155. Helping People Die

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Most doctors focus on prolonging human life, but not today's guest.

Ellen Weave is a physician who spends her days ending lives.

I have had these wonderful conversations with so many people

where I say,

now that you have the approval to go ahead.

When would you like to die?

Where would you like to die?

Who do you want to invite to your death?

Anything special you want at the day.

Welcome to People I Mostly Admire with Steve Levitt.

Ellen Webb lives and works in Canada where medical assistance in dying or MAID M-A-I-D as it's abbreviated is not only legal, it's widely practiced.

Almost 5% of all Canadian deaths are the result of physician assistance.

I began our conversation conversation by asking Ellen to explain the history of Canada's law enabling medical assistance in dying.

It was 2015 that Canadians were given this right.

There was a court case.

It was based on a Kay Carter who had gone to Switzerland in order to get an assisted death and her family brought the case to say that she shouldn't have had to go to Switzerland, that she had the right to control her own death and should have been able to have it in her own country.

And then we got our law in 2016, in June, and they added a whole lot of safeguards, rules, regulations that we all had to follow.

Over the years, there have been one court challenge after another.

So what we have now

is that people are allowed to request an assisted death if they have a grievous and irremediable medical condition, are suffering unbearably, and are in an advanced state of decline of capability.

And they must have the ability to consent.

Of course, Canada isn't the only place that has assisted dying.

As you said, Switzerland, I think it's been legal since 1942 or something like that.

The Netherlands, it's been legal there and in Belgium since the early 2000s.

And there are a handful of other countries where it's allowed.

I was surprised myself to discover that it's legal in 10 U.S.

states.

I was aware of Oregon and Washington.

That really got a lot of media coverage when it was approved there.

But even in the states in the U.S.

where it's legal, it's not used that much.

So per capita, the rate in Oregon is about maybe one-fourth or one-fifth of the rate in Canada, even though it was legalized almost 20 years earlier in Oregon.

And the rate rate in Oregon is higher than the rest of the other U.S.

states.

Do you understand why there's so much more in Canada?

Is the process simpler?

Is the set of allowable conditions broader?

I thought about this one a lot.

We think of California because their law came in at the same year ours did, and their population is similar to Canada's.

It looks like about 85%

of the people who access assisted dying in Canada wouldn't be eligible in California where it's required that you're within six months of a natural death

and yet we have so much more.

Why is that?

Well, there's a number of reasons.

One is that there was immediately a group, including me, who

believed that this was a right that people should have access to.

And we formed an organization called the Canadian Association of Maid Assessors and Providers.

We trained other doctors and we supported them and we set standards that were beyond what the government set in terms of really good care.

You have to have somebody to do it.

And then

we got

government buy-in in most places.

So it's different across the country.

Health is provided locally in provinces and in health authorities.

And my health authority has a MAID coordinating office where patients can call, get all the information they need, get connected to assessors and providers so that they can access.

So access is a big issue.

Also, media, people have to know about their choices.

In the first years, we had great media coverage with wonderful people who gave their own stories of how they came to decide that they would want an assisted death at the end.

All of those things, the fact that our law does not require a terminal illness, the fact that we have a strong group of providers and we have a government that, I shouldn't say government, we have governments, provincial, health authority, jurisdictions that believe people should have support through the end of life.

Could you describe the steps involved in medically assisted dying in Canada?

So let's say I have terminal cancer.

I'm in intense pain.

What do I need to do to get approval for an assisted death?

So you would ask your doctor, if you're in the hospital, you're a nurse, or you'd call the coordinating center.

They would bring a written request form that must be witnessed by an independent witness.

So that means somebody who doesn't benefit from your death.

and then get two assessors.

These are doctors or nurse practitioners who would do an assessment to make sure you fit all of the criteria to have a legal assisted death, and then it would get organized.

Unlike most of the states that have assisted dying, we have the ability to do things quite quickly.

Somebody's in crisis in the hospital, they probably just need really good palliative care.

But sometimes they say, no, what I want is to leave and we can, you know, pull it together quickly in an urgent case like that.

And I've had the wonderful experiences of families coming together to give their loved one, you know, the best possible send-off.

Yeah, because we'll probably describe it and talk about it as a medical procedure as we talk about it today.

But really, first and foremost, it's a rite of passage, right?

It's not that different from birth or graduation or a wedding.

