678. Who Gets to Choose a “Good Death”? | Freakonomics Radio

New York is the latest state to legalize medical aid in dying. Stephen Dubner speaks with the governor who signed the law, a Nobel Prize-winning economist, a death doula — and an ethicist who thinks the very idea is wrong. You can find the transcript and show notes for this episode on our website here: https://freakonomics.com/podcast/who-gets-to-choose-a-good-death/ Sign up here to pre-screen our new video show: https://docs.google.com/forms/d/e/1FAIpQLSdMQ0RUWCXYQNI0sdz2kj46nOL-diutRkjJ8WxJIXp0n2EHaA/viewform FOLLOW FREAKONOMICS RADIO: YouTube: https://freak.ws/3yIl6dl Apple Podcasts: https://freak.ws/3yAvQh0 Spotify: https://freak.ws/3TsdCmV ABOUT FREAKONOMICS RADIO: Discover the hidden side of everything with host Stephen J. Dubner, co-author of the Freakonomics books. Each week, Dubner speaks with Nobel laureates and provocateurs, intellectuals and entrepreneurs, and various other underachievers to uncover things you always thought you knew (but didn’t) and things you never thought you wanted to know (but do) — from the economics of sleep to the future of education, from markets for marriage to the surprising utility of wolves. ABOUT THE FREAKONOMICS RADIO NETWORK: Freakonomics began as a book, which led to a blog, a documentary film, more books, a pair of pants, and in 2010, a podcast called Freakonomics Radio. Hosted by Stephen J. Dubner, it’s one of the most popular podcasts in the world, with a reputation for storytelling that is both rigorous and entertaining. Its archive of more than 500 episodes is available, for free, on any podcast app, and the show airs weekly on NPR stations. Freakonomics Radio is now the flagship show of the Freakonomics Radio Network, which includes the podcasts No Stupid Questions, People I (Mostly) Admire, and The Economics of Everyday Things. FREAKONOMICS RADIO NETWORK PODCASTS: Freakonomics Radio: https://freakonomics.com/series/freakonomics-radio/ No Stupid Questions: https://freakonomics.com/series/nsq/ People I (Mostly) Admire: https://freakonomics.com/series/people-i-mostly-admire/ The Economics of Everyday Things: https://freakonomics.com/series/everyday-things/ Special series: https://freakonomics.com/topics/ CONNECT WITH US: [email protected] https://twitter.com/freakonomics https://www.instagram.com/freakonomics/ https://www.facebook.com/freakonomics/ https://www.tiktok.com/@freakonomicsradio https://www.linkedin.com/company/freakonomics-media Subscribe to our newsletter: https://stephendubner.substack.com/subscribe

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:04Stephen J. Dubner?

  Daniel Kahneman was a celebrated and influential scholar, trained in psychology, but with a seemingly limitless way of thinking about the world. In 2002, he won a Nobel Prize in Economics. In 2011, he published a popular book called Thinking: Fast and Slow. His primary topic was human decision-making, especially how we make decisions under uncertainty. His work has influenced people in government and policymaking, and medicine and finance, and the military, the criminal justice system, and more. And why were Kahneman's insights so valuable? Maybe because uncertainty is a feature, not a bug, of human existence.

• 0:46Stephen J. Dubner?

  Whatever you do in your professional or personal life, you have to deal with uncertainty. As for certainties, well, there just aren't that many of them. Perhaps the most reliable certainty in life is death. A couple of years ago, as Kahneman approached his 90th birthday, that certainty must have felt particularly salient. He was still in relatively good health, and his mind was sharp, but he decided that his time had come. He traveled to France, where he'd grown up, barely surviving the Nazis. He gathered with his family in Paris to celebrate his 90th birthday: meals, museum visits, nice walks.

• 1:29Stephen J. Dubner?

  From there, Kahneman traveled on to Switzerland, where the laws on assisted suicide are more permissive than most other places, and he ended his life. In an email to friends, he wrote, "I have believed since I was a teenager that the miseries and indignities of the last years of life are superfluous, and I am acting on that belief."

• 1:57Speaker 01

  Danny Kahneman made a very considered decision.

• 2:00Stephen J. Dubner?

  That is Al Roth. He is an economist at Stanford. He too has a Nobel Prize.

• 2:05Speaker 01

  He was not rushed. He wasn't being pressed by his family and friends, on the contrary. But he had himself witnessed some difficult deaths in his life, and he didn't want to experience one. What he said to people over the course of his life was that he'd had that conviction for a long time, that he didn't want a long, lingering death.

• 2:26Stephen J. Dubner?

  There are people that you and I both know, who were very close to Danny, who were pissed off at him. At least, that's what one person in particular that I'm thinking of expressed to me. The way this person put it was, I know Danny was 90, but his physical health was decent, his mental health was very, very good, and he left the rest of us bereft because we lost a year, or maybe two or three of Danny. So this person found Danny's decision, I would call it repugnant, maybe, because it really didn't include the feelings of people who loved him. What's your view on that?

• 3:00Speaker 01

  I think these decisions are very personal. I've talked to Danny several times a year. I wasn't very close. If I had been closer to him and involved in the discussion, I probably would have argued against doing it. He seemed okay to me, too. And he had a partner, he had a lot to live for. But I wouldn't want to legislate my opinions about what he should do.

• 3:25Stephen J. Dubner?

  The reason I asked Al Roth whether Kahneman's decision might strike some people as repugnant is because Roth is perhaps the world's leading authority on what he calls repugnant transactions. He's just published a book called Moral Economics: From Prostitution to Organ Sales: What Controversial Transactions Reveal About How Markets Work. One chapter is about the growing acceptance of assisted suicide, or what is often called MAID, or Medical Aid in Dying. Today on Freakonomics Radio, how we think about death generally.

