The Reign of the Farmer James E. McClellan and Harold Dorn. At the end of the last Ice Age, around 12,000 years ago, the Neolithic Revolution began to unfold. This revolution, first and foremost a socioeconomic and

technological transformation, involved a shift from food gathering to food

producing. It originated in a few regions before eventually spreading around the

globe. In habitats suitable only as pasture it led to pastoral nomadism or herding

animal flocks; in others it led to farming and settled village life. Thus arose the

Neolithic or New Stone Age.

Growing Your Own

A surprising but grand fact of prehistory: Neolithic communities based on

domesticated plants and animals arose independently several times in different

parts of the world after 10,000 bce—the Near East, India, Africa, North Asia,

Southeast Asia, and Central and South America. The physical separation of the

world’s hemispheres—the Old World and the New World—decisively argues

against simple diffusion oef Neolithic techniques, as do the separate domestications

of wheat, rice, corn, and potatoes in different regions. On the time scale of

prehistory the transformation appears to have been relatively abrupt, but in fact the

process occurred gradually. Nonetheless, the Neolithic revolution radically altered

the lives of the peoples affected and, indirectly, the conditions of their habitats.

Although different interpretations exist concerning the origin of the Neolithic, no

one disputes its worldtransforming effects.

The Neolithic was the outcome of a cascading series of events and processes. In

the case of gardening—lowintensity farming—we now know that in various

locales around the world human groups settled down in permanent villages, yet

continued to practice hunting, gathering, and a Paleolithic economy before the full

transition to a Neolithic mode of production. These settled groups lived by

complex foraging in limited territories, intensified plant collection, and

exploitation of a broad spectrum of secondary or tertiary food sources, such as nuts

and seafood. They also lived in houses, and in this sense early sedentary humans

were themselves a domesticated species. (The English word “domestic” derives

from the Latin word domus, meaning “house.” Humans thus domesticated

themselves as they domesticated plants or animals!) But the inexorable pressure of

population against dwindling collectible resources, along with the greater

nutritional value of wild and domesticated cereal grains, ultimately led to

increasing dependence on food production and a more complete food producing

way of life. In most places in the world people continued a Paleolithic existence

after the appearance of Neolithic settlements 12,000 years ago. They were

blissfully unpressured to take up a new Neolithic mode of food producing, and as a

cultural and economic mode of existence even today a few surviving groups follow

a Paleolithic lifestyle. As a period in prehistory, the Neolithic has an arc of its own

that covers developments from the first simple horticulturists and pastoralists to

complex late Neolithic groups living in “towns.” In retrospect, especially compared

to the extreme length of the Paleolithic period, the Neolithic of prehistory lasted

just a moment before civilization in Mesopotamia and Egypt began to usher in

further transformations around 5,000 years ago. But even in its diminished time

frame the Neolithic spread geographically and persisted in particular locales over

thousands of years from roughly 12,000 to 5,000 years ago, when the Neolithic

first gave way to civilization in the Near East. To those experiencing it, Neolithic

life must have proceeded over generations at a leisurely seasonal pace.

Two alternative paths toward food production led out of the Paleolithic: one from

gathering to cereal horticulture (gardening), and then to plow agriculture; the other

from hunting to herding and pastoral nomadism. A distinct geography governed

these Neolithic alternatives: In climates with sufficient atmospheric or surface

water, horticulture and settled villages arose; in grasslands too arid for farming,

nomadic people and herds of animals retained a nomadic way of life. Of these very

different paths, one led historically to nomadic societies such as the Mongols and

the Bedouins. The other, especially in the form that combined farming and

domestication of animals, led to the great agrarian civilizations and eventually to

industrialization. Opportunistic and even systematic hunting and gathering

persisted alongside foodproducing, but where Neolithic settlements arose the basic

economy shifted to raising crops on small cleared plots. Gardening contrasts with

intensified agriculture using irrigation, plows, and draft animals, which later

developed in the first civilizations in the Near East. Early Neolithic peoples did not

use the plow but, where necessary, cleared land using large stone axes and adzes;

they cultivated their plots using hoes or digging sticks. In many areas of the world,

especially tropical and subtropical ones, swidden, or “slash and burn,” agriculture

developed where plots were cultivated for a few years and then abandoned to

replenish themselves before being cultivated again. The Neolithic toolkit continued

to contain small chipped stones, used in sickles, for example, but was augmented

by larger, often polished implements such as axes, grinding stones, and mortars and

pestles found at all Neolithic sites. Animal antlers also proved useful as picks and

digging sticks. And grain had to be collected, threshed, winnowed, stored, and

ground, all of which required an elaborate set of technologies and social practices.