To me, one of the beauties of it is that you have the opportunity to put the kind of thought into that rite of passage, which is absent in the typical death because it's uncertain and everyone's on call.

No one really knows when it'll happen.

But more than that, you know, the person who is dying is there.

I've been a doctor for almost 50 years and I have been around lots of other deaths.

And in those cases, the person leaves sooner than when they die.

They almost always go into a coma before.

And even before that, they are so sick, so weak, they no longer converse.

This is different.

People actually plan their last words.

Yeah.

Yeah.

It's interesting to think about because in most medical situations, a lot of the treatment is doctor

right?

The doctor says, Here's the situation, and I would propose you take these steps.

But I can imagine it is not an easy thing or maybe an acceptable thing for you as a doctor to say, Hey, you're really sick.

Is assisted suicide something you'd like to talk about?

Do you initiate the conversation, or is that verboten?

We are allowed.

There are jurisdictions where people are not allowed to bring it up, they have to wait for the patient to bring it up.

But as far as our medical association and law is concerned, when a doctor is helping somebody at the end of life, they need to give them options in order for them to have informed choices.

So when you give someone the option of various forms of active treatment, of palliative treatment, comfort care, and so on, an assisted death can be one of those options that you offer.

It's not required, but

it's the ethical thing to do because people

should have all their choices put in front of them.

So I know having talked to various doctors who work, say, in oncology, they hate telling the patients that there's no hope.

I think many doctors who are not necessarily aligned with assisted suicide actually do a lot of extra care just to avoid the personal unpleasantness of having to explain to the patient that they really are dying and they're going to die soon.

So they keep on treating them because it's easier for the doctor.

I imagine that is even worse with this idea of assisted suicide.

You're at home with it.

You do it.

But for the 90 plus percent of doctors who are out there with sick patients who don't, I wonder if they just avoid that conversation because it's unpleasant.

Exactly.

What you're saying is that it's the entire conversation, the conversation.

When somebody has has a terminal illness or a very serious illness, they personally are thinking about death.

It's hard for some of their caregivers, both the medical professionals and the family, to actually discuss death.

When I come to meet somebody for the first time who's asked for an assisted death, I just start right with it because that's why I'm there.

And

when it comes to people like my friends, my friends get get diagnosed with horrible illnesses, I make sure that they have had the deaths conversation.

What are your choices?

But we'll also talk about, you know, what it's like to die from lung cancer or bowel cancer or ALS, that sort of thing.

What's available for comfort care at each stage?

What's likely to happen?

And many of them say, oh, my doctors never talked about what it would be like to die from this,

even though they had said there was no treatment left.

Yeah.

And the actual act, can you describe medically what steps do you take to bring upon death?

So in Canada, we're allowed to either take it orally or by intravenous.

You're allowed to choose, just like the Netherlands, they're allowed to choose, and almost everybody chooses IV.

So I arrive at somebody's home with a nurse.

I get the last consent.

The nurse puts in an IV.

Then we talk about who gets to sit on the bed beside them, who's holding which hand because the IV has to be placed reasonably.

And then when everybody's ready, I give them a general anesthetic.

It starts with a sedative.

I tell people they'll feel.

relaxed and calm and we usually see a smile coming on to people's faces as they feel the midazolam.

And then the general anesthetic is propofol.

And we use a very high dose, about 10 times what you use for surgery.

And that's actually enough for very frail people.

But then we also have rocuronium and bupivacaine, which stop breathing and stop hearts.

I promise my patients that it really will work, and it does.

The timing is usually about five minutes.

Well, really fast, yeah.

It's interesting.

Really fast, yeah.

I delivered over a thousand babies earlier in my career and it was such a privilege to welcome new people into the world and now to watch my patients say goodbye to their loved ones for the last time.

Such a privilege to be in that room at that time.

It sounds medically really pretty straightforward.

And I suspect rarely, if ever, does something go wrong.

You've done this many hundreds of times.

Roughly, how often would you say there's an important complication?

Oh, less than 1%.

And it's IV complications where an IV goes interstitial, meaning that it's not in the vein anymore and it has to be redone.

It rarely causes too much distress because we can always give the sedative and have them asleep.

There have been a few occasions, once for me, once for another of my colleagues, where we actually took the patient to an emergency department to get the IV.

And

with the oral, there can be prolonged deaths, which is really hard on the family.

That's exactly what natural deaths are like.

People are in coma for hours and hours before they actually pass.