• 4:00Speaker 02

  I cannot live my life to the extent of fullness until I make friends with death.

• 4:07Stephen J. Dubner?

  We'll hear from a governor who just signed a new Medical Aid in Dying law.

• 4:12Speaker 03

  I kept my personal story to myself. I never want to make policy based on my life experience. It's not appropriate.

• 4:19Stephen J. Dubner?

  And we hear an opposing view.

• 4:22Speaker 04

  I think it's bad medicine, bad ethics and bad public policy and a grave mistake for society.

• 4:29Stephen J. Dubner?

  At least for now, death is still a certainty. But more and more, the timing is not.

• 4:48Speaker 05

  This is Freakonomics Radio, the podcast that explores the hidden side of everything with your host, Stephen Dubner.

• 5:04Stephen J. Dubner?

  Al Roth won his Nobel Prize for his work in market design. He's best known for his pioneering research on kidney exchange programs. Buying and selling organs is illegal in most places, but by designing a better way to match up potential donors with people who need a kidney, Roth has helped save thousands of lives. We once made an episode about this called "Make Me a Match."

• 5:27Speaker 01

  When I started working on kidney exchange, there were about 40,000 people, Americans, on the waiting list for a deceased donor kidney. Today, there are almost 100,000, and there are 500,000 people on dialysis in the United States. So that means lots of people who could potentially profit from a transplant aren't even on the waiting list because the waiting list is too long and you don't live long enough. So we need more kidneys. And in the meantime, we can continue to expand kidney exchange to make it work better.

• 5:56Stephen J. Dubner?

  In most markets that economists study, buyers and sellers are brought together by the pricing mechanism. But in some markets, people are reluctant to use prices, with kidneys, for instance.

• 6:07Speaker 01

  One of the curious facts of the world is not everyone agrees with economists about what should happen in the world.

• 6:14Stephen J. Dubner?

  Does anyone agree with economists about what should happen in the world?

• 6:16Speaker 01

  Well, just you and me. But you know, if you're going to be a market designer, you have to understand the full scope. And part of the scope is that markets need social support to work well. And not all markets get social support. And we market designers have to understand that better if we want to make interventions in markets.

• 6:34Stephen J. Dubner?

  This brings us back to repugnant transactions, an idea that Roth has been studying for a while.

• 6:40Speaker 01

  So a repugnant transaction is some people want it, some people object to it, even though they can't tell if it has happened for moral or religious reasons. Now, one transaction that used to be repugnant by that definition, maybe still is, but used to be illegal and is no longer illegal, is same-sex marriage, also interracial marriage, incidentally. Both of those were things that at least some states had laws against. And in the United States, there weren't even laws against same-sex marriage so much as it was inconceivable. So that's something that was an illegal, a banned transaction that is now a legal transaction.

• 7:18Stephen J. Dubner?

  So when it comes to aid or medical aid in dying, where does that lie in your thinking about repugnance? I'm especially curious to know how the issue may have shifted over the past few decades, let's say.

• 7:30Speaker 01

  So Hippocrates was an ancient Greek doctor, and the Hippocratic oath is an oath that he administered to his students. They're supposed to promise to be good doctors. And part of it was, I will not give medical aid in dying. That's a loose translation from the ancient Greek.

• 7:45Stephen J. Dubner?

  To be fair, religious thinking about death was a little bit different, perhaps, than it is now, yes?

• 7:50Speaker 01

  Religions still are very against. I mean, certainly, there's active religious opposition to medical aid in dying, which is, however, a growing practice. Like, a dozen American states now have some medical aid in dying. New York State, where you're living, I think they're going to have it this year.

• 8:09Stephen J. Dubner?

  That is true. There are now 12 US states, plus the District of Columbia, where some form of assisted dying is allowed. Oregon was the first in 1997. The modern movement toward legal assisted dying began in Switzerland, where Danny Kahneman chose to end his life. In Switzerland, it has been legal since 1942. By now, the policy has been adopted in some form in the Netherlands, Belgium, Canada, Spain, much of Australia. The American movement has had its own characteristics.

• 8:42Speaker 01

  There was an organization called the Hemlock Society that published a book of how to. It was called Let Me Die Before I Wake. But the problem there, so I know people who are in this situation. They hoarded pills. They were ready. They had a plan. But then they couldn't swallow a lot of pills when they were very ill. So one of the activists for medical aid and dying was a fellow named Jack Kevorkian, who I write about, Dr. Death. And he arranged to help people when it was illegal everywhere in the United States. He arranged to help people and eventually went to prison.

• 9:16Stephen J. Dubner?

  He went to prison because of one case in which he administered the drug rather than having the patient administer the drug, right?

• 9:23Speaker 01

  He was pushing the envelope. So he developed a machine that would allow people to inject themselves with lethal drugs. And he would make videos and have the discussions with them to make clear that they were interested and all that. And he would inform the police because it was against the law and he wanted to challenge the law. He was tried for murder on multiple occasions. And as you say, it's only on the last occasion that he was convicted and imprisoned. And he was on national television. He was a very public defender of medical aid and dying.

• 9:52Stephen J. Dubner?

  It may have seemed at the time, this was a few decades ago, it may have seemed at the time that this was about to go much more mainstream than it actually did. Would you agree with that?

• 10:02Speaker 01

  Yes. And it's been very slow. So they're really trying to be careful that this isn't help in stopping living, but aid in dying.

• 10:14Stephen J. Dubner?

