Reframing Our Approach to End of Life

F Eonomics Rudodo is sponsored by Pacific Life Insurance. From pinky swears to I do, you make promises throughout your life. For nearly one hundred and sixty years, Pacific Life has been helping you keep them by protecting those who matter most. Pacific Life, the power of a promise. Ask a financial professional how Pacific Life can help you create a more confident financial future. Pacific Life Insurance company, Omaha, Nebraska, and in New York, Pacific Life and Annuity, Phoenix, Arizona. Economics Stadio is sponsored by Low'. Son's out, and so is Dad. This is Father's Day. Find what'll make his summer with Lowe's Father's Day deals. Get two free deWalt power tools when you buy a select five amp hour battery kit Plus get a free Blackstone six piece stainless steel griddle kit when you buy a select Backstone griddle Low's Father's Day deals in store or online, valid through june twenty fourth while supplies last. Selection varies by location Economics video is sponsored MintM Mobile, Unlimited talk text and data and fast reliable coverage on the nation's largest five G network. No catch. To get your new wireless plan for just fifteen bucks a month, go to mintmobile d. com slash freak. That's it. There's no catch. forty five dollars upfront payment required, equivalent to fifteen dollars a month, new customers on first month plan only speeds slower above forty gigabytes on unlimited plan. Additional taxes fees and restrictions apply, see MintMobile for details Daniel Konneman was a celebrated and influential scholar, trained in psychology, but with a seemingly limitless way of thinking about the world. In two thousand two, he won a Nobel prize in economics In twenty eleven, 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 policy making medicine and finance, in the military, the criminal justice system, and more. And why were Konnoman's insights so valuable mayaybe 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 There just aren't that many of them Perhaps the most reliable certainty in life is death. A couple of years ago, as Konneman approached his ninetieth birthday, that certainty must have felt particularly salient. He was still in relatively good health and his mind was sharp He decided that his time had come He'd traveled to France where he'd grown up, barely surviving the Nazis He gathered with his family in Paris to celebrate his ninetieth birthday, meals, Museum visits, nice walks F From there, Connman 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 friendriends, 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 Connman made a very considered decision Al R 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 he said to people overver 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 The people that you and I both know who were very close to Danny, who were pissed off at him 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 ninety, 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 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 Konnemman'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, fromrom 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 mid or medical aid in dying Today on Freconomics 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 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 At least for now, death is still a certainty, but more and more, the timing is not This is Freakonomics Radio, the podcast that explores the hidden side of everything with your host, Stehen 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 When I started working on kidney exchange, there were about forty thousand people Americans on the waiting list for a deceased donor kidney Today they there were almost a hundred thousand. And there were five hundred thousand 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. 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 a commments smell 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 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 reasonons 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 mAIid 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 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 a loose translation from the ancient Greek To be fair, religious thinking about death was a little bit different perhaps than it is now, yes. releligions still are very against. I mean, certainly there's active religious opposition to medical aid and dying, which is however a growing practice. likeike a dozen American states now have some medical aid and dying. New York State where you're living, I think they're gonna have it this year That is true, there are now twelve US states plus the District of Columbia, where some form of assisted dying is allowed. Oregon was the first in nineteen ninety seven The modern movement toward legal assisted dying began in Switzerland, where Danny Connemman chose to end his life In Switzerland, it has been legal since nineteen forty two 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 published a book of How to It was called Let me Die before I wake probleblem 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 ivis. for medical aid and dying was a fellow named Jack Kavorkin who I write about, doctor Dath 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 administter 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 in 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 in prison 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, may have seemed at the time 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 been stopping living, but aid in dying 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 Hokel 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 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 Hol I told him 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 Hokl how this issue came to her attention. 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 ILS two months before I became a nominee for Lieutenant goovernor. 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, five, six months And how long ago did she die That was in twenty fourteen. This bill has probably been around almost that long, is that right? twenty sixteen 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. erri that she didn'tieve 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 I'm hardwired, mayaybe it's because I'm the first woman governor. I'm hardwired to solve problems can give compassion and alleviate emotional pain. I'm going to do that And this seemed to be in that category of people 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 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 Listen 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, you by spouse who really didn't love them or a family member who got tired of taking care of a parent or take care of someone with severe disabilities. 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 listen to them and engage their concerns and really legislated to solve them 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 was 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 Oh 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 notaying 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 gotone into effect yet. So what are you expecting? Because once people start availing themselves of this law, there will be stories and headlines arere you prepared for another wave Yes. I have waves on every issue every day of the week, Stehven. So this job is not for the fain of heart condition 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 twenty 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 whenateever 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 and dying, let's say People can me whatever they want I'm not the judge to say whether you're being consistent or not. That's not my role. know many cafeteria Catholics, for example. You still love what the church stands for. It's charitabableess and taking care of people and the teachings of Jesus Christ that I was raised on about It 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 sixties. We didn't eat grapes. or let us 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 phhilosophies 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 and 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 That's why it is so narrly tailored. It is someone who literally has etermined by a doctor and a mental health professional, this person is 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 who be 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. 