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

Episode Summary

Executive Summary: This episode examines the rapidly evolving ethics and politics of medical aid in dying (MAID), using Daniel Kahneman’s assisted death as a poignant entry point. It contrasts pro-choice, autonomy-based arguments from Governor Kathy Hochul and Al Roth with strong objections from bioethicist Daniel Sulmasy, while also exploring how end-of-life care, hospice, and death doulas may change how society approaches dying.

Main Topics: Daniel Kahneman’s assisted death and the ethics of personal choice (Priority: 5/5): The episode opens with Kahneman’s decision to end his life in Switzerland, framing it as a deeply considered response to aging, uncertainty, and the desire to avoid prolonged decline. His case serves as a catalyst for debate over individual autonomy versus obligations to loved ones. Medical aid in dying as a growing legal framework (Priority: 5/5): The conversation surveys MAID’s spread across U.S. states and internationally, emphasizing the importance of safeguards, eligibility limits, and the tension between compassionate access and abuse prevention. Al Roth’s “repugnant transactions” lens (Priority: 4/5): Roth explains why some transactions become socially and legally acceptable over time, placing MAID alongside historically contested issues such as same-sex marriage and interracial marriage. He argues markets and laws need social support and careful design. Governor Kathy Hochul and New York’s MAID law (Priority: 5/5): Hochul describes signing New York’s MAID legislation with strict guardrails, citing her mother’s death from ALS and the testimonies of suffering patients and families as motivation, while stressing that policy must not be based solely on personal experience. The opposition argument: bad medicine, bad ethics, bad policy (Priority: 5/5): Daniel Sulmasy argues MAID undermines trust in medicine, reflects a problematic cultural obsession with control, and disproportionately appeals to educated, well-off people while potentially harming disabled and vulnerable communities. Death care, hospice, and death doulas (Priority: 4/5): Suzanne O’Brien argues the real issue is society’s poor preparation for death, not just MAID. She advocates for education, presence, and compassionate support through death doulas, highlighting how modern healthcare and reimbursement models leave families underprepared.

Key Arguments: Kahneman’s choice was portrayed as deliberate, longstanding, and rooted in a belief that the final years of life can involve unnecessary misery and indignity. Supporters of MAID argue that people with terminal illness should have the right to avoid prolonged suffering and die with dignity on their own terms. Roth argues that laws in contested areas require guardrails so that a legal right is not abused or turned into coercion. Hochul says her law balances compassion and liberty with safeguards such as mental health evaluation, in-person physician review, waiting periods, and recording requirements. Sulmasy argues MAID is inconsistent with the medical profession’s core duty not to kill, and that requests often reflect fear, loss of autonomy, or burden rather than treatable pain. Sulmasy warns that legalization reflects a deeper social belief that control is the highest value, which he sees as inadequate for confronting birth, death, and love. O’Brien contends end-of-life care should be more human, communal, and educational, and that many people seek MAID because they are frightened and unsupported rather than fully informed. The episode suggests MAID debates are also debates about how modern societies understand dignity, autonomy, suffering, and the role of medicine at life’s end.

Data Points: Daniel Kahneman’s age: 90 - He ended his life shortly after celebrating his 90th birthday in France and traveling to Switzerland. Year Kahneman won Nobel Prize in Economics: 2002 - Referenced in the introduction to establish his influence on decision-making research. Year Thinking, Fast and Slow published: 2011 - Used to situate Kahneman’s public impact. U.S. states allowing some form of MAID: 12 states plus the District of Columbia - Describing the current legal landscape in the United States. First U.S. state to legalize MAID: Oregon, 1997 - The episode notes Oregon as the first state with legal assisted dying. Countries/regions with MAID in some form: Switzerland, the Netherlands, Belgium, Canada, Spain, much of Australia - Illustrates the international spread of assisted dying laws. New York MAID eligibility: Terminally ill with less than 6 months to live - Governor Hochul explains the new law’s scope. New York MAID safeguards: Mandatory mental health evaluation, in-person physician visit, 5-day waiting period, patient video/audio request - Listed as guardrails in the New York law. Gallup support for physician-assisted death: 71% - Survey result cited to show broad public support in the U.S. Americans on deceased-donor kidney waiting list: Almost 100,000 - Al Roth uses this to discuss kidney exchange and demand for transplants. Americans on dialysis: 500,000 - Shows the scale of kidney disease and need for transplants. Canada MAID share of deaths: About 1 in 20 deaths (5%) - Roth cites this as a high uptake rate that has sparked backlash. People trained by Doula Givers Institute: Over 400,000 in 39 countries - Suzanne O’Brien cites this as evidence of growing interest in death doula training. Average annual deaths among Americans over 60: 2.5 million - Used to underscore the need for more end-of-life support. Average funeral cost in the U.S.: $7,000 to $11,000 - O’Brien suggests redirecting some funeral spending toward end-of-life care. Support for MAID medication use: 61% do not use the medication - O’Brien cites this statistic to argue that having the option may itself reduce fear.

Pivotal Quotes: "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." — Daniel Kahneman: Email cited after his assisted death, explaining his decision. "I told him I would only sign it with my guardrails." — Kathy Hochul: Explaining why New York’s MAID law includes safeguards and limits. "I think it's bad medicine, bad ethics, and bad public policy, and a grave mistake for society." — Daniel Sulmasy: His core objection to medical aid in dying.

Implications: MAID is likely to keep expanding state by state, but controversy will remain over coercion, disability rights, and medicine’s role. The broader debate may reshape hospice, death education, and how people think about dignity at life’s end.