Human populations around the world independently domesticated and began

cultivating a variety of plants: several wheats, barleys, rye, peas, lentils, and flax in

Southwest Asia; millet and sorghum in Africa; millet and soybeans in North China;

rice and beans in Southeast Asia; maize (corn) in Mesoamerica; potatoes, quinoa,

manioc, and beans in South America. Domestication constitutes a process (not an

act) that involves taming, breeding, genetic selection, and occasionally introducing

plants into new ecological settings. In the case of wheat, for example, wild wheat is

brittle, with seeds easily scattered by the wind and animals, a trait that enables the

plant to survive under natural conditions. Domesticated wheat retains its seeds,

which simplifies harvesting but leaves the plant dependent on the farmer for its

propagation. Humans changed the plant’s genes; the plant changed humanity. And,

with humans raising the grain, the rat, the mouse, and the house sparrow

“selfdomesticated” and joined the Neolithic ark.

The domestication of animals developed out of intimate and longstanding human

contact with wild species. Logically, at least, there is a clear succession from

hunting and following herds to corralling, herding, taming, and breeding. The

living example of the Sami (Lapp) people who follow and exploit semiwild

reindeer herds illustrates how the shift from hunting to husbandry and pastoral

nomadism may have occurred. As with plant culture, the domestication of animals

involved human selection from wild types, selective slaughtering, selective

breeding, and what Darwin later called “unconscious selection” from among flocks

and herds. Humans in the Old World domesticated cattle, goats, sheep, pigs,

chickens, and, later, horses. In the New World Andean communities domesticated

only llamas and the guinea pig; peoples in the Americas thus experienced a

comparative deficiency of animal protein in the diet.

Animals are valuable to humans in diverse ways. Some of them convert inedible

plants to meat, and meat contains more complex proteins than plants. Animals

provide food on the hoof, food that keeps from spoiling until needed. Animals

produce valuable secondary products that were increasingly exploited as the

Neolithic unfolded in the Old World. Cattle, sheep, pigs, and the rest are “animal

factories” that produce more cattle, sheep, and pigs. Chickens lay eggs, and cows,

sheep, goats, and horses produce milk. Treated and storable milk products in

yogurts, cheeses, and brewed beverages sustained the great herding societies of

Asia and pastoralists everywhere. Manure became another valuable animal product

as fertilizer and fuel. Animal hides provided raw material for leather and a variety

of products, and sheep, of course, produced fleece. (Wool was first woven into

fabric on Neolithic looms.) Animals provided traction and transportation. The

Neolithic maintained the close dependence on plants and animals that humankind

had developed over the previous 2 million years. But the technologies of exploiting

them and the social system sustained by those technologies had changed radically.

After a few thousand years of the Neolithic in the Near East, mixed economies that

combined the technologies of horticulture and animal husbandry made their

appearance. Late Neolithic groups in the Old World apparently kept animals for

traction and used wheeled carts on roads and pathways that have been favorably

compared to those of medieval Europe. The historical route to intensified

agriculture and to civilization was through this mixed Neolithic farming. If biology

and evolution were partly responsible for the character of our first mode of

existence in the Paleolithic, then the Neolithic Revolution represents a change of

historical direction initiated by humans themselves in response to their changing

environment.

Complementing the many techniques and skills involved in farming and

husbandry, several ancillary technologies arose as part of the shift to the Neolithic.

First among these novelties was textiles, an innovation independently arrived at in

various parts of the Old and New Worlds. Recent findings show that some

Paleolithic groups occasionally practiced techniques of weaving, perhaps in

basketry, but only in the Neolithic did the need for cloth and storage vessels

expand to the point where textile technologies flourished. The production of

textiles involves several interconnected steps and technological practices: shearing

sheep or growing and harvesting flax or cotton, processing the raw material,

spinning thread (an everpresent part of women’s lives until the Industrial

Revolution 10,000 years later), constructing looms, dyeing, and weaving the cloth.

In considering the advent of textile production in the Neolithic, one cannot

overlook design considerations and the symbolic and informational role of dress in

all societies. Then, as now, how people dress conveys a lot of information about

who they are and where they come from.

