in some form or other, as a basic moral principle; but
not many of them have
recognized that this principle applies to members of other

species as well as to our own.
Jeremy Bentham was one of the few who did realize this. In a
forward-looking passage written
at a time when black slaves had been freed by the French but in
the British dominions were
still being treated in the way we now treat animals, Bentham
wrote:
“The day may come when the rest of the animal creation may
acquire those rights which never
could have been withholden from them but by the hand of
tyranny. The French have already
discovered that the blackness of the skin is no reason why a
human being should be
abandoned without redress to the caprice of a tormentor. It may
one day come to be
recognized that the number of the legs, the villosity of the skin,
or the termination of the os
sacrum are reasons equally insufficient for abandoning a
sensitive being to the same fate.
What else is it that should trace the insuperable line? Is it the
faculty of reason, or perhaps the
faculty of discourse? But a full-grown horse or dog is beyond
comparison a more rational, as
well as a more conversable animal, than an infant of a day, or a

week or even a month, old.
But suppose they were otherwise, what would it avail? The
question is not, Can they reason?
nor Can they talk? but, Can they suffer?”
In this passage, Bentham points to the capacity for suffering as
the vital characteristic that
gives a being the right to equal consideration. … If a being
suffers, there can be no moral
justification for refusing to take that suffering into
consideration. No matter what the nature of
the being, the principle of equality requires that [his or her]
suffering be counted equally with
the like suffering—insofar as rough comparisons can be made—
of any other being. …
Racists violate the principle of equality by giving greater
weight to the interests of members of
their own race when there is a clash between their interests and
the interests of those of
another race. Sexists violate the principle of equality by
favoring the interests of their own
sex. Similarly, speciesists allow the interests of their own

species to override the greater
interests of members of other species. The pattern is identical in
each case.
Most human beings are speciesists. … [O]rdinary human
beings—not a few exceptionally
cruel or heartless humans, but the overwhelming majority of
humans—take an active part in,
acquiesce in, and allow their taxes to pay for practices that
require the sacrifice of the most
important interests of members of other species in order to
promote the most trivial interests
of our own species.…
Even if we were to prevent the infliction of suffering on animals
only when it is quite certain
that the interests of humans will not be affected to anything like
the extent that animals are
affected, we would be forced to make radical changes in our
treatment of animals that would
involve our diet, the farming methods we use, experimental
procedures in many fields of
science, our approach to wildlife and to hunting, trapping and
the wearing of furs, and areas of
entertainment like circuses, rodeos, and zoos. As a result, a vast
amount of suffering would be

avoided.
Ethics and the Legalization of Physician-Assisted Suicide: An
American
College of Physicians Position Paper
Lois Snyder Sulmasy, JD, and Paul S. Mueller, MD, MPH, for
the Ethics, Professionalism and Human Rights Committee of the
American College of Physicians*
Calls to legalize physician-assisted suicide have increased and
public interest in the subject has grown in recent years despite
ethical prohibitions. Many people have concerns about how they
will die and the emphasis by medicine and society on interven-
tion and cure has sometimes come at the expense of good end-
of-life care. Some have advocated strongly, on the basis of au-
tonomy, that physician-assisted suicide should be a legal option
at the end of life. As a proponent of patient-centered care, the
American College of Physicians (ACP) is attentive to all voices,
including those who speak of the desire to control when and
how life will end. However, the ACP believes that the ethical
arguments against legalizing physician-assisted suicide remain
the most compelling. On the basis of substantive ethics, clinical
practice, policy, and other concerns articulated in this position
paper, the ACP does not support legalization of physician-
assisted suicide. It is problematic given the nature of the
patient–
physician relationship, affects trust in the relationship and in
the
profession, and fundamentally alters the medical profession's

