Overview of Freakonomics Radio Episode 678: “Who Gets to Choose a ‘Good Death’?”
This episode examines the ethics, policy, and growing legalization of medical aid in dying (MAID)—also called assisted suicide or physician-assisted dying—through the lens of economist Al Roth’s “repugnant transactions” framework. It opens with the story of Nobel laureate Daniel Kahneman, who chose to end his life in Switzerland, and asks a larger question: Who should decide what a “good death” looks like, and under what rules?
Main Topics Discussed
Daniel Kahneman’s decision
- Kahneman, still mentally sharp and in relatively good health, traveled to Switzerland and ended his life on his own terms.
- The episode uses his choice to highlight how personal, emotional, and morally contested end-of-life decisions can be.
- Some close to him were upset, arguing that his decision denied loved ones more time with him.
Al Roth and “repugnant transactions”
- Al Roth, a Nobel-winning economist known for market design and kidney exchange, explains that some transactions are deeply contested even when people cannot always articulate why.
- He frames MAID as a repugnant transaction: some people want it, others object strongly for moral, religious, or ethical reasons.
- Roth compares its trajectory to other once-contested practices that became accepted over time, such as same-sex marriage and interracial marriage.
The legal landscape of MAID
- The episode notes that 12 U.S. states plus Washington, D.C. allow some form of MAID.
- It has been legal in Oregon since 1997 and in Switzerland since 1942.
- Internationally, countries such as Canada, the Netherlands, Belgium, Spain, and Australia have also adopted forms of assisted dying.
Governor Kathy Hochul on New York’s MAID law
- New York recently passed a Medical Aid in Dying Act, scheduled to take effect in August.
- Hochul says she signed it only with strict safeguards, including:
- a terminal prognosis of six months or less to live
- a mental health evaluation
- an in-person physician visit
- a five-day waiting period
- a requirement that the patient—not a caregiver or relative—make the request on video or audio
- She says her own mother’s death from ALS shaped her thinking, but emphasizes she does not want to make policy based solely on personal experience.
Opposition from ethicists and physicians
- Daniel Sulmasy of Georgetown argues strongly against MAID.
- His core criticism: it is bad medicine, bad ethics, and bad public policy.
- He says:
- medicine can already do more to relieve pain than ever before
- people often request MAID due to fear, loss of control, or feeling like a burden, not because of a medical symptom alone
- the physician’s role should be to heal and comfort, not to kill
- He also warns that safeguards often erode over time, pointing to Canada as an example of a system that has expanded well beyond the narrow original model.
Death doulas and the broader problem of end-of-life care
- The episode also features Suzanne O’Brien, a former hospice nurse and founder of the Doula Givers Institute.
- O’Brien argues that many people need better education, presence, and support at the end of life—not just access to MAID.
- She says death has become overly medicalized and overly rushed, while families often lack training and time.
- Her philosophy centers on:
- preparing for death earlier in life
- reducing fear
- seeing death as a natural part of life
- improving end-of-life care rather than relying on institutions alone
Key Arguments For and Against MAID
Arguments in favor
- Individual autonomy: people should be able to choose how they die, especially in terminal illness.
- Compassion: it can spare people prolonged suffering, indignity, and loss of dignity.
- Practicality: many patients already seek ways to hasten death informally; legal options can add safeguards.
- Public support: polling suggests a majority of Americans support some form of MAID.
Arguments against
- Ethical concern: medicine’s role is to care, not intentionally end life.
- Slippery slope: safeguards may expand or weaken over time.
- Disability-rights concern: legal MAID may send a harmful message that lives with disability or dependency are less valuable.
- Social pressure: some fear vulnerable people could feel pushed toward death by family, finances, or cultural norms.
Notable Takeaways
- The episode shows that assisted dying is no longer a fringe issue; it is moving into mainstream policy debates.
- Much of the conflict comes down to a tension between:
- personal freedom and control
- medical ethics and social protection
- relieving suffering and preserving life
- There is also a larger critique of modern society: both Sulmasy and O’Brien suggest that Americans are often too focused on control, and too disconnected from the realities of dying well.
- The discussion implies that MAID is only one part of a much bigger conversation about hospice care, pain management, family support, and how society treats death.
Bottom Line
This episode is less about whether MAID should exist in the abstract and more about who gets to define a dignified death. It presents the issue as a clash between autonomy, compassion, religious ethics, disability concerns, and the limits of medicine. While the law is expanding, the moral debate remains deeply unsettled.