Pottery, which also originated independently in multiple centers around the world,

is another new technology that formed a key part of the Neolithic Revolution. If

only inadvertently, Paleolithic peoples had produced firedclay ceramics, but

nothing in the Paleolithic economy called for a further development of the

technique. Pottery almost certainly arose in response to the need for a storage

technology: jars or vessels to store and carry the surplus products of the first

agrarian societies. Neolithic communities used plasters and mortars in building

construction, and pottery may have arisen out of plastering techniques applied to

baskets. Eventually, “manufacturing centers” and smallscale transport of ceramics

developed. Pottery is a “pyrotechnology,” for the secret of pottery is that

chemically combined water is driven from the clay when it is fired, turning it into

an artificial stone. Neolithic kilns produced temperatures upwards of 900°C. Later,

in the Bronze and Iron Ages, the Neolithic pyrotechnology of pottery made

metallurgy possible.

In Neolithic settings, hundreds if not thousands of techniques and technologies

large and small melded to produce the new mode of life. Neolithic peoples built

permanent structures in wood, mud brick, and stone, all of which testify to expert

craft skills. They twisted rope and practiced lapidary crafts, and Neolithic peoples

even developed metallurgy of a sort, using naturally occurring raw copper. The

technology of cold metalworking produced useful tools. The now famous “Ice

man,” the extraordinary frozen mummy exposed in 1991 by a retreating glacier in

the Alps, was first thought to belong to a Bronze Age culture because of the fine

copper axe he was carrying when he perished. As it turns out, he lived in Europe

around 3300 bce, evidently a prosperous Neolithic farmer with a superior cold

forged metal tool.

The Neolithic was also a social revolution and produced a radical change in

lifeways. Decentralized and self-sufficient settled villages, consisting of a dozen to

two dozen houses, with several hundred inhabitants became the norm among

Neolithic groups. Compared to the smaller bands of the Paleolithic, village life

supported collections of families united into tribes. The Neolithic house doubtless

became the center of social organization; production took place on a household

basis. The imaginative suggestion has been made that living inside houses forced

Neolithic peoples to deal in new ways with issues concerning public space,

privacy, and hospitality. Neolithic peoples may have used hallucinatory drugs, and

they began to experiment with fermented beverages. Although a sexual division of

labor probably persisted in the Neolithic, horticultural societies, by deemphasizing

hunting, may have embodied greater gender equality. A comparatively sedentary

lifestyle, a diet higher in carbohydrates, and earlier weaning increased fertility,

while freedom from the burden of carrying infants from camp to camp enabled

women to bear and care for more children. And one suspects that the economic

value of children—in tending animals or helping in the garden, for example—was

greater in Neolithic times than in the Paleolithic. At least with regard to Europe,

archaeologists have made compelling claims for the existence of cults devoted to

Neolithic goddesses and goddess worship. There were doubtless shamans, or

medicine “men,” some of whom may also have been women. Neolithic societies

remained patriarchal, but males were not as dominant as they would become with

the advent of civilization.

In the early Neolithic, little or no occupational specialization differentiated

individuals who earned their bread solely through craft expertise. This

circumstance changed by the later Neolithic, as greater food surpluses and

increased exchange led to more complex and wealthier settlements with fulltime

potters, weavers, masons, toolmakers, priests, and chiefs. Social stratification kept

pace with the growth of surplus production. By the late Neolithic, low level

hierarchal societies, tribal chiefdoms, or what anthropologists call “big men”

societies appeared. These societies were based on kinship, ranking, and the power

to accumulate and redistribute goods sometimes in great redistributive feasts.

Leaders now controlled the resources of 5,000 to 20,000 people. They were not yet

kings, however, because they retained relatively little for themselves and because

Neolithic societies were incapable of producing truly huge surpluses.

Compared to the Paleolithic economy and lifestyle, one could argue that the

standard of living actually became depressed in the transition to the Neolithic in

that lowintensity horticulture required more labor, produced a less varied and

nutritious diet, and allowed less leisure than Paleolithic hunting and gathering in its

heyday. But—and this was the primary advantage—Neolithic economies produced

more food and could therefore support more people and larger population densities

(estimated at a hundredfold more per square mile) than Paleolithic foraging.

Populations expanded and the Neolithic economy spread rapidly to fill suitable

niches. By 3000 bce thousands of agrarian villages dotted the Near East, usually

within a day’s walk of one another. Wealthier and more complex social structures

developed, regional crossroads and trading centers arose, and by the late Neolithic

real towns had emerged. The Neolithic town Çatal Hüyük in modern Turkey dates

from 6000 bce, but the classic example is the earlier and especially rich Neolithic

town of Jericho. Neolithic settlements appeared along the Jordon River in the

Middle East by 9000 bce, and by 7350 bce Jericho itself had become a

wellwatered, brickwalled city of 2,000 or more people tending flocks and plots in

the surrounding hinterland. Jericho had a tower nine meters high and ten meters in

diameter, and its celebrated walls were three meters thick, four meters high, and

700 meters in circumference. The walls were necessary because the surplus stored

behind them attracted raiders. The later walled enclosure at Great Zimbabwe (c.