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 gonna 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 Hol. Coming up after the break, we will hear the opposition argument. I'm Stephen Dubner. This is Free e Eonomics Radio, and I appreciate your listening. We will be right back Economics Radio is sponsored by Range Rover Sport, a vehicle that blends power, poise, and performance With a distinctly British design, the Range Rover Sport is built to take on roads anywhere. Free from unnecessary details, its raw power and agility shine. Combining a dynamic sporting personality with elegance and agility, it delivers an instinctive drive. Its assertive stance hints at an equally refined driving performance. Defining true modern luxury, the Range Rover Sport features the latest innovations in comfort and convenience Cabin air purification system alongside the active noise cancellation creates a new level of quality, comfort and control. 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It's not widely talked about and some men may feel reluctant to bring it up, but it's more common than you would think. PD can happen when scar tissue builds up under the skin of the penis, causing a curve with a bump during an erection that for some men may lead to pain during intimacy and impact Mental health Trusted Uurology specialists can help diagnose PD and walk you through your options including non surgical treatment. Visit talkaboutpD. com. The twenty twenty four Gallup survey found that seventy one 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 and dying The two justices he's talking about are Neil Gorsuch and Amy Coni Barret In nineteen ninety seven, the Supreme Court ruled unanimously that there is no constitutional right to un assisted suicide, but it left the issue largely to the states Barrett is a Catholic. Gorsuch was raised Catholic, but now attends Episcopal Church. Barret right when she was just Amy Coy, not Amy Coy Barret She writes about the obligations of Catholic judges. and there's a line in there which says the objection to Medical aid and dying is much stronger than punishment or war, right? Be 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 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. And Neil Gorsuch, if I recall wrote a book about assisted suicide, yes he did. He thinks it's not justified. And so ents of medical aid and dying are no doubt now looking for a case that can be appealed to the Supreme Court. you anticipate that ten years from now, of course medical assistance in dying will be legal in all fifty states and maybe federally? Or maybe do you think it's going in the other direction? or do we just not know 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 and dying should be illegal makes me skeptical about what I would otherwise notice, which is that medical aid and 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 I see there's no standardized federal database on medically assisted suicide. And I'm just wondering if you think the count is you 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 It's hard to get the actual numbers, but I think there's no question that there's a lot of coovert 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 and 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. It's roughly one in twenty deaths in Canada runs through the government run assisted suicide program. five percent 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 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 mod In Canada, mid 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 The logical slippery slope suggests all of the safeguards that are built into laws eventually become seen as barriers to access Daniel Slmazy, a physician, philosopher and director of the Kennedy Institute of Ethhics at Georgetown University 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 Salmz'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 orrder, and he lived as a friar for more than twenty five years He left the order after falling in love and deciding to marry Wh the Catholic Church opposes assisted suicide, So Maisie says his views come more from his experience as a physician at the bedside 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 ort run away from them. There's nothing more to do, It was experiences like that and an interest in philosophy, theology that led me to really think that my contribution in medicine be through medical ethics. 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 Sure, I think it's bad medicine, bad ethics, and bad public policy, and a grave mistake for society Okay, Walk me through those. Bad medicine. why 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's symptoms And the data will bear out that the reason people want euthanasia assisted suicide when they actually foollow through are reasons like loss of control feeling like a burden to other people loss autonomy. These are not medical diagnoses and they're not reasons to give lethal medication I also think that it's bad medicine because Tust that is necessary for a patient 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 hyppocratic 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. As you well know, the medical aid and dying movement is growing. moreore and more states are legalizing, including New York where I live and we've interviewed for this program, New York Governor Kathy Hokel, 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 I think I'm fighting a battle and I think that it is difficult one because of the 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 arere indifferent to what the legalization of this does to countless other people, like you probably saw in New York is in other places the way in which the disabled 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 Being in control being independent of other people not having disfigurement, Be in control of your bowels, right This is a justification for state sanctionsed suicide And the person who's in a wheelchair and needs help with toileting every day says, This isn't an affront to my dignity 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's a certain consistency on Catholic positions, particularly toward medical aid in dying, as well as abortion, gay marriage. which is that there iss a right way to do things in a wrong way. but each of those issues, medically aid and 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 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 choos and how do we use that freedom things aren't right because we choose them. We choose them because we think they're right And we have to admit that we can be mistaken in our moral views, right? And that's the way in which I would this Another thing I wanted to mention, particularly this is fre economics, right is some of the economics of assisted suicide in Ehan Asia Shortly after Canadian court decision that required