  Okay, that's a big point that Al Roth is raising. If you want to legalize medical aid in dying, you need to do what you can to make sure the law isn't exploited or abused. In other words, you'll need to put some guardrails around the law. Earlier this year, New York Governor Kathy Hochul signed the Medical Aid in Dying Act. It is scheduled to take effect in August, and it will allow terminally ill New Yorkers with less than six months to live to request medication to end their lives. The law has a number of safeguards baked in: a mandatory mental health evaluation, an in-person visit with a physician, a five-day waiting period after the prescription is written. The law also requires that the patient, not a relative or caregiver,

• 10:58Stephen J. Dubner?

  make the request on a video or audio recording. Here is Governor Hochul.

• 11:04Speaker 03

  I told them I would only sign it with my guardrails. That is the power the governor has. You can pass all you want. I can veto every time. But if you want to get it enacted into law, you have to look at what I want to do.

• 11:16Stephen J. Dubner?

  I asked Hochul how this issue came to her attention.

• 11:19Speaker 03

  It came to my attention from a number of advocates, individuals who saw their loved one die under what one could consider inhumane circumstances, when they literally were given a death sentence and had to linger on and on and on. And something that I dealt with with my own mother. I was raised a pretty staunch Irish Catholic and believe in many of the tenets of the faith. But this one became personal. My mother was diagnosed with ALS probably two months before I became a nominee for lieutenant governor. So she never saw me ascend to this position. We lost her, but she deteriorated rapidly. And we knew nothing about the disease other than she would not survive it. To watch her lose her own voice physically

• 12:04Speaker 03

  and her vision and ability to communicate, it was just heartbreaking.

• 12:08Stephen J. Dubner?

  How long did she? I don't know if linger is the right word, but how long was that process?

• 12:13Speaker 03

  I'd say the worst was probably four, five, six months.

• 12:16Stephen J. Dubner?

  And how long ago did she die?

• 12:18Speaker 03

  That was in 2014.

• 12:20Stephen J. Dubner?

  This bill has probably been around almost that long? Is that right?

• 12:24Speaker 03

  2016 was when it was first introduced in our state legislature. But this was the first time there had been really much more advocacy around this. People came to my office and told their stories and I held their hands of women, particularly who told the most horrific stories. You know, one woman whose husband was suffering so much. He wasn't an elderly man at all, but he was diagnosed with a terminal disease and he just begged her to pull out the gun and shoot him someday. And she felt terrible that she didn't relieve him of his pain, but she knew she couldn't kill her husband. So these are the horrible circumstances that ordinary people find themselves in. And I'm just one who's hardwired. Maybe it's because I'm the first woman governor.

• 13:06Speaker 03

  I'm hardwired to solve problems and if I can give compassion and alleviate emotional pain, I'm going to do that. And this seems to be in that category of people who are really suffering and I could do something about it.

• 13:19Stephen J. Dubner?

  Why did it take so long for it to happen here? Because the way that you describe it with your mom and the way you describe hearing from other people, it seems, I don't want to say like a no brainer, but it seems like something that there should have been pretty broad support for. Why did it take so long to get through legislature?

• 13:35Speaker 03

  Well, legislators first proposed it, but never could get it passed in the legislature. I kept my personal story to myself. I never want to make policy based on my life experience. It's not appropriate. What really happened was the advocates became much more intentional. It seems like it took a long time, but I also listened to the opposition intently as well. That's why I crafted a bill like no other in the country.

• 13:59Stephen J. Dubner?

  It's got a lot of guardrails in it.

• 14:01Speaker 03

  I put a lot of safeguards in because I knew that when people said their fear was that someone could be coerced, you know, by a spouse who really didn't love them or a family member who got tired of taking care of a parent or taking care of someone with severe disabilities and thought that their life didn't have value. I wanted to let them know their life does have value. And so I had to stand up and figure out a path forward where I would let them know I listened to them. And engage their concerns and really legislated to solve them.

• 14:30Stephen J. Dubner?

  As you've noted, the Catholic Church opposes medical aid in dying. You've touched on how you reconciled that it's a personal issue, but you also believe there is enough justification for it to become law. I am curious, though, how much heat you may have taken from Catholic family members, friends, maybe priests who tell you that they've objected to what you've done.

• 14:52Speaker 03

  Oh, it was bigger than that. It was, you know, people told to preach from the pulpit against me and to put in the church bulletin, which everybody reads when they're not paying attention in church. So, no, it was far reaching, the opposition.

• 15:07Stephen J. Dubner?

  And this is for the law that's been passed, but hasn't even gone into effect yet. So what are you expecting? Because once people start availing themselves of this law, there will be stories and headlines. Are you prepared for another wave?

• 15:20Speaker 03

  Yes, I have waves on every issue every day of the week, Stephen. So this job is not for the faint of heart. I'm conditioned to make a decision based on all the facts. I did do a lot of study, also personal reflection, but my views cannot dictate what happens for 20 million people who may have a different opinion. That is that personal liberty that I don't think government should interfere with. I can't impose my morality on others. This is the foundation of our country, that you have free will and you can make decisions. And I did put parameters on. There are others who think I shouldn't have had any restrictions, right? Why is it limited to six months? Why can't people just do this whenever they want? I have to find that sweet spot.

• 16:00Stephen J. Dubner?

  I'm curious to know how you think about access to legal abortion in concert with or in relation to medical aid in dying. As you've noted, as a Catholic, there may be personal beliefs that need to be set aside, or there may be larger beliefs that you think may even trump your personal beliefs. But can someone be, in your view, anti-abortion and pro-medical assistance in dying, let's say?