1300 ce) in Africa evidences similar forces at play. Warlike clashes between

Paleolithic peoples had undoubtedly occurred repeatedly over the millennia in

disputes over territory, to capture females, or for cannibalistic or ritual purposes.

But with the Neolithic, for the first time, humans produced surplus food and wealth

worth stealing and hence worth protecting. Paleolithic groups were forced to adapt

to the Neolithic economies burgeoning around them. Thieving was one alternative;

joining in a settled way of life was another. In the long run, Neolithic peoples

marginalized huntergatherers and drove them virtually to extinction. Idealized

memories of the foraging lifestyle left their mark in “Garden of Eden” or “happy

hunting grounds” legends in many societies.

Blessed or cursed with a new economic mode of living, humans gained greater

control over nature and began to make more of an impact on their environments.

The ecological consequences of the Neolithic dictated that the domestic replace the

wild, and where it occurred the Neolithic Revolution proved irreversible—a return

to the Paleolithic was impossible because Paleolithic habitats had been transformed

and the Paleolithic lifestyle was no longer sustainable.

Moonshine

The Neolithic Revolution was a technoeconomic process that occurred without the

aid or input of any independent “science.” In assessing the connection between

technology and science in the Neolithic, pottery provides an example exactly

analogous to making fire in the Paleolithic. Potters made pots simply because pots

were needed and because they acquired the necessary craft knowledge and skills.

Neolithic potters possessed practical knowledge of the behavior of clay and of fire,

and, although they may have had explanations for the phenomena of their crafts,

they toiled without any systematic science of materials or the selfconscious

application of theory to practice or any higher learning to tap for practical

purposes. It would denigrate Neolithic crafts to suppose that they could have

developed only with the aid of higher learning.

Can anything, then, be said of science in the Neolithic? In one area, with regard to

what can be called Neolithic astronomy, we stand on strong ground in speaking

about knowledge in a field of science. Indeed, considerable evidence makes plain

that many, and probably most, Neolithic peoples systematically observed the

heavens, particularly the patterns of motion of the sun and moon and that they

regularly created astronomically aligned monuments that served as seasonal

calendars. In the case of Neolithic astronomy, we are dealing not with the

prehistory of science, but with science in prehistory.

The famous monument of Stonehenge on the Salisbury Plain in southwest England

provides the most dramatic and best understood case in point. Stonehenge, it has

now been determined by radiocarbon dating, was built intermittently in three major

phases by different groups over a 1,600 year period from 3100 bce to 1500 bce, by

which time the Bronze Age finally washed across the Salisbury Plain. The word

“Stonehenge” means “hanging stone,” and transporting, working, and erecting the

huge stones represents a formidable technological achievement on the part of the

Neolithic peoples of prehistoric Britain.

A huge amount of labor went into building Stonehenge—estimates range to 30

million manhours, equivalent to an annual productive labor of 10,000 people. In

order to create a circular ditch and an embankment 350 feet in diameter 3,500

cubic yards of earth were excavated. Outside the sanctuary the first builders of

Stonehenge erected the so-called Heel Stone, estimated to weigh 35 tons.

Eightytwo “bluestones” weighing approximately 5 tons apiece were brought to the

site (mostly over water) from Wales, an incredible 240 kilometers (150 miles)

away. Each of the 30 uprights of the outer stone circle of Stonehenge weighed in

the neighborhood of 25 tons, and the 30 lintels running around the top of the ring

weighed 7 tons apiece. More impressive still, inside the stone circle stood the five

great trilithons or threestone behemoths. The average trilithon upright weighs 30

tons and the largest probably weighs over 50 tons. (By contrast, the stones that

went into building the pyramids in Egypt weighed on the order of 5 tons.) The

great monoliths were transported 40 kilometers (25 miles) overland from

Marlborough Downs, although the suggestion has been made that ancient glaciers

may have been responsible for moving them at least part way to Stonehenge. The

architects of Stonehenge appear to have laid out the monument on a true circle, and

in so doing they may have used some practical geometry and a standard measure,

the so-called megalithic yard.