role in society. Furthermore, the principles at stake in this
debate
also underlie medicine's responsibilities regarding other issues
and the physician's duties to provide care based on clinical
judg-
ment, evidence, and ethics. Society's focus at the end of life
should be on efforts to address suffering and the needs of pa-
tients and families, including improving access to effective hos-
pice and palliative care. The ACP remains committed to
improving
care for patients throughout and at the end of life.
Ann Intern Med. 2017;167:576-578. doi:10.7326/M17-0938
Annals.org
For author affiliations, see end of text.
This article was published at Annals.org on 19 September 2017.
How we die, live, and are cared for at the end of lifeis
important, with implications for individuals, their
families, and society. The 1997 report Approaching
Death: Improving Care at the End of Life, by the Insti-
tute of Medicine (IOM), documented inadequate end-
of-life care in the United States (1). The investigators of
SUPPORT (Study to Understand Prognoses and Prefer-
ences for Outcomes and Risks of Treatment; 2000)
agreed (2, 3). The emphasis by medicine and society
on intervention and cure has sometimes come at the
expense of good end-of-life care. Inappropriate treat-
ment at the end of life may be harmful and draining—
physically, emotionally, and financially—for patients and
their families. Many people have concerns about death.
At the end of life, some patients receive unwanted care;
others do not receive needed care (4 – 6). Some end-of-
life concerns are outside of medicine's scope and
should be addressed in other ways. Although medicine
now has an unprecedented capacity to treat illness and

ease the dying process, the right care in the right place
at the right time has not been achieved.
Medicine and society still struggle with getting it
right for all patients. Although progress has been
made, the principles and practices of hospice and pal-
liative medicine have not been fully realized (4). Revis-
iting these issues in 2014, the IOM's Dying in America:
Improving Quality and Honoring Individual Preferences
Near the End of Life reported that challenges remain in
delivering quality end-of-life care to a growing and di-
verse elderly population, especially with regard to ac-
cess to care, communication barriers, time pressures,
and care coordination (7). Inadequate reimbursement
and other disincentives also are barriers to palliative and
hospice care.
Hospice and palliative care may ease apprehension
about the dying process. Such care requires improving
access to, financing of, and training in palliative care;
improving hospital, nursing home, and at-home capa-
bilities in delivering care; and encouraging advance
care planning and openness to discussions about dy-
ing. Of note, 90% of U.S. adults do not know what pal-
liative care is; however, when told the definition, more
than 90% say they would want it for themselves or fam-
ily members if severely ill (4).
Within this context of challenges in providing palli-
ative and hospice care, a few U.S. jurisdictions have
legalized physician-assisted suicide. This paper pres-
ents the position of the American College of Physicians
(ACP) on the topic. The ACP recognizes the range of
views on, the depth of feeling about, and the complex-
ity of this issue. This executive summary is a synopsis of

See also:
Related article . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Editorial comments . . . . . . . . . . . . . . . . . . . . 595, 597
* This paper, authored by Lois Snyder Sulmasy, JD, and Paul S.
Mueller, MD, MPH, was developed for the Ethics,
Professionalism and Human Rights Committee
of the American College of Physicians. Individuals who served
on the Ethics, Professionalism and Human Rights Committee at
the time of the paper's approval
were Carrie A. Horwitch, MD, MPH† (Chair); Omar T. Atiq,
MD† (Vice Chair); John R. Ball, MD, JD†; Nitin S. Damle, MD,
MS†; Pooja Jaleel, BA†; Daniel B.
Kimball Jr., MD†; Lisa S. Lehmann, MD, PhD†; Ana Marı́a
López, MD, MPH†; Paul S. Mueller, MD, MPH‡; Alexandra
Norcott, MD†; Sima Suhas Pendharkar, MD,
MPH†; Julie R. Rosenbaum, MD†; Molly B. Southworth, MD,
MPH†; and Thomas G. Tape, MD†. Approved by the ACP Board
of Regents on 27 March 2017.
† Nonauthor contributor.
‡ Author.
POSITION PAPER Annals of Internal Medicine
576 © 2017 American College of Physicians
Downloaded from https://annals.org by guest on 03/18/2020
http://www.annals.org
the ACP's position. See the Glossary for definitions and
the Appendix for the full position paper.

METHODS
This position paper was developed from Septem-
ber 2015 to March 2017 on behalf of the ACP Ethics,
Professionalism and Human Rights Committee (EPHRC).
Committee members abide by the ACP's conflict-of-
interest policy and procedures (www.acponline.org
/about-acp/who-we-are/acp-conflict-of-interest-policy
-and-procedures), and appointment to and procedures
of the EPHRC are governed by the ACP's bylaws (www
.acponline.org/about-acp/who-we-are/acp-bylaws). Af-
ter an environmental assessment to determine the
scope of issues and literature reviews, the EPHRC eval-
uated and discussed several drafts of the paper; the
paper was then reviewed by members of the ACP
Board of Governors, Board of Regents, Council of Early
Career Physicians, Council of Resident/Fellow Mem-
bers, Council of Student Members, Council of Subspe-
cialty Societies, Patient Partnership in Healthcare Cen-
ter and Advisory Board, and other committees and
experts. The paper was revised on the basis of com-
ments from the aforementioned groups and individu-
als, reviewed again by the full leadership, and then
revised further. Finally, the ACP Board of Regents re-
viewed the paper and approved it on 27 March 2017.
Financial support for this project is exclusively from the
ACP operating budget.
BACKGROUND AND BRIEF RATIONALE
In 2001, the ACP published a position paper op-
posing legalization of physician-assisted suicide (8).
This issue also has been considered every few years in
the American College of Physicians Ethics Manual, in-
cluding the current edition (9). Given recent changes in