• 16:23Speaker 03

  People can be whatever they want. I'm not the judge to say whether you're being consistent or not. That's not my role. I know many cafeteria Catholics, for example. You still love what the church stands for. It's charitableness and taking care of people and the teachings of Jesus Christ that I was raised on about, you know, really inspiring me to go into public service, based on what my parents taught me. They were social justice Catholics. We protested everything. We stood up for farm workers in the 60s. We didn't eat grapes or lettuce in support of the boycotts. We marched against the Vietnam War. Our Catholic police were leaders of social movements for my early part of my life. I've not seen the same philosophies that I did growing up, but that had a lifelong impact on me. So I don't judge people by their consistency.

• 17:08Stephen J. Dubner?

  What are some of the unintended consequences that you were or are concerned about with the medical aid in dying act? One thing that just came to mind is I know New York State has seen pretty high suicide numbers in recent years, especially among veterans. I also know that New York State spends a lot of money on suicide prevention. And yet here now is the state endorsing or legalizing at least what some people call elective suicide. So I'm wondering how you're thinking through how people may act upon this law, if there are things that you're concerned about.

• 17:41Speaker 03

  That's why it is so narrowly tailored. It is someone who literally has, determined by a doctor and a mental health professional, this person has six months or less to live on this earth. And if they want to leave in the comfort of their families, surrounded by loved ones, maybe hearing their grandkids in the next room laugh, instead of being in a sanitary building, a hospital that's so devoid of life and denying them the existence that they're familiar with, I can't do that. So yes, people will criticize. Yes, it's going to be difficult when it starts happening. Yes, there's always someone who thinks they can do it better, but I'm going to do everything I can based on the best judgment I have.

• 18:25Stephen J. Dubner?

  You may not be surprised to learn that there are people who disagree with Governor Hochul. Coming up after the break, we will hear the opposition argument. I'm Stephen Dubner. This is Freakonomics Radio, and I appreciate your listening. We will be right back.

• 18:52Stephen J. Dubner?

  A 2024 Gallup survey found that 71% of Americans believe that doctors should be, quote, "allowed by law to end the patient's life by some painless means if the patient and his or her family request it." But there's still substantial political and legal opposition. Here again is Al Roth, the author of Moral Economics.

• 19:15Speaker 01

  Two of our current Supreme Court justices are very, very much against medical aid in dying.

• 19:20Stephen J. Dubner?

  The two justices he's talking about are Neil Gorsuch and Amy Coney Barrett. In 1997, the Supreme Court ruled unanimously that there is no constitutional right to an assisted suicide, but it left the issue largely to the states. Barrett is a Catholic. Gorsuch was raised Catholic, but now attends an Episcopal church.

• 19:42Speaker 01

  Barrett writes, when she was just Amy Coney, not Amy Coney Barrett, she writes about the obligations of Catholic judges. And there's a line in there which says, you know, the objection to medical aid in dying is much stronger than capital punishment or war, right? Because she thinks there might be reasons for capital punishment and war. But the Catholic Church is quite clear that it thinks there's never justification for medical aid in dying. Although, I mean, the Catholic Church is also at the forefront of providing hospice care. They don't think people necessarily have to die after months of agony. They're willing to try to take care of people who are dying to ease the agony, but they don't like shortening life.

• 20:24Stephen J. Dubner?

  And Neil Gorsuch, if I recall, wrote a book about assisted suicide, yes?

• 20:30Speaker 01

  He did. He thinks it's not justified. And so opponents of medical aid in dying are no doubt now looking for a case that can be appealed to the Supreme Court.

• 20:38Stephen J. Dubner?

  Do you anticipate that 10 years from now, of course, medical assistance in dying will be legal in all 50 states and maybe federally? Or maybe do you think it's going in the other direction? Or do we just not know?

• 20:49Speaker 01

  Well, I don't know. And the fact that we have a Supreme Court, which has two conservative members. Very much committed that medical aid in dying should be illegal makes me skeptical about what I would otherwise notice, which is that medical aid in dying has a lot of appeal to a society like ours where advances in medicine have not ended death by any means, but have allowed the dying process to sometimes go on for a long time in uncomfortable, undignified, painful ways.

• 21:21Stephen J. Dubner?

  I see there's no standardized federal database on medically assisted suicide, and I'm just wondering if you think the count is, you know, much, much higher than we think, because there are obviously a lot of ways to navigate that. Do we know anything about the actual numbers?

• 21:36Speaker 01

  It's hard to get the actual numbers, but I think there's no question that there's a lot of covert medical aid in dying in places where it's not legal. And the reason is that the same medicines that relieve pain can also shorten life. When I talk to doctors, many of them know of cases that they think of as having been medical aid in dying. And there have been some papers, there's one from Australia, that says that when you survey doctors privately, there's quite a bit of medical aid in dying. So I think that the high numbers in Canada that are causing some backlash against the Canadian laws.

• 22:10Stephen J. Dubner?

  It's roughly one in 20 deaths in Canada runs through the government-run assisted suicide program.

• 22:15Speaker 01

  Five percent. Incidentally, the large majority of those are elderly, late-stage cancer patients. I think that a lot of those big numbers come from the fact that there was medical aid in dying before it was legal in Canada, just because when you have bony metastases from cancer, you're in pain. So your doctors give you high doses of painkiller, and when you say that's not enough, they say, all right, we'll give you more, and then maybe you don't wake up.

• 22:45Stephen J. Dubner?

  I'm guessing there are physicians in Canada, especially palliative care physicians, who would take issue with Al Roth's assessment, but the fact remains that the medical aid in dying law in Canada has moved beyond the narrow scope of the American model. In Canada, aid is available not only in terminal cases, but in some cases where death is not imminent. The legislature has also debated whether to expand eligibility for people whose sole underlying condition is mental illness. Critics of medical aid in dying see the Canadian system as a warning.