The labor was probably seasonal, taking place over generations. A stored food

surplus was required to feed workers, and some relatively centralized authority was

needed to collect and distribute food and to supervise construction. Neolithic

farming and ranching communities appeared on the Salisbury Plain by the fourth

millennium bce and evidently reached the required level of productivity. Although

Neolithic farming never attained the levels of intensification later achieved by

civilized societies, Stonehenge and the other megalithic (“large stone”) structures

show that even comparatively low intensity agriculture can produce sufficient

surpluses to account for monumental building.

Recognition that Stonehenge is an astronomical device has been confirmed only in

our day. As literate peoples encountered Stonehenge over the centuries, any

number of wild interpretations emerged as to who built it and why. Geoffrey of

Monmouth in his twelfth century History of the Kings of Britain has Merlin from

King Arthur’s court magically transporting the stones from Wales. Other authors

have postulated that the Romans or the Danes built Stonehenge. A still current

fantasy holds that the Druids built and used Stonehenge as a ceremonial center. (In

fact, the Celtic Iron Age Druids and their culture only appeared a thousand years

after Stonehenge was completed.) Even in the 1950s, when the possibility became

clear that Neolithic peoples from the Salisbury Plain themselves were responsible

for Stonehenge, there was considerable resistance to the idea that “howling

barbarians” might have been capable of building such an impressive monument,

and some supposed that itinerant contractors from the Near East built it. All

scholars now agree that Stonehenge was a major ceremonial center and cult site

built by the people of the Salisbury Plain. Its astronomical uses indicate that it

functioned as a ceremonial center aligned around the motions of the sun and the

moon and it provided the basis for a regional calendar.

The English antiquarian William Stukeley (1687–1765) was the first modern to

write about the solar alignment of Stonehenge in 1740. The sun rises every day at a

different point on the horizon; that point moves back and forth along the horizon

over the course of a year, and each year at midsummer the sun, viewed from the

center of the sanctuary at Stonehenge, rises at its most northern point, which is

precisely where the builders placed the Heel Stone. The monument’s primary

astronomical orientation toward the midsummer sunrise is confirmed annually and

has not been disputed since Stuckeley.

In the 1960s, however, controversy erupted over claims for Stonehenge as a

sophisticated Neolithic astronomical “observatory” and “computer.” The matter

remains disputed today, but wide agreement exists on at least some larger

astronomical significance for Stonehenge, especially with regard to tracking

cyclical movements of the sun and the moon. The monument seems to have been

built to mark the extreme and mean points of seasonal movement of both heavenly

bodies along the horizon as they rise and set. Thus, the monument at Stonehenge

marks not only the sun’s rise at the summer solstice, but the rise of the sun at

winter solstice and at the fall and spring equinoxes. It also indicates the sun’s

settings at these times, and it tracks the more complicated movements of the moon

back and forth along the horizon, marking four different extremes for lunar motion.

The construction of Stonehenge required sustained observations of

the sun and the moon over a period of decades and mastery of horizon astronomy.

The monument embodied such observations, even in its earliest phases. The ruins

testify to detailed knowledge of heavenly movements and to a widespread practice

of “ritual astronomy.” We have no access to what megalithic Europeans thought

they were doing; their “theories” of the sun and the moon, if any, may have been

utterly fantastic, and we would probably label their explanations more religious

than naturalistic or scientific. Still, megalithic monuments embody a scientific

approach in that they reflect understanding of regularities of celestial motions and

they bespeak longterm systematic observations of nature. Paleolithic peoples knew

of the periodic motion of the sun and the moon, of course, but to create a Neolithic

monument like Stonehenge that records these longerterm motions along the

horizon required careful observation and (presumably oral) recordkeeping over

many years, probably over generations. In this way the knowledge accumulated

and embodied in Stonehenge required a degree of organization and systematization

not seen in the historical record to that point. Although religious elders, hereditary

experts, or priestly keepers of knowledge doubtless built and tended Stonehenge, it

probably goes too far to suggest that megalithic monuments provide evidence for a

class of professional astronomers or for astronomical research of the sort that later

appeared in the first civilizations. Stonehenge may better be thought of as a

celestial orrery or clock that kept track of the major motions of the major celestial

bodies and possibly some stars. In addition, Stonehenge certainly functioned as a

seasonal calendar, accurate and reliable down to a day. As a calendar, Stonehenge

kept track of the solar year and, even more, harmonized the annual motion of the

sun with the more complicated periodic motion of the moon. It may even have

been used to predict eclipses. In these telling ways—systematically observing the

heavens, mastering the clocklike movement of the sun and the moon, gaining

intellectual control over the calendar—it is possible and even necessary to speak of

Neolithic “astronomy” at Stonehenge. The further development of astronomy

awaited the advent of writing and cohorts of fulltime experts with the patronage of

centralized bureaucratic governments. But long before those developments,

Neolithic farmers systematically investigated the panorama of the heavens.

