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678. Who Gets to Choose a “Good Death”?
Brief
The episode traces how assisted dying moved from taboo to law in parts of the world and to the center of contemporary ethical debate. Economist Al Roth uses his concept of “repugnant transactions” to show how social acceptance changes over time—citing examples like interracial and same‑sex marriage—and places assisted dying on that arc. Roth and the host survey global policy landmarks (Switzerland since 1942; Oregon in 1997) and current U.S. patchwork rules: roughly a dozen states plus D.C. now allow some form of aid in dying. Governor Kathy Hochul describes signing New York’s Medical Aid in Dying Act after watching her mother’s ALS decline: the law (effective August 2026) is intentionally tightly constrained (physician in‑person visit, mandatory mental‑health evaluation, five‑day wait, recorded patient request) to respond to coercion and abuse fears while preserving personal liberty.
Voices in the episode sharply disagree about consequences and ethics. Daniel Sulmasy, Georgetown physician‑philosopher, opposes legalization as harmful medicine and public policy, warning that safeguards erode and that legal sanction of “control” can harm disabled and marginalized people. Roth notes high uptake in Canada (about 1 in 20 deaths goes through its program) and signals a possible cultural momentum, though he and others acknowledge data gaps—no federal U.S. database and evidence of covert hastening where laws are restrictive. The program also explores practical, non‑legal responses: Suzanne O’Brien, a former hospice nurse turned death‑doula trainer, argues for revitalizing communal end‑of‑life care, describes hospice funding limits (family caregivers provide ~98% of hands‑on care) and the doula model (self‑pay, sliding scales, 400,000 trainees over 16 years). The episode ends with the sense that policy, clinical practice, and cultural care must evolve together: laws expand choice for some, but critics warn of unintended harms and advocates point to improved education, palliative care, and community support as essential complements.
Why it matters
Al Roth (Nobel-winning economist) framed assisted dying as a changing “repugnant transaction,” noting social norms can shift (examples: interracial and same-sex marriage) and recounting kidney‑exchange numbers: when he started ~40,000 Americans were on the deceased‑donor kidney waiting list; today nearly 100,000 are listed and ~500,000 people are on dialysis.
Key details
- Governor Kathy Hochul signed New York’s Medical Aid in Dying Act (effective August 2026), which limits eligibility to terminal patients with ≤6 months to live and includes mandatory safeguards: an in‑person physician visit, a mandatory mental‑health evaluation, a five‑day waiting period, and a requirement that the patient (not a relative) make the request on recorded audio/video.
- Daniel Sulmasy (Georgetown ethicist) argued against legalization as “bad medicine, bad ethics, and bad public policy,” warning of a slippery slope (guardrails becoming ‘vaporware’) and raising concerns about pressure on disabled and vulnerable people and cultural over‑valuation of personal control.
- Al Roth and others stressed uneven global/regional rules: Switzerland has permitted assisted dying since 1942, Oregon was first U.S. state to legalize in 1997, and as of the episode ~12 U.S. states plus D.C. allow some form of medical aid in dying; Canada’s program already accounts for about 1 in 20 deaths and has expanded beyond imminent terminal cases.
- Listeners learned there is no standardized federal database tracking assisted deaths in the U.S.; evidence of covert or clinician‑assisted hastening exists where laws are restrictive, and surveying physicians privately suggests undercounting.
- Suzanne O’Brien (former hospice nurse, founder of Doulagivers Institute) described death doulas as a non‑medical, largely self‑pay support model (hourly pay ~$25–$150), said hospice delivers ~98% of hands‑on care via family caregivers, and noted her training reached ~400,000 people from 39 countries over 16 years; she also cited that 61% of people who obtain lethal meds do not end up using them.