the legal landscape, public interest in the topic, and
continuing barriers to palliative and hospice care, an
updated position paper is presented here. Within a
framework that considers clinical practice, ethics, law,
and policy, this paper provides background, discusses
the role of palliative and hospice care, explores the na-
ture of the patient–physician relationship and the dis-
tinction between refusal of life-sustaining treatment
and physician-assisted suicide, and provides recom-
mendations for responding to patient requests for
physician-assisted suicide.
Medical ethics establishes the duties of physicians
to patients and society, sometimes to a greater extent
than the law (9). Physicians have duties to patients on
the basis of the ethical principles of beneficence (that
is, acting in the patient's best interest), nonmaleficence
(avoiding or minimizing harm), respect for patient au-
tonomy, and promotion of fairness and social justice
(9). Medical ethics and the law strongly support a
patient's right to refuse treatment, including life-
sustaining treatment. The intent is to avoid or withdraw
treatment that the patient judges to be inconsistent
with his or her goals and preferences. Death follows
naturally, after the refusal, as a result of the underlying
disease (9).
Ethical arguments in support of physician-assisted
suicide highlight the principle of respect for patient au-
tonomy and a broad interpretation of a physician's duty
to relieve suffering (10). Proponents view physician-
assisted suicide as an act of compassion that respects
patient choice and fulfills an obligation of nonabandon-
ment (11). Opponents maintain that the profession's
most consistent ethical traditions emphasize care and

comfort, that physicians should not participate in inten-
tionally ending a person's life, and that physician-
assisted suicide requires physicians to breach specific
prohibitions as well as the general duties of benefi-
cence and nonmaleficence. Such breaches are viewed
as inconsistent with the physician's role as healer and
comforter (12, 13).
Both sides agree that patient autonomy is critical
and must be respected, but they also recognize that it
is not absolute and must be balanced with other ethical
principles (9, 14). To do otherwise jeopardizes the phy-
sician's ability to practice high-value care in the best
interests of the patient, in a true patient–physician part-
nership. Only by this balancing of ethical principles can
physicians fulfill their duties, including those in more
everyday encounters, such as when a physician advises
against tests requested by a patient that are not medi-
cally indicated, declines to write an illegal prescription,
or breaches confidentiality to protect public health. It
also undergirds the physician's duty not to engage in
futile care (such as care based on requests for nonindi-
cated cardiopulmonary resuscitation or end-of-life
treatment of brain-dead patients under an expansive
view of patient autonomy). Physicians are members of a
profession with ethical responsibilities; they are moral
agents, not merely providers of services (15).
The suffering of dying patients may be great and is
caused by somatic symptoms, such as pain and nausea;
psychological conditions, such as depression and anx-
iety; interpersonal suffering due to dependency or un-
resolved conflict; or existential suffering based in hope-
lessness, indignity, or the belief that one's life has
ended in a biographical sense but has not yet ended
biologically. For some patients, a sense of control over

the manner and timing of death brings comfort. How-
ever, is it reasonable to ask medicine to relieve all hu-
man suffering? Just as medicine cannot eliminate
death, medicine cannot relieve all human suffering.
Both proponents and opponents of physician-assisted
suicide wish to alleviate suffering of dying patients, and
physicians have an ethical duty to provide competent
palliative and hospice care (9). However, is physician-
Glossary
Suicide: The act of killing oneself intentionally.
Physician-assisted suicide: Physician participation in advising
or
providing, but not directly administering, the means or
information
enabling a person to intentionally end his or her life (e.g.,
ingesting a
lethal dose of medication prescribed for that purpose).
Euthanasia: The act of intentionally ending a life to relieve pain
or other
suffering (e.g., lethal injection performed by a physician).
Ethics and the Legalization of Physician-Assisted Suicide
POSITION PAPER
Annals.org Annals of Internal Medicine • Vol. 167 No. 8 • 17
October 2017 577
http://www.acponline.org/about-acp/who-we-are/acp-conflict-
of-interest-policy-and-procedures