On the other side of the globe the remarkable giant statues of Easter Island (also

known as Rapa Nui) provide mute testimony to the same forces at play. Easter

Island is small and very isolated: a 46-square-mile speck of land 1,400 miles west

of South America and 900 miles from the nearest inhabited Pacific island.

Polynesian peoples reached Easter Island by sea sometime after 300 ce and

prospered through cultivating sweet potatoes, harvesting in a subtropical palm

forest, and fishing in an abundant sea. The economy was that of settled Paleolithic

or simple Neolithic societies, but local resources were rich, and even at slow

growth rates over a millennium the founding population inevitably expanded,

reaching 7,000 to 9,000 at the peak of the culture around 1200 to 1500 ce. (Some

experts put the figure at over 20,000.)

Islanders carved and erected more than 250 of their monumental moai statues on

giant ceremonial platforms facing the sea. Notably, the platforms possessed built-in

astronomical orientations. Reminiscent of the works of the peoples of Stonehenge

or the Olmecs of Central America, the average moai stood over 12 feet in height,

weighed nearly 14 tons, and was transported up to six miles overland by gangs of

55 to 70 men; a few mammoth idols rose nearly 30 feet tall and weighed up to 90

tons. Hundreds more statues—some significantly larger still—remain unfinished in

the quarry, where all activity seems to have stopped abruptly. Remote Easter Island

became completely deforested because of the demand for firewood and

construction material for seagoing canoes, without which islanders could not fish

for their staple of porpoise and tuna. By 1500, with the elimination of the palm tree

and the extinction of native bird populations, demographic pressures became

devastatingly acute, and islanders intensified chickenraising and resorted to

cannibalism and eating rats. The population quickly crashed to perhaps onetenth its

former size, the sad remnant “discovered” by Europeans in 1722. Only 100 souls

lived there in 1887. The wealth of the pristine island had provided rich resources

where a human society evolved in a typically Neolithic (or settled Paleolithic)

pattern. But human appetites and the island’s narrow ecological limits doomed the

continuation of the stone-working, heaven-gazing, and wood-burning culture that

evolved there.

In general, through observation of the sun and the moon Neolithic peoples around

the world established markers, usually horizon markers, that monitored the

periodic motion of these bodies across the horizon and sky, tracked the year and

the seasons, and provided information of great value to communities of early

farmers. In some cases the devices they created to reckon the year and predict the

seasons became quite elaborate and costly and were possible only because of the

surplus wealth produced in favored places.

Before Stonehenge and long before the settlement and ruination of Easter Island, in

certain constricted environments growing populations pressed against even

enlarged Neolithic resources, setting the stage in Egypt, Mesopotamia, and

elsewhere for a great technological transformation of the human way of life—the

advent of urban civilization.

Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment Imagine yourself with a disease that has recently be- come terminal. What kinds of treatments and options would be most important to you?

Almost everyone would want to be sure their physicians had considered, if not tried, all potentially effective disease-directed therapy and best possible palliative treatments to max- imize their quantity and quality of life.

Many patients would want to consider a timely transition to hospice care if no acceptable disease-directed therapies ex- isted, hoping to live as fully as possible for their remain- ing time, and then to die peacefully.

On these points we are completely in sync with the American College of Physicians (ACP) position paper (1).

We also know that most patients would want to know that they could refuse burdensome treatments that may keep them alive but with a low quality of life. (In fact, most patients die having forgone some poten- tially life-sustaining treatment.)

A substantial minority of terminally ill patients also would want some assurances about their ability to access or potentially activate a physician-assisted suicide if their suffering becomes un- acceptable (2).

For many of these patients, the motiva- tion is to maintain control over the manner and timing of their own death (many have been making a series of very challenging decisions throughout their illness and see no reason not to stay in charge of the last phase).

Others fear the potential of unacceptable physical suf- fering in the last phase of their illness, perhaps on the basis of experience. Still others might find that the pro- longed debility and dependence that might occur dur- ing the dying process are unacceptable (3).

Knowledge about what “last-resort” options are available (4), as well as which options one’s own doctor can support, would be reassuring to these patients.