• 23:22Speaker 04

  The logical slippery slope suggests all of the safeguards that are built into laws eventually become seen as barriers to access.

• 23:32Stephen J. Dubner?

  That is Daniel Solmazy, a physician, philosopher, and director of the Kennedy Institute of Ethics at Georgetown University.

• 23:40Speaker 04

  All these restrictions are vaporware. Every place they've been put in, every guardrail becomes a barrier. The states that have had waiting periods are now eliminating waiting periods. The requirement for residency gets waived by states.

• 23:57Stephen J. Dubner?

  Solmazy's path to a career in medicine and ethics was not a typical path. After his first year in an internal medicine residency at Johns Hopkins, he joined a Franciscan order and he lived as a friar for more than 25 years. He left the order after falling in love and deciding to marry. While the Catholic Church opposes assisted suicide, Solmazy says his views come more from his experience as a physician at the bedside.

• 24:25Speaker 04

  As a medical student, I was drawn actually to caring for patients who were ill and dying and at a time when other people would sort of run away from them. There's nothing more to do, right? It was experiences like that and an interest in philosophy, theology, that led me to really think that my contribution in medicine would be through medical ethics.

• 24:52Stephen J. Dubner?

  So, recent polling, which is imperfect polling, we have to admit that, and it also shifts a lot over time and it shifts depending on how the question is asked and who's asking the question, but- Recent polling on the topic shows that roughly two thirds of Americans are in support of some form of medical aid in dying. You are among the one third who is not in support of that. Give me the main arguments against that, please.

• 25:17Speaker 04

  Sure, I think it's bad medicine, bad ethics and bad public policy and a grave mistake for society.

• 25:26Stephen J. Dubner?

  Okay, walk me through those. Bad medicine, why?

• 25:28Speaker 04

  I think it's bad medicine because at this point in history, we can do more than we have ever been able to do to treat patients' symptoms. And the data will bear out that the reason people want euthanasia or assisted suicide when they actually follow through are reasons like loss of control, feeling like a burden to other people, loss of autonomy. These are not medical diagnoses and they're not good reasons to give lethal medication. I also think that it's bad medicine because the trust that is necessary for a patient

• 26:10Speaker 04

  to be able to bear their body, bear their soul, all their intimate secrets before a physician, requires some very fundamental, basic rules. And these go back to Hippocrates. In a nutshell, the Hippocratic oath says, I won't disclose your secrets, I won't have sex with you and I won't kill you. And that's the bottom line.

• 26:35Stephen J. Dubner?

  As you well know, the medical aid in dying movement is growing. More and more states are legalizing it, including New York, where I live. And we've interviewed for this program, New York Governor Kathy Hochul, who has advocated for the policy, although hers is a little bit different from other states, in part because she says she watched her mother die of ALS and came away believing that people should have this option. How do you feel seeing these laws pass in more jurisdictions? Do you feel like you're losing the battle? Do you try to avoid the framing of this being a fight? Do you feel like we're just in the early stages? How do you see that?

• 27:14Speaker 04

  I think I'm fighting a battle and I think that it is a difficult one because of the...

• 27:22Speaker 04

  Social valuing of control. Most of the people, if you see, who really, in the end, want this and do it, at least in the United States, are people who are probably your listeners. They're very educated, typically well-off, largely white people, who are used to being in control of everything, and the moment they lose control, they want to have this. They want to have it in their back pocket, even if they don't use it. And there's a sense in which they are indifferent to what the legalization of this does to countless other people. Like, you probably saw in New York, as in other places, the way in which the disabled

• 28:03Speaker 04

  community really is very fearful of these kinds of laws. And it's not because they think they're going to be lined up in wheelchairs and forcibly injected, but the fact that people say what's most important, and the state has now given sanction to this, is being in control, being independent of other people, not having disfigurement, being in control of your bowels, right? That this is a justification for state-sanctioned suicide. And the person who's in a wheelchair and needs help with toileting every day says, "This is an affront to my dignity."

• 28:43Stephen J. Dubner?

  I hear your point there, but I guess the devil's advocate in my mind moves toward the idea of individual autonomy here. And it does strike me that there is a certain consistency on Catholic positions, particularly toward medical aid in dying, as well as abortion, gay marriage, which is that there is a right way to do things and a wrong way. But each of those issues, medical aid in dying, abortion, gay marriage, they also intersect with this notion of individual autonomy or bodily autonomy. But then there are other Catholic positions that run in favor of autonomy, like free will is, it's a pretty big one. Some people might see that as a contradiction. I gather you don't. I'd love you to explain why it's not.

• 29:26Speaker 04

  Well, basically, free will makes the possibility of morality real. If you don't have free will, then there is no choice. And if there is no choice, there's no possibility of assessing praise or blaming what any of us do. Right? Aristotle says that ethics is about what to do when what to do is up to us. So to have a system of morality, you have to have a concept of free will. But then you have to ask, what is the purpose of free will? Right? Why do we have the possibility of choosing? And how do we use that freedom? Things aren't right because we choose them. We choose them because we think they're right.

• 30:10Speaker 04

  And we have to admit that we can be mistaken in our moral views. Right? And that's the way in which I would talk about this. Another thing I wanted to mention particularly, this is Freakonomics, right? Is some of the economics of assisted suicide and euthanasia. Shortly after the Canadian court decision that required the legalization of euthanasia there, there were already health economists publishing papers on how great this would be for the financially strapped Canadian healthcare system. One of my colleagues has said, if your healthcare system isn't giving you the kind of care at the end of life that you need, then for God's sake, change your healthcare system.