http://www.acponline.org/about-acp/who-we-are/acp-bylaws
http://www.acponline.org/about-acp/who-we-are/acp-bylaws
assisted suicide a type of control over suffering and the
dying process that is within the goals and scope of
medicine?
Balancing respect for patient autonomy against
other principles reflects ethical arguments about the
nature of the patient–physician relationship—a relation-
ship that is inherently unequal because of power differ-
entials and the vulnerability of illness—physicians' du-
ties, and the role of the medical profession in society. A
fuller consideration of this ethical balance, intent and
causation in acts near the end of life, medicalization
versus personalization of death, and the ethics and im-
plications of physician-assisted suicide are presented in
the Appendix (16–81).
POSITION STATEMENT
The ACP affirms a professional responsibility to im-
prove the care of dying patients and their families.
The ACP does not support the legalization of
physician-assisted suicide, the practice of which raises
ethical, clinical, and other concerns. The ACP and its
members, including those who might lawfully partici-
pate in the practice, should ensure that all patients can
rely on high-quality care through to the end of life, with
prevention or relief of suffering insofar as possible, a

commitment to human dignity and management of
pain and other symptoms, and support for families.
Physicians and patients must continue to search to-
gether for answers to the challenges posed by living
with serious illness before death (9).
CONCLUSION
Society's goal should be to make dying less, not
more, medical. Physician-assisted suicide is neither a
therapy nor a solution to difficult questions raised at the
end of life. On the basis of substantive ethics, clinical
practice, policy, and other concerns, the ACP does not
support legalization of physician-assisted suicide. This
practice is problematic given the nature of the patient–
physician relationship, affects trust in that relationship
as well as in the profession, and fundamentally alters
the medical profession's role in society. Furthermore,
the principles at stake in this debate also underlie med-
icine's responsibilities on other issues and the physi-
cian's duty to provide care based on clinical judgment,
evidence, and ethics. Control over the manner and tim-
ing of a person's death has not been and should not be
a goal of medicine. However, through high-quality care,
effective communication, compassionate support, and
the right resources, physicians can help patients control
many aspects of how they live out life's last chapter.
From the American College of Physicians, Philadelphia,
Pennsylvania.
Acknowledgment: The authors and the ACP Ethics, Profes-
sionalism and Human Rights Committee thank the many re-
viewers of the paper for helpful comments on drafts and
Kathy Wynkoop for administrative assistance.

Financial Support: Exclusively from the ACP operating
budget.
Disclosures: Disclosures can be viewed at www.acponline
.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17
-0938.
Requests for Single Reprints: Lois Snyder Sulmasy, JD, Amer-
ican College of Physicians, Center for Ethics and Professional-
ism, 190 N. Independence Mall West, Philadelphia, PA 19106;
e-mail, [email protected]
Current author addresses and author contributions are avail-
able at Annals.org.
References
1. Field MJ, Cassel CK, eds; Committee on Care at the End of
Life.
Approaching Death: Improving Care at the End of Life.
Washington,
DC: National Academies Pr; 1997.
2. Phillips RS, Hamel MB, Covinsky KE, Lynn J. Findings from
SUPPORT and HELP: an introduction. Study to Understand
Progno-
ses and Preferences for Outcomes and Risks of Treatment.
Hospital-
ized Elderly Longitudinal Project. J Am Geriatr Soc.
2000;48:S1-5.
[PMID: 10809450]
3. A controlled trial to improve care for seriously ill
hospitalized pa-
tients. The study to understand prognoses and preferences for
out-
comes and risks of treatments (SUPPORT). The SUPPORT
Principal
Investigators. JAMA. 1995;274:1591-8. [PMID: 7474243]
4. Kelley AS, Morrison RS. Palliative care for the seriously ill.