It would free their emotional energy for other psychoso- cial and spiritual matters potentially critical to this last phase of life, and most patients ultimately will not need a medically assisted death if they receive excellent end-

of-life care. However, even with the best possible palli- ative and hospice care, a small percentage of patients eventually will want direct assistance with dying now.

Carefully exploring the why now for such requests and redoubling efforts to palliate suffering are the next steps, followed by an exploration of legally available options for responding (2).

The legal landscape for patients who want to end their life now is rapidly changing in North America and western Europe (5).

Both physician-assisted suicide and voluntary active euthanasia have been legal in the Netherlands, Belgium, and Luxembourg for many years, and both recently were legalized in Canada.

Physician-assisted suicide is now legal in 6 states and the District of Columbia (affecting one sixth of the U.S. population), whereas it remains either explicitly illegal or legally uncertain in the remaining states.

Most of the U.S. population favors legalization of physician-assisted death, although support decreases slightly when the word suicide is used in questionnaires (5).

The medical profession’s views are decidedly mixed on the subject of legal access.

Most U.S. physi- cians would want access for themselves, but a smaller percentage would be willing to provide assistance to their patients (6).

Positions of professional organiza- tions also vary on this subject.

For example, the ACP joins the American Medical Association in opposing the practice (1), whereas the American Academy of Hos- pice and Palliative Medicine has a neutral position, and the American Medical Student Association and the American Medical Women’s Association are in favor of legalization.

How should individual physicians proceed when opinions are so deeply divided?

We clearly support the steps outlined in the ACP position statement with regard to “responding to pa- tient requests for assisted suicide” (1). However, if re- quests persist and the unacceptable suffering contin- ues, we believe all legally available last-resort options

This article was published at Annals.org on 19 September 2017.

Table 1. Last-Resort Options

Intervention Ethical Consensus Regarding Permissibility

Legal Status

Aggressive symptom management Widely accepted in North America and western Europe

Legally permitted

Stopping or not starting life-sustaining therapy Widely accepted in North America and western Europe

Legally permitted

Palliative sedation (potentially to unconsciousness) Consensus if death unintended; controversial otherwise

Probably permissible but never tested

Voluntarily stopping eating and drinking Some controversy, often depending on religious views

Probably permissible but never tested

Physician-assisted suicide Opinion about permissibility differs widely Legally permitted in 6 states and the District of Columbia; legality uncertain in most other states; legal in Canada

Voluntary active euthanasia Opinion about permissibility differs widely Illegal and likely to be prosecuted in the United States; legal in Canada

Annals of Internal Medicine EDITORIAL

© 2017 American College of Physicians 597

should be explored (Table 1). Clinicians should deter- mine in advance which options they can and cannot personally support (4). They should extend themselves, if possible, to respond to their patients’ needs and re- quests without violating their fundamental personal val- ues, regardless of the status of the law.

If a patient de- sires a legally permitted option that the physician cannot support and common ground cannot be found, the patient should be given the opportunity to change physicians in a timely way so that access is allowed.

Given the rapidly changing legal environment with regard to physician-assisted suicide and voluntary ac- tive euthanasia, we are concerned that concluding a guideline by stating “physicians should not do this” is a problematic public health response.

Even if one per- sonally disagrees with the behavior, studying it might tell us much about the state of end-of-life care and how it can be improved. The Remmelink studies from the Netherlands (5) and Oregon Health Department data (7) provide examples of collecting meaningful informa- tion in an attempt to understand and improve practice. The scale and diversity of a state like California and a country like Canada warrant similar studies.

Table 2 gives examples of areas that should be examined as these large-scale implementation efforts are under way.

In addition, we worry that the ACP’s rigid opposi- tion will prevent physicians who will practice physician- assisted suicide from sharing ideas about better poli- cies and procedures.

Given the diversity of opinions and the legality of the procedure for so many people, this response seems like a missed opportunity to edu- cate clinicians and learn about best practices.

We should continue to debate the ethical and moral implications of permitting or prohibiting poten-

tially life-ending medical practices.

We need to support an environment that both redoubles our efforts to pro- vide palliative and hospice care to all seriously ill pa- tients and enhances our imperative to listen and re- spond to those who still feel they may need an escape from the last stages of this process.

We currently have an opportunity to learn about this process on a larger scale with a more diverse population than ever before. Let’s make sure our processes and safeguards are as robust and responsive as possible, and let’s learn as much as we can so that these new laws help us serve our patients and families in the best way possible.

Timothy E. Quill, MD University of Rochester Medical Center Rochester, New York

Robert M. Arnold, MD University of Pittsburgh Pittsburgh, Pennsylvania

Stuart J. Youngner, MD Case Western Reserve University Cleveland, Ohio

Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M17-2160.