the legalization of Ean Asia 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, For God's sake, change your healthcare system commit suicide 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? I doubt it's going get to the Supreme Court again They 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 Do you feel that this is an argument that you and your like minded colleagues are losing th thinkink that arguments matter And ideas matter And even if cases that States are continuing to legalize this that Eventually we'll 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 What would that wrong be I think it is a sense that Being in control is the most important in life And that's very American. If being in control is the most important thing, it's a pretty paltry philosophy, right 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. Daniel Salmisy from Georgetown Coming up after the break, another close up look at death, the thing we like to look away from This is Freeconomics Radio. I'm Stehen Dubner. We will be right back Economicsodia sponsored Dpro Trusted by firefighters, medical professionals, and over ninety percent of top college and pro sports teams, drip drop is doctor developed proven fast hydration that helps your body and mind work better Support for busy days, long workouts and everything in between, DripDrop uses science based formulas for rapid hydration so you feel results fast while getting three times the electrolytes of leading sports drinks. 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For a limited time, new customers can get ten dollars added to their balance, just use code cash app ten When you sign up and don't forget this part, send at least five dollars to a friend in the first two weeks Terms apply, Cash apppp is a financial services platform, not a bank Banking services provided by Cash App's bank partners. Bitcoin services provided by Block Inc brand. For additional information, see the Bitcoin disclosures at cashot app slash legal slash podcast. Economics radio sponsored by Southern Comp. The world and its energy needs are always changing. Southern compompany's commitment to meeting this demand stays the same That's because Southern compompany believes energy is more than a utility. it's what powers possibilities. So they are looking ahead and investing eighty billion dollars in infrastructure upgrades and are committed to fueling growth in ways that benefit all customers so that reliable and affordable energy is accessible for generations to come Go to southerncompany. com to learn more. Southern Company, builduilding the future of energy. Economist E Roth is seventy four years old. He's in good health. onn the day of our interview, he rode his bike to the studio on the Stanford campus. Even economists have to die someday Im curious whether all this thinking about and writing about medical assistance and dying has changed the way you think about not dying, but life I'm enjoying life. I'm glad to hear that. 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 preserve yourgget. There are people who want that But I've thought about it and when we moved to California in twenty twelve, 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,. 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 I have a sister who died last year. It was a pretty rotten death, honestly and she wanted to hasten it 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 cered 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, mayaybe that's just me. Do you have any sense of how broad the support is for it generally 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 and dying May I wave my wand and go into a perfect scenario? Please. The perfect scenario would be brringing back the awareness that end of life is a natural part of life's journey. And one hundred 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 That is Suzanne O'Brien. She used to be a hospice nurse and now she works as what is called a death doua. the founder of Dulaivers Institute, and I'm also the author of The Good Death, a guide supporting your loved one through the end of life First of all, Dula Givers Institute I know Doulah from birthing, but we're talking now about Douulah at the end of life. So what is a Doulah giver? Is that the phrase that you typically use or death douula? What is the phrase you prefer So Doulah Givers is the unique name to my education and my institute, but it really is about a death doulah, 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, 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 gonna grow up and be a deeath dua. 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. I could be making a difference with what I do. pllus I could do lots of different type of nursing and also I can you know, live different places. So it sounded good in that sense S 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 do Come, whyy were you not getting the fulfillment 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 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, goo 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 to 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 in my life O'Brien worked in hospice care for many years, but she ultimately found that wasn't quite right either. current hospice model relies on ninety eight percent 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 nineteen eighty two with Ronald Reagan. That's right. 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 prevent and there for one hour once a week. What can really be done there? It's not working well And that's when Suzanne O'Brien discovered a different model, the Doula model Death douas 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 twenty five dollars to one hundred and fifty dollars an hour O'Brien offers free training through her Dula Givers Institute Over sixteen years, we've had over four hundred thousand people from thirty nine countries take that training So there are around two point a half million Americans over age sixty who die every year. How many death doulas are there in the country Not enough. Death is not a medical experience. It's a human one. and we just forgot that. It sounds like you want a revolution Yes. of love and of care and of compassion and of presence and of bringing backack to the sacred natural experience it was meant to be 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, 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 health carere industry? Is it part of insurance? and other coverage like that. 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 ten or fifteen people and we'd be rushed and it wouldn't have the value, right? So what the difference is is that Hospice is 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 ourdoulas they have people on sliding scales and they have other things point out this if I may. The average cost of a funeral again, in the United States is between seven and eleven thousand dollars. youk Faction 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 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 forty two at the time, seven year old children were taking 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 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, Wh? He goes, we won't get reimbursed for it So won't fit into the model So how does your work as a death duela intersect with what's called assisted suicide, medical assistance in dying, elective suicide? 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 and dying. Tell me how you feel about the concept of choosing when and how to die on your own terms 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 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 is the sole caregiver.