N Engl J
Med. 2015;373:747-55. [PMID: 26287850] doi:10.1056/NEJMra
1404684
5. Johnson KS. Racial and ethnic disparities in palliative care. J
Palliat
Med. 2013;16:1329-34. [PMID: 24073685]
doi:10.1089/jpm.2013
.9468
6. Payne R. Racially associated disparities in hospice and
palliative
care access: acknowledging the facts while addressing the
opportu-
nities to improve. J Palliat Med. 2016;19:131-3. [PMID:
26840847]
doi:10.1089/jpm.2015.0475
7. Institute of Medicine; Committee on Approaching Death.
Dying in
America: Improving Quality and Honoring Individual
Preferences
Near the End of Life. Washington, DC: National Academies Pr;
2014.
doi:10.17226/18748
8. Snyder L, Sulmasy DP; Ethics and Human Rights Committee,
American College of Physicians-American Society of Internal
Medi-
cine. Physician-assisted suicide. Ann Intern Med.
2001;135:209-16.
[PMID: 11487490]
9. Snyder L; American College of Physicians Ethics,
Professionalism,
and Human Rights Committee. American College of Physicians
Eth-
ics Manual: sixth edition. Ann Intern Med. 2012;156:73-104.
[PMID:
22213573] doi:10.7326/0003-4819-156-1-201201031-00001
10. Angell M. The Supreme Court and physician-assisted

suicide—
the ultimate right [Editorial]. N Engl J Med. 1997;336:50-3.
[PMID:
8970940]
11. Quill TE, Back AL, Block SD. Responding to patients
requesting
physician-assisted death: physician involvement at the very end
of
life. JAMA. 2016;315:245-6. [PMID: 26784762]
doi:10.1001/jama
.2015.16210
12. Gaylin W, Kass LR, Pellegrino ED, Siegler M. ‘Doctors
must not
kill’. JAMA. 1988;259:2139-40. [PMID: 3346989]
13. Decisions near the end of life. Council on Ethical and
Judicial
Affairs, American Medical Association. JAMA. 1992;267:2229-
33.
[PMID: 1372944]
14. Callahan D. When self-determination runs amok. Hastings
Cent
Rep. 1992;22:52-5. [PMID: 1587727]
15. Yang YT, Curlin FA. Why physicians should oppose
assisted sui-
cide. JAMA. 2016;315:247-8. [PMID: 26784763]
doi:10.1001/jama
.2015.16194
POSITION PAPER Ethics and the Legalization of Physician-
Assisted Suicide
578 Annals of Internal Medicine • Vol. 167 No. 8 • 17 October
2017 Annals.org

http://www.acponline.org/authors/icmje/ConflictOfInterestForm
s.do?msNum=M17-0938
s.do?msNum=M17-0938
s.do?msNum=M17-0938
mailto:[email protected]
Current Author Addresses: Ms. Snyder Sulmasy: American
College of Physicians, Center for Ethics and Professionalism,
190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Mueller: Mayo Clinic, Gonda Building 17, 200 First Street
Southwest, Rochester, MN 55905.
Author Contributions: Conception and design: P.S. Mueller.
Analysis and interpretation of the data: L. Snyder Sulmasy, P.S.
Mueller.
Drafting of the article: L. Snyder Sulmasy, P.S. Mueller.
Critical revision for important intellectual content: P.S.
Mueller.
Final approval of the article: L. Snyder Sulmasy, P.S. Mueller.
Administrative, technical, or logistic support: L. Snyder
Sulmasy.
Collection and assembly of data: L. Snyder Sulmasy, P.S.
Mueller.
APPENDIX AND EXPANDED RATIONALE: ETHICS
AND THE LEGALIZATION OF PHYSICIAN-
ASSISTED SUICIDE—AN AMERICAN COLLEGE
OF PHYSICIANS POSITION PAPER
Framing the Issues: Care Near the End of Life
We all will die. How we die—and live at the end of

life—is important, with implications for individuals, their
families, and society. How we are cared for at the end
of life matters.
The groundbreaking 1997 report Approaching
Death: Improving Care at the End of Life, by the IOM,
documented inadequate end-of-life care in the United
States (1). In 2000, the SUPPORT investigators agreed
(2, 3). Although the cultural norm of fighting disease
aggressively is the right approach in many cases, the
emphasis by medicine, as well as society, on interven-
tion and cure sometimes comes at the expense of good
end-of-life care. Inappropriate treatment at the end of
life may be harmful and draining—physically, emotion-
ally, and financially—for patients and their families.
Many of us have concerns or apprehensions about how
we will die. Indeed, some patients receive unwanted
care at the end of life, whereas others do not receive
the care they need (4 – 6). Although medicine now has
an unprecedented capacity to treat illness and ease the
dying process, the right care in the right place at the
right time has not been achieved.
Medicine and society still struggle to get it right for
all patients. Although progress has been made, the
principles and practices of hospice and palliative med-
icine have not been fully realized (4). Revisiting these
issues in 2014, the IOM report Dying in America: Im-
proving Quality and Honoring Individual Preferences
Near the End of Life found that challenges remain in
delivering quality end-of-life care to a growing and di-
verse elderly population, especially regarding access to
care, communication barriers, time pressures, and care
coordination (7). Inadequate reimbursement and other
disincentives also create barriers to palliative and hos-