But when somebody's all ready for an assisted death, they are expecting it within a couple of hours and it doesn't happen.

It's hard.

In our case, because of the way we do it, I tell all my oral patients who insist on drinking the fluid that if it isn't finished in an hour, I'll give them the IV.

It's not really a complication because the patient is in coma already.

The family has said their final goodbyes, and we just take care of it.

In the U.S.,

when we do capital punishment, when the government does executions, it's often done with a lethal dose.

And at least the critics of capital punishment claim, the activists claim that they botch it all the time.

There are many examples of how they've failed and had to restart it and whatnot.

And did you find out who it was that was providing it?

They weren't doctors.

The prison officials who are trying to do it?

Yep.

In our case, it was doctors.

It was medically organized and it doesn't fail.

I mean, we get access and we give enough medication and it always works.

I don't even think they're using the same drugs in the U.S.

I know there's been a big controversy.

The drug suppliers, I think it's pentobarbital or something like that.

The drug producers are not willing to even sell it to the government anymore.

But having heard you describe it, it's an even bigger puzzle to me than it's always been of why the government is so ineffective at doing this.

Yeah, nobody wants to help them execute people, I think.

We'll be right back with more of my conversation with physician Ellen Weap after this short break.

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You spent most of your career as a family practice doctor specializing in women's health doing a thousand deliveries, as you described before.

Extending your practice to assisted suicide doesn't really seem like such an obvious path.

Have you always had an interest in assisted suicide?

Were you just ready and waiting for the law to change in Canada so you could start providing the service?

No, I did palliative care for my own patients over 30 years as a family doctor.

So I was used to end-of-life care.

But I had stopped that and was doing just women's women's health, meaning abortions and contraception.

So in 2015, when we knew that the law was coming in, I had not been involved at all at that point.

But I discovered from one of my palliative care doctor friends that the National Organization of Palliative Care Doctors didn't want anything to do with medical assistance and dying.

Really?

Do you remember why?

I only know one palliative care doctor.

It's a guy named B.J.

Miller who I've had on the show.

And it strikes me that he would see this as one extra option in a big menu of things that you try to do to let patients have dignity and whatever joy they can at the end of life.

But you talk as if it's like completely obvious that the palliative care doctors wouldn't want anything to do with it.

I was working at my hospital, Vancouver General Hospital.

And the palliative care doctors at first would

actually turn their backs to to me when I'd come in.

They were so upset that I was coming in there to assist one of their patients.

But a few years later, we're sitting there talking in a lovely collegial manner about the best way to keep this person comfortable until they have their assisted death.

And it's because of the patients.

They care about their patients.

And when their patients would tell them why they thought they wanted an an assisted death rather than a natural death, they were listening.

So it is changing.

And it's lovely to see that now we can do exactly what you said, which is that people are offered the full range of care at the end of life.

But in 2015, when we knew that the law was coming in, I said to one of my abortion providing friends, hey, they're going to have trouble getting providers, just like abortion.

I've been through decades and decades of abortion care.

Our colleagues were being shot and stabbed, and I was getting death threats frequently.

There was a limited number of abortion providers for obvious reasons.

And I said, this is going to be the same.

They're going to need providers.

So she and I went to the Netherlands and got trained and came back.

And together for the first person in Canada, outside of Quebec, we provided made for in February of 2016.

You say it like it's completely normal.

Oh, I flew to the Netherlands and I learned how to do this, but how do you even come to arrange this sort of thing?

I

contacted the organizations in the Netherlands and they were very welcoming and very helpful.

They wanted Canada to do a good job when they knew that our law was changing.

And I couldn't learn from anybody here in Canada.

I did talk to American doctors who were providing an Oregon, but our law was more similar to the Netherlands.

So that's where I went to find out more.

Assisted dying, it's one of those topics where just the mention of it gets people into a tizzy.

It's the kind of subject that the economist L.

Roth has labeled as repugnant.

But if a person slows down for just a little bit and actually thinks about it, It's really hard for me to come up with any really good counter arguments for assisted dying.

But we haven't really made the full case for it.

Could I give you the chance to just explain what your case is for assisted dying?

It's a human right.

That is my basis.

We have the right to control our own bodies.

And that

has very much to do with reproduction and women having the right to choose if they're going to bear children and when and with who and what they do with accidental pregnancies.

And that just translates directly into how you manage your life at the end or even when you have a grievous and irremediable condition that's not deadly but causes you unbearable suffering and interferes with all the things that made life worth living.