• 30:55Speaker 04

  Don't commit suicide.

• 30:56Stephen J. Dubner?

  Do you think there's going to be the momentum that gets an issue like this to the Supreme Court? And if so, how do you see that playing out?

• 31:04Speaker 04

  I doubt it's going to get to the Supreme Court again. They said it goes to the states, right? And the states are the places where this is being played out. What I think you're beginning to see is a map that looks a lot like the abortion map. A red state, blue state distinction on places where this is permitted and where it's still banned.

• 31:25Stephen J. Dubner?

  Do you feel that this is an argument that you and your like-minded colleagues are losing, though?

• 31:32Speaker 04

  I think that arguments matter and ideas matter. And even if the case is that states are continuing to legalize this, that eventually will come to our senses as a society and I will be justified. I don't know how far it's going to go before that happens. I think it's a symptom of something more deeply wrong with our society.

• 31:57Stephen J. Dubner?

  What would that wrong be?

• 31:59Speaker 04

  I think it is a sense that being in control is the most important thing in life. And that's very American. If being in control is the most important thing, it's a pretty paltry philosophy, right? You can't control who your biological parents were. You can't not die and you can't make somebody love you, right? Because at the moment that it's not a free choice from them, but you're in control, then it's no longer love. So if control is the most important thing, it's something that can't account for birth, death, or love. And that's a problem.

• 32:35Stephen J. Dubner?

  That was Daniel Solmazey from Georgetown. Coming up after the break, another close-up look at death, the thing we like to look away from. This is Freakonomics Radio. I'm Stephen Dubner. We will be right back. The economist Al Roth is 74 years old. He's in good health. On the day of our interview, he rode his bike to the studio on the Stanford campus. But even economists have to die someday.

• 33:20Stephen J. Dubner?

  I'm just curious whether all this thinking about and writing about medical assistance in dying has changed the way you think about not dying, but life.

• 33:32Speaker 01

  I'm enjoying life.

• 33:33Stephen J. Dubner?

  I'm glad to hear that.

• 33:34Speaker 01

  I'm enjoying life. I mean, I've also thought a lot about organ donation, so I'm very prepared to be a deceased organ donor. There's some intersection between those two things, incidentally. In places like Belgium, you can have medical assistance in dying that allows you to be an organ donor, you know, that you die in a way that preserves your organs. Then there are people who want that. But I've thought about it, and when we moved to California in 2012, we considered at least the possibility that we would grow old here one day. And so our house is not wheelchair accessible, but it can easily be made wheelchair accessible. And that had to do with how we did renovations. The bathrooms are big enough, but so we're enjoying ourselves. We hope to keep enjoying ourselves. But I don't think that I want to die at great length and in great pain.

• 34:17Stephen J. Dubner?

  I have a sister who died last year. It was a pretty rotten death, honestly. And she wanted to hasten it. We couldn't physically orchestrate it. And it really made me see this issue in a new way. It just seemed, you know, I don't want to say the scales fell from my eyes, but I'd never encountered it firsthand. And it made me think that almost anyone who did encounter it firsthand might have a reckoning, might be in favor of it. But I don't know, maybe that's just me. Do you have any sense of how broad the support is for it generally?

• 34:52Speaker 01

  We're an aging population. So I think that not only do more people have a reason to contemplate their own death, but more people know a peer who's died, and certainly parents have died, and relatives, you know, siblings and friends. So I would think that anyone who's seen an agonizing death should at least give some thought to whether we should be legalizing medical aid in dying.

• 35:22Speaker 02

  So may I wave my wand and go into a perfect scenario?

• 35:25Stephen J. Dubner?

  Please.

• 35:26Speaker 02

  The perfect scenario would be... Bringing back the awareness that end of life is a natural part of life's journey. And 100 years ago, this skill of caring for somebody at the end of life was handed down from a grandmother to a grandchild. It was a communal event. We knew how to do it. So if we can bring that skill back now, we can have the opportunity to have that end of life go as well as possible.

• 35:50Stephen J. Dubner?

  That is Suzanne O'Brien. She used to be a hospice nurse, and now she works as what is called a death doula.

• 35:57Speaker 02

  I am the founder of Doula Givers Institute, and I'm also the author of The Good Death, A Guide Supporting Your Loved One Through the End of Life.

• 36:06Stephen J. Dubner?

  First of all, Doula Givers Institute. I know doula from birthing, but we're talking now about doula at the end of life. So what is a doula giver? Is that the phrase that you typically use? Or death doula? What is the phrase you prefer?

• 36:22Speaker 02

  So doula givers is the unique name to my education and my institute, but it really is about a death doula, which, again, you had said about a birthing doula, very similar in the experience. And I know they're very different as well, but bringing somebody into this world holistically, think about the preparation we put into that. And then we don't do anything right now towards the end of life. I don't think anyone, when they're younger, says, I'm going to grow up and be a death doula. I just don't think that's one of the options. At least, it's not right now. I did grow up in a medical family. My father was a doctor, a surgeon. There was a day where I said, you know what? I think I'm going to become a nurse, and this is the reason why. I feel that becoming a nurse could have purpose on a daily basis.

• 37:07Speaker 02

  I could be making a difference with what I do. Plus, I could do lots of different types of nursing, and also I can, you know, live different places. So it sounded good in that sense. Six months into working at the hospital after I graduated, three years of nursing school, I remember the day I realized I was never going to get the fulfillment from nursing that I thought I was. And I thought, what am I going to do?

• 37:28Stephen J. Dubner?

  How come? Why were you not getting the fulfillment?