pice care.
Wide agreement exists that hospice and palliative
care may ease apprehension about the dying process.
Such care requires improving access to, financing of,
and training in palliative care; improving hospital, nurs-
ing home, and at-home capabilities in delivering care;
and encouraging advance care planning and openness
to discussions about dying. Of note, 90% of U.S. adults
do not know what palliative care is, but when told the
definition, more than 90% say they would want it for
themselves or family members if severely ill (4).
Access to state-of-the-art symptom control remains
limited for all dying patients. Of particular concern, ev-
idence of ethnic and racial disparities in access, out-
comes, and communication is increasing (5, 6). Many
patients fear they will not receive appropriate end-of-
life care when they need it. Others are concerned
about being a financial, physical, or other burden on
their family, losing autonomy or control, or being
placed in a long-term care facility. Some are alone or
lonely; loneliness has a mortality risk similar to that of
cigarette smoking, yet its health implications are un-
derappreciated (16). Many persons approaching death
are clinically depressed or have other psychiatric co-
morbid conditions, and some contemplate suicide (17,
18). According to Wilson and colleagues, “the expres-
sion of a desire for death by a terminally ill patient
should raise a suspicion about mental health problems;
by itself, however, it is not definitively diagnostic of
one” (17). This desire fluctuates over time (19, 20) and
may be related to inadequate symptom management.
Medicine can and should ameliorate many of these
problems; some, however, are outside the scope or
goals of medicine and should be addressed in other

ways.
As challenges in providing palliative and hospice
care continue, a few jurisdictions have legalized
physician-assisted suicide (see the Glossary for defini-
tions and the Appendix Table for U.S. jurisdictions with
physician-assisted suicide laws). The ACP recognizes
the range of views, depth of feeling, and complexity of
the issue of physician-assisted suicide.
Appendix Table. U.S. Jurisdictions Where Physician-
Assisted Suicide Is Legal
Where When How
Oregon 1997 Voter-approved ballot initiative
Washington 2008 Voter-approved ballot initiative
Montana 2009 Court decision*
Vermont 2013 Legislation
California 2015 Legislation
Colorado 2016 Voter-approved ballot initiative
District of Columbia 2016 Legislation
* A patient's request for physician-assisted suicide can be an
affirma-
tive defense for a physician who participates.
Annals.org Annals of Internal Medicine • Vol. 167 No. 8 • 17
October 2017
Revisiting Physician-Assisted Suicide

In 2001, the ACP published a position paper op-
posing legalization of physician-assisted suicide (8).
The issue also has been considered every few years in
the American College of Physicians Ethics Manual, in-
cluding the current edition (9). Given recent changes in
the legal landscape, public interest in the topic, and
continuing barriers to palliative and hospice care, an
updated position paper is presented here. Within a
framework that considers clinical practice, ethics, law,
and policy, this paper provides background, discusses
the role of palliative and hospice care, explores the na-
ture of the patient–physician relationship and the dis-
tinction between refusal of life-sustaining treatment
and physician-assisted suicide, and provides recom-
mendations for responding to patient requests for
physician-assisted suicide.
The Context
Physician-assisted suicide is medical help with a pa-
tient's intentional act to end his or her own life (for ex-
ample, an individual taking a lethal dose of medication
prescribed by a physician for that purpose). It is ethi-
cally, legally, and clinically different from patient refusal
of life-sustaining treatment through the withdrawal or
withholding of treatment. Physician-assisted suicide
also differs from euthanasia, an act in which a physician
intentionally terminates the life of a patient (such as by
lethal injection), the purpose of which is to relieve pain
or other suffering (8). Dictionaries define suicide as in-
tentionally ending one's own life. Despite cultural and
historical connotations, the term is neither disparaging
nor a judgment. Terms for physician-assisted suicide,
such as aid in dying, medical aid in dying, physician-
assisted death, and hastened death, lump categories of

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