You should have the right to choose the best way.

And it's so different from suicide.

In suicide, you have to be alone because if you involve anybody, they're committing a crime.

People say to me over and over again, I would not do this myself because first I'm afraid I'll fail and only make things worse.

And secondly, I want it to be recognized as my choice and have people there.

It's a basic control over one's life and death that matters.

One of my religious patients, I asked him how he saw this issue and he said, well, some people think it's playing God, but I say, it was playing God when I went to the doctors with this cancer and I agreed to have surgery and then I agreed to have chemotherapy.

Now, when that part is over,

instead of asking a doctor to prolong my life, I want my death hastened.

And that just makes sense to him within his religious beliefs, but it also makes sense to a lot of other people.

Now, I know you were raised as a Mennonite.

You've studied the Bible with great vigor when you were younger.

I'm a little confused what it is in Christianity or Judaism that says that assisted suicide is bad.

Is there something explicit about that?

Well, there's the commandment, thou shalt not kill.

But there's all sorts of other things like thou shalt not covet thy neighbor's wife or whatever.

People don't protest over stuff like that.

It seems to me it's much less about what's actually written down than some sense of moral righteousness or something that is much more cultural, I think, than truly religious.

Well, exactly.

I mean, think about abortion.

Why does it matter to

someone like your president that a woman is making a decision about her own life?

It doesn't affect him and it doesn't affect hardly anybody except her.

And so she should be the one to make the decision.

And yet

people believe that other people should not be allowed to make decisions about their own lives.

I guess one argument I've heard that I don't understand at all is that certain ethicists have said this is demeaning to the disabled because it's devaluing a life of disability.

Have you heard that argument and does it make any sense to you?

I have heard it many times.

And since I've been disabled and using a wheelchair for the last 32, 33 years,

I consider this just another

right that all disabled people should have

because you're not in their body.

They are.

There's no question that disabled people are devalued.

Frequently, if I'm out with my husband, somebody will talk to him about me as if I'm not there

because I'm the one in the wheelchair.

Other people get a whole lot more of that.

If a disabled person says they want maximum treatment for their cancer and someone else looks at them and says, wow, they're so disabled.

Why would they want to go through cancer treatments?

They should just die.

Well, the point is that person has the right to make the call.

We can't take away somebody's rights over their own life

just because they're disabled.

One time years ago already, I had two patients who both had severe progressive neurological diseases that had left them both pretty much quadriplegic at the time and they were getting worse.

I mean they were dying.

One was rich and she lived lived in a beautiful home with 24-hour caregivers that she hired and fired.

She was rich in every way.

She had loving husband, children, friends.

And the other patient I had around the same time

was estranged from all family, lived in a horrible

shelter with caregivers whom he fought with regularly.

And I couldn't help look at that and think, if he had had a million dollars and could set himself up more like she was in a beautiful place with his own caregivers that he hired, would he want to live longer?

Both of them said,

I know I'm not getting better, I'm getting worse.

All I can do is sit in this chair, watch TV.

That's not life.

I want to move on now and not wait.

You've totally made the case for this based on personal liberty.

But I think one can also make more,

I don't know if utilitarian is the right word, but more economic arguments in the sense that there are real benefits that come with this choice that

just accrue to people.

So being able to plan, like you talked about being present at your own death and having this rite of passage be done in a way that feels good to you, it's just a better outcome.

Once it accrues, you've got to make good arguments why you shouldn't let people have benefits like that, even aside from personal liberty.

Do you agree with that?

Or do you think that's just so trivial compared to personal liberty that it's a distraction to even talk about it?

No, it's an important issue.

You're an economist and nobody wants to bring up the economics of assisted dying, but it exists.

There's very good evidence that we spend a lot of money on the last year of life.

And most of that is, what can I say,

useless?

It's not comfort care.

Comfort care isn't that expensive.

It's more procedures, trying to prolong life against the odds, say.

So stating the obvious, look, it is money saving for society for people to elect assisted suicide.

And I suspect suspect that of all the arguments that are in the back of many people's minds, that one might be first and foremost flipping on its head, which is, wait a second, if I'm dying and it will save other people money if I die faster, am I going to be tricked into making the wrong choice?

Are there going to be bureaucrats that are trying to trick me into choosing this?

I suspect you must hear that argument all the time.

Yes, of course.

That has been a big thing that someone's going to be pressured in.