• 37:31Speaker 02

  I have to tell you that our healthcare system is struggling. It's fragmented. We have way too many patients. We have very little actual time with the patient. It's about documentation. It's about passing medications, but also watching patients and families not have the education or the support or the time. And I really will say that time is our greatest medicine when we really can support people with presence and compassion and also education.

• 37:59Speaker 02

  For aging well and symptom management, and it's just not available. And also, it was just a burnout. The whole thing was an eye opener to me. And I heard a little voice that said, go to hospice. And I remember thinking, first of all, why am I hearing that? I have no end of life experience. But when I thought about working with people at the end of life, there was something that was so connected. The very first day I went out to see hospice patients, I knew I was in the exact place I was supposed to be in my life.

• 38:24Stephen J. Dubner?

  O'Brien worked in hospice care for many years, but she ultimately found that wasn't quite right either.

• 38:30Speaker 02

  The current hospice model relies on 98% of the hands-on end-of-life care being done by the family caregiver. And so hospice, we can talk about how it started, but based when the reimbursement model came through, which I believe the hospice benefit came in 1982 with Ronald Reagan.

• 38:48Stephen J. Dubner?

  That's right, yeah.

• 38:49Speaker 02

  It changed everything. So in one sense, they said, well, now everyone has access, right? So that's like the big banner and that sounds great. So the hospice model today is that the hospice nurse is supposed to teach the loved ones how to do that end-of-life care. When I was a hospice nurse, I had about one hour once a week to teach that care. There's this perfect storm that's happening right now, the late time that people are getting admitted to hospice, the fear of death that's prevalent. And I'm there for one hour once a week. What can really be done there? It's not working well.

• 39:24Stephen J. Dubner?

  And that's when Suzanne O'Brien discovered a different model, the doula model. Death doulas are still a pretty loosely organized profession. There's no national licensing system, no official count of their numbers. The hourly wage varies from around $25 to $150 an hour. O'Brien offers free training through her Doula Givers Institute.

• 39:47Speaker 02

  Over 16 years, we've had over 400,000 people from 39 countries take that training.

• 39:55Stephen J. Dubner?

  So there are around 2.5 million Americans over age 60 who die every year. How many death doulas are there in the country?

• 40:05Speaker 02

  Not enough. Death is not a medical experience. It's a human one, and we just forgot that.

• 40:11Stephen J. Dubner?

  It sounds like you want a revolution.

• 40:15Speaker 02

  Yes, of love and of care and of compassion and of presence and of bringing death back to the sacred, natural experience it was meant to be.

• 40:23Stephen J. Dubner?

  So I'm guessing that almost anyone listening to this who's either thinking about death themselves or for a loved one, they're thinking, well, gosh, yeah, sure, a death doula sounds fantastic, but there aren't that many of them. How do I get one? And oh, by the way, isn't this going to be very expensive? So how does the death doula occupation intersect with the healthcare industry? Is it part of insurance and other coverage like that?

• 40:52Speaker 02

  So it's not reimbursed by insurance, and that's a great thing. Why? Because if it were, then it would be put in every one of those categories where we'd have to see 10 or 15 people and we'd be rushed and it wouldn't have the value, right? So what the difference is, is that hospices, the medical manager of that case, they don't have a lot of time. It's not their fault. The death doula is educated in medical terminology, medical disease processes, the progression. So think of it like this. They act as the eyes and ears for that hospice team that can't be there. They can alert them at the first time of change. They can reinforce the patient teaching. And it is a self-pay, but I know that our doulas, they have people on sliding scales and they have other things. But I

• 41:35Speaker 02

  do want to point out this, if I may. The average cost of a funeral, and again, in the United States, is between $7,000 and $11,000. If you took a fraction of that money and put it towards some care when you needed it, the difference that that could make. So I think sometimes it's how we choose to allocate the money. I remember going on a volunteer trip to Zimbabwe to be a hospice nurse to go help them, right? The average age of a woman's life was about 42 at the time. Seven-year-old children were taken care of, end-of-life parents. They don't have the medications and all of the equipment that we have, but what they did have was education and they did have time. It was so effective. I came back to the United States, wrote this program, went into my CEO of my hospice and said,

• 42:20Speaker 02

  "End of life is not going well for most of the patients. What about this training from three phases of end of life, the interventions to use, everything that I've learned from bedside?" He said, "This is great. We can't use it." I said, "Why?" He goes, "We won't get reimbursed for it, so it won't fit into the model."

• 42:36Stephen J. Dubner?

  So how does your work as a death doula intersect with what's called assisted suicide, medical assistance in dying, elective suicide? You know, there are many, many phrases over the years. I can't really tell from your work whether you would be necessarily opposed to medical assistance in dying. Tell me how you feel about the concept of choosing when and how to die on your own terms.

• 43:03Speaker 02

  My whole platform is education and not making decisions out of fear. I remember coming to see my ALS patient for the very first time and he was already paralyzed, but you know, the mind is totally intact. And he made a comment on the very first visit that said, you know, "When the time comes, I'll take care of it." You could hear the fear that was underneath there. And we know from ALS that the diaphragm is not at one point going to be able to expand and people are not going to be able to breathe. That's a terrible thing to know that that's coming. He also was very concerned about being a burden to his wife, who was the sole caregiver. And so I knew, building the trust with him, but also educating them on the medications we have for breathing issues. And when it became more challenging that he would need more medication, but then be

• 43:48Speaker 02

  in a sleeping coma, and that we would be here to support his wife. So when I hear medical aid in dying from the experience that I've had, there is an undercurrent of fear and wanting to be in control. And I want to address the fear and the control issues for people. I'm not saying it's not a choice, but I want you to be making it subjectively with a clear, sound mind. People are out there fighting for medical aid in dying, like really fighting to get their laws passed. And I'm like, you have things available if you know what they are and how to access them right at the ready. When somebody has brain cancer or some kind of intractable pain, which does happen, we need more medication. They need to know to ask for it. And that's part of the gap with the education of families.

