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Chapter 1: What recent legislation did New York pass regarding medical aid in dying?
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. 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. 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.
Danny Kahneman made a very considered decision.
That is Al Roth. He is an economist at Stanford. He, too, has a Nobel Prize.
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.
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.
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Chapter 2: How does Al Roth's work relate to the concept of repugnant transactions?
What's your view on that?
I think these decisions are very personal. I 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.
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.
I cannot live my life to the extent of fullness until I make friends with death.
We'll hear from a governor who just signed a new medical aid in dying law.
I kept my personal story to myself. I never want to make policy based on my life experience. It's not appropriate.
And we hear an opposing view.
I think it's bad medicine, bad ethics, and bad public policy, and a grave mistake for society.
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Chapter 3: What personal experiences influenced Governor Kathy Hochul's support for medical aid in dying?
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.
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.
One of the curious facts of the world is not everyone agrees with economists about what should happen in the world.
Does anyone agree with economists about what should happen in the world?
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.
This brings us back to repugnant transactions, an idea that Roth has been studying for a while.
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.
So when it comes to MAID 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.
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Chapter 4: What ethical concerns are raised about medical aid in dying?
There are now 12 U.S. 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.
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 in 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
He went to prison because of one case in which he administered the drug rather than having the patient administer the drug, right?
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 in dying.
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?
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.
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Chapter 5: How do death doulas support individuals at the end of life?
OK, 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, make the request on a video or audio recording. Here is Governor Hochul.
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.
I asked Hochul how this issue came to her attention.
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 and her vision and ability to communicate, it was just heartbreaking.
How long did she, I don't know if linger is the right word, but how long was that process? I'd say the worst was probably four or five, six months. And how long ago did she die? That was in 2014. This bill has probably been around almost that long. Is that right?
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Chapter 6: What arguments exist against medical aid in dying?
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. 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 are really suffering and I could do something about it.
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?
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.
It's got a lot of guardrails in it.
I put a lot of safeguards in because I knew that when people said their fear was that someone could be coerced 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 engaged their concerns and really legislated to solve them.
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Chapter 7: How does the public perceive medical aid in dying legislation?
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.
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?
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
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?
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...
really inspiring me to go into public service based on what my parents taught me. They were social justice Catholics. We protested everything.
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Chapter 8: What future trends might we see regarding medical aid in dying laws?
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.
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 measures. 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.
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 family, 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.
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.
A 2024 Gallup survey found that 71 percent 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.
Two of our current Supreme Court justices are very, very much against medical aid in dying patients.
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.
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