Certainly I have never heard or seen it.

I've done a lot more assessments than I have provisions because a lot of people

want to have the right to do it.

And I have to look for that.

That's part of my job.

Is this person being coerced?

But never seen it.

So now I'm going to speak like an economist.

I'm probably going to offend everyone.

But let's say that we didn't have health insurance and families had to pay the entire cost of end-of-life treatment.

In that world, these costs are absurdly high.

And for many families, they'd be completely unable to pay.

But if they were able to pay it, it might very well be the choice between can the grandchildren go to college or should grandfather...

his life be extended by an extra month or two.

And that would be maybe the scale of the trade-off.

And in that world, although people hate to think about it, a lot of sensible families would say, look, we're not going to provide that care.

There's scarce resources, and I'd rather spend it on the next generation, not on the last one.

We talk all the time about trade-offs between money and the quality of life, right?

Money buys you good things.

But when it comes to money and the quantity of life, the length of life, people flip if you ever talk about the fact that that trade-off should matter.

But it does.

It's a trade-off that we increasingly can't ignore as medical care gets more and more expensive.

Yeah.

Here's the puzzle I have.

If you look around the world, in most places, assisted suicide is not available.

And if you look at the survey results, if you ask Americans how many people support the idea of assisted dying, the numbers are really high.

The puzzle to me is, and I'm not sure I have an answer, but I'd love to hear your opinions.

Why is it that assisted suicide is so infrequently available when most people support it and it doesn't seem that fraug morally.

Have you thought about that at all?

Oh, yes.

Canada was lucky because our constitution is different than yours and different than most countries in that the government is required to address it.

So when the courts say that something is constitutional or unconstitutional, the government was forced to create create a law to deal with it.

And it's not true in other countries.

When you have to get politicians who want to be re-elected to create a bill and bring it through, you run into so many problems.

In New Zealand and Australia, they brought bill after bill after bill that failed before they finally got all of the Australian states and New Zealand has assisted dying.

This is happening in the UK right now.

They have to do it through Parliament, but we got the right from Constitutional Court.

That was the difference.

Politicians have a really hard time with this one.

Are the same folks who are mobilized in the pro-life contingency, are they standing by ready to stop this or try to stop this if assisted suicide gets broader?

Yes.

In Canada, we didn't have a lot of protest in the first years, but since 2021, when Canadians got the right to an assisted death if their natural death was not reasonably foreseeable, so people with chronic illness, that has brought them out.

So now there's a lot more people

really against assisted dying.

You're listening to People I Mostly Admire.

I'm Steve Lovitt.

And after this short break, Ellen Weave and I will return to talk about why the way the law is currently written leads some people to choose to die prematurely.

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Subject to change.

Medically assisted death laws, as they are currently written, require that the person asking to die be able to make sound judgments.

Now, that certainly seems like a reasonable requirement, but it does create a real dilemma for people in the early stages of dementia who prefer medically assisted death to living with advanced dementia.

The problem is, once they're deep into dementia, they can't make sound judgments, so they aren't eligible anymore for medical assistance in dying.

Consequently, they might have to choose to die earlier than they otherwise would have to ensure that they're eligible.

Now, that might sound like a purely hypothetical problem, but it's not.

Take the example of Danny Kahneman.

He's the hugely influential founder of behavioral economics and the author of Thinking Fast and Slow.

It only recently was revealed that he traveled to Switzerland in 2024 to die with the help of a physician.

Now, Danny could see that his mental facility was declining, but it wasn't at all obvious to those who knew him well.

If Danny could have been certain that medically assisted death would still be an option once he went into serious decline, he might have waited longer.

I asked Ellen whether Danny's case is unusual.

I've had that conversation many times.

All of the major dementias like Alzheimer's and vascular dementia and frontal temporal, etc., they're They're all fatal illnesses.

They are progressive.

They lead to death.

And so all those people are eligible under our current law, but they also then have to be in an advanced state of decline and capability.

Yet they have to have the ability to consent to medical procedures.

So I have this conversation with people all the time.

They've been diagnosed with a dementia.

They're struggling with their memories, but they're still very much aware.

And I tell them, the only way you'll be able to have an assisted death and skip the end of this dementia is if you give up some part of good life.

You have to actually be willing to leave early.

And some do and some don't.

I've watched people go through that process.

Their dementia gets worse and worse.

We meet on a regular basis.

We talk about it and

they'll often say, I'm enjoying my grandkids.