• 44:32Speaker 02

  People are overwhelmed. They're usually in fight or flight. It's very hard for them to even know what to do next.

• 44:39Stephen J. Dubner?

  Does this mean that you think that the medical aid in death laws that are increasingly passing around the country, do you feel they're unnecessary or redundant?

• 44:48Speaker 02

  No, I think that you can have them. I think that in certain circumstances, absolutely. But here's an interesting statistic. 61% of the people who get the medications to end their life do not use them.

• 44:59Stephen J. Dubner?

  Hmm, interesting. Let me ask you, if I'm, let's say, 60 years old and in good health, when should I think about starting the big plan?

• 45:09Speaker 02

  When you were 40.

• 45:11Speaker 02

  I'm really not trying to be funny.

• 45:12Stephen J. Dubner?

  I'm not trying to laugh either, but I am.

• 45:14Speaker 02

  But sooner rather than later. And why do I say that? Because I cannot live my life to the extent of fullness until I make friends with death, that it's going to happen one day. When I started working with people at the end of their lives, my life changed overnight. I was taking care of people younger than me. I started to live with a very different level of gratitude for everything. No longer it was like, oh, I have to go to the gym. It's like, I get to go to the gym. I also treat each day like one little lifetime because this is the only one that I know. So finding those moments of joy, presence, purpose, and gratitude, and it's completely changed my life. Don't sweat the small stuff. Forgive,

• 45:58Speaker 02

  forgive and receive forgiveness. This is like one of the biggest tools that I could ever tell people. And be able to know that, you know, at any time, this journey as we know it can come to an end. What are you willing to leave undone? And if you're not willing to leave it undone, get to it now.

• 46:22Stephen J. Dubner?

  I ran Suzanne O'Brien's philosophy past Kathy Hochul, governor of New York. So some people in the, I guess you'd call it the death and dying community, say that, yes, medical aid in dying is a good option, but that the real problem... Is our overall approach to death and dying that we, modern people, just don't handle it very well. We don't really know how to usher someone into death, as someone said, the way that earlier generations did. I'm curious what your thoughts are on that, especially having gone through what you went through with your mom. Do you think this is just the tip of the spear that medical aid and dying is maybe a way to change the way that we approach death and dying generally? Do you have any personal or legislative thoughts on that?

• 47:07Speaker 03

  I agree with that assessment. Once you open up this door, which had been closed up until this year, that people may start thinking about quality of life, what dignity in death is all about, and personal choice. Those are important concepts to talk about in society, but also in government. And what that could lead to is more of an awakening of people understanding that there's inevitability about this. This is what's going to happen to everyone. And how can we just treat it more with respect and acknowledge people's personal choices more so? I think there's always a different way to think about medicine, broader than we do traditionally. We're very narrow in our focus, what you teach in medical school. I wanted to know why New York State Medical Schools were not teaching about how

• 47:52Speaker 03

  we can alleviate people's pain without having opioids as the only place to go. Why aren't they also teaching people how to handle people in their care, whether you're a nurse, nurse practitioner, or a doctor?

• 48:04Stephen J. Dubner?

  Did you get a good answer to that?

• 48:05Speaker 03

  No, I never get good answers, but I keep asking the question. Right? I keep asking the question.

• 48:15Stephen J. Dubner?

  I appreciate anyone willing to ask hard questions, and I'm sure you do, too. My thanks to Kathy Hochul, Suzanne O'Brien, Daniel Solmazy, and Al Roth, and thanks especially to you for listening. I- Firmly believe that the Freakonomics Radio audience is one of the best audiences in this weird, fractured media environment, which leads me to one more thing. In July, I am launching a new project, a video show that I've been working on for a while. All of us at Freakonomics Radio are really excited about it, and we're looking for listeners who want to pre-screen each episode and share feedback. We're still in stealth mode, so we're only going to select the first 100 people who sign up to participate. If you are interested in being an extension of our

• 49:00Stephen J. Dubner?

  crew, go to the link in the show notes. And thanks. Coming up next time on the show, one of the most polarizing and ambitious figures in American higher education. Not everybody agrees with me on that, but my strong belief, and I think there's increasingly evidence now, that we have a problem. A conversation with Daniel Deere Meyer, the chancellor of Vanderbilt University, who is trying to solve that problem. That's next time on the show. Until then, take care of yourself, and if you can, someone else, too. Freakonomics Radio is produced by Renbud Radio. You can find our entire archive on any podcast app. It's also at Freakonomics.com, where we publish transcripts and show notes. This episode was produced by Dalvin Abawaji

• 49:44Stephen J. Dubner?

  and Zach Lipinski. It was edited by Gabriel Roth and mixed by Jake Loomis, with help from Jeremy Johnston. The Freakonomics Radio Network staff also includes Augusta Chapman, Eleanor Osborne, Ellen Frankman, Elsa Hernandez, Alaria Montenacort, Mandy Gorstein, Peter Madden, and Tayo Jacobs. Our theme song is "Mr. Fortune" by The Hitchhikers, and our composer is Luis Guerra. As always, thanks for listening.

• 50:11Stephen J. Dubner?

  You ready to roll?

• 50:12Speaker 03

  I mean, let's finish swallowing a cough drop first.

• 50:19Speaker 05

  The Freakonomics Radio Network, the hidden side of everything.