Requests for Single Reprints: Timothy E. Quill, MD, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY 14642; e-mail, timothy_quill@urmc.rochester .edu.

Current author addresses are available at Annals.org.

Ann Intern Med. 2017;167:597-598. doi:10.7326/M17-2160

References 1. Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians.

Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper.

Ann Intern Med. 2017;167:576-8. doi:10 .7326/M17-0938 2. Quill TE. Doctor, I want to die. Will you help me? JAMA. 1993;270: 870-3. [PMID: 8340988] 3. Pearlman RA, Hsu C, Starks H, Back AL, Gordon JR, Bharucha AJ, et al.

Motivations for physician-assisted suicide. J Gen Intern Med. 2005;20:234-9. [PMID: 15836526] 4. Quill TE, Lo B, Brock DW.

Palliative options of last resort: a com- parison of voluntarily stopping eating and drinking, terminal seda- tion, physician-assisted suicide, and voluntary active euthanasia. JAMA. 1997;278:2099-104. [PMID: 9403426] 5. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J.

Atti- tudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90. [PMID: 27380345] doi:10.1001/jama.2016.8499 6. Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK.

A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med. 1998;338:1193-201. [PMID: 9554861] 7. Oregon Health Authority. Death with Dignity Act Annual Reports. 2017. Accessed at www.oregon.gov/oha/PH/PROVIDERPARTNER RESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT /Pages/ar-index.aspx on 18 August 2017.

Table 2. Representative Study Questions to Understand the Effect of Legalization of Physician-Assisted Suicide

Cases Numbers Diagnoses Second opinions Presence of palliative care and/or hospice

Requests Main reason Acceptance rates Refusal rates Hypothetical future vs. now

Second opinions Who provides Palliative care certification Acceptance vs. refusal rates

Practical aspects Change in primary treating physician Number of visits from initial request Documentation Actual methods

Long-term effect Family members Participating clinicians Participating consultants Hospice workers

EDITORIAL Physician-Assisted Suicide: A Path Forward in a Changing Legal Environment

598 Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017 Annals.org

Current Author Addresses: Dr. Quill: University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY 14642. Dr. Arnold: 1232 North Highland Avenue, Pittsburgh, PA 15206. Dr. Youngner: Department of Bioethics, Case Western Re- serve University, 10900 Euclid Avenue, Cleveland, OH 44106.

Annals.org Annals of Internal Medicine • Vol. 167 No. 8 • 17 October 2017

Copyright © American College of Physicians 2017.

In your own words, answer the questions below based on the reading: The Great Depression. John Steinbeck wrote The Grapes of Wrath based on primary sources from the Dust Bowl migration. He borrowed field notes written by Farm Security Administration worker and author Sanora Babb.

Babb collected personal stories about the lives of displaced migrants in preparation for her own novel, Whose Names Are Unknown.

Her supervisor, Tom Collins, who served as the director of Arvin Camp in California, shared her reports with Steinbeck. Steinbeck also used Collin’s records from Arvin Camp, photographs taken by Dorthea Lange, and conducted his own field research.

Steinbeck then wrote a series of seven articles for the San Francisco News, which ran from October 5-12, 1936.

These articles served as the basis for the novel, The Grapes of Wrath. In a long letter to editor Pascal Covici for the Viking Press, Steinbeck wrote: “Throughout I’ve tried to make the reader participate in the actuality, what he takes from it will be scaled on his own depth and shallowness.

There are five layers in this book, a reader will find as many as he can and he won’t find more than he has in himself.” He is later quoted to have stated, “I tried to write this book the way lives are being lived not the way books are written.”

1. What perspective does this excerpt provide regarding socioeconomic class standing in U.S. society during the Great Depression?

2. How can we as historians use fictional novels like The Grapes of Wrath to better understand historical causality, events, and the legacy of the Dust Bowl Crisis and the Great Depression?

3. This novel received both acclaim and negative attention when it was released. For example, Oklahoma Congressman Lyle Borden participated in ad hominem attacks on Steinbeck, stating, “‘this book exposes nothing but the total depravity, vulgarity, and degraded mentality of the author.’”

Throughout history, the book has become more celebrated in American literature, with return to critical attention throughout history.

○ Based on the lectures and this reading excerpt why do you think reception to the novel has changed over time?

What does this suggest about the preservation of the history of the Great Depression, or about U.S. history in general?

Here is the last example that I edit. Remember to put the quote like example