I'm enjoying life.

And often what they're saying is, oh yeah, I'm pretty much the same as I was.

But of course, I've got the neurologist's report that they are much worse.

And I've got the wife's report that they're much worse.

And so they are now no longer capable of making the decision because they're no longer aware of their own disability.

Only Quebec has an advanced consent law.

It's very detailed, complex, with a lot of safeguards in it.

And it just started, but you can create a document that says that when I no longer can take care of myself, when I no longer recognize my family, whatever, details about the progress of your dementia, then I would like an assisted death, even if I look

like I'm happy

or whatever.

It's a very detailed form they have to complete.

And we don't have that in the rest of Canada.

The Netherlands does have the ability to have an advanced consent for assisted dying.

Now, we do have something in the Canadian law called a waiver of final consent.

It's also called Audrey Parker's amendment.

Audrey Parker had cancer with metastases to the brain, and she wanted to spend one last Christmas with her family, but didn't dare because she was afraid she would lose her mental capacity because of these brain metastases before Christmas.

So she died a month or so before Christmas.

And we now have the ability to write waivers of final consent.

So a patient says, okay,

I want to see my granddaughter graduate in June.

But if I lose capacity before that time, I want to have an assisted death.

Can I ask you a question about that?

Because to an economist, that makes perfect sense.

Of course, you should have that.

But I also know with things like organ donation, where you can sign and say, look, I really want to donate my organs.

But in the end, if your family doesn't go along with it, doctors will virtually never say over the will of the family, well, we're going to do this anyway.

Is it the family in the end that you think will be enforcing this?

I don't know what you call it, living will or what it is, or do you think it would really rely on the doctors?

And the doctors would overrule family members for saying, No, but they do look happy, even though everything they said on this legal form suggested that they would want suicide.

We're not going to let you do it.

Well, I mean, we know that families can get very upset and can cause problems.

And a whole lot of doctors would not ever do it without the families okay

because it's dangerous for the doctor.

And

it is sad that the patient's will, it would not be followed.

Now, there's judgment on the part of the assessors or the doctors who are deciding whether to approve a patient's request.

The judgment in medicine seems like it always raises the problem of malpractice suits.

Do you have incredibly expensive malpractice insurance because of the fact that a disgruntled family could sue you for saying that you had misinterpreted what a patient had said to you?

Have you run into that personally at all?

I've certainly run into disgruntled families, yes.

And in Canada, we have a medical association that provides our legal care.

That means, no, it's not expensive.

They are very clear that they will defend doctors who are doing things right

and not necessarily if they feel they're doing them wrong.

That's because it's a medical association with doctors on the board who decide what's going to happen and whether we get our legal coverage.

In a world in which the palliative care doctors turn their back on you, I'm not sure I'd want that association representing me in legal situations.

Well,

in some ways, they'll defend you for

all the other doctors, right?

They don't want any kind of precedent set

that might interfere with the working of other doctors because they cover all of us.

I know a lot of people fear death and dying so much that they avoid thinking about it or planning sensibly around it.

And one reason I think that's a mistake is because death and dying are two very different things.

Dying is a process, and death is a state of not existing.

And one can have a lot of fear about one and be at peace with the other.

And that might matter for choices and preparations.

Do you feel like that's an important distinction for people to have in their mind?

Oh, yes.

yes, so we have many conversations about this.

I ask people what do you think happens to you after you're dead and for some they're going to meet their parents and other family members in heaven.

Others say nothing.

Nothing happens afterwards.

And others say I don't know.

And then I ask whether that part is scary.

Are they worried about what happens after?

And some people are, most are not.

When it comes to the actual day, almost always people are at such peace, so ready to go.

But there are a few people who are really anxious about

the actual

death as opposed to the dying, which, yeah, I've seen enough dying to know that some unpleasantness involved.

I suspect as many of these cases as you've been involved with, there must have been people who the day came and they changed their mind.

Not really.

Really?

I've had people cancel the day before, only a few that actually canceled, and that was usually on pressure from somebody else, like a religious family member who managed to persuade them that they had the duty to continue.

I've had a couple of people who just wanted an hour's delay or something because they weren't finished, weren't finished with all the things they wanted to say or do at the very end.

And that's lovely because they had planned for me to come at two o'clock, but two o'clock just wasn't quite right.

So I come back at three.

Going back to this idea of dying versus death, personally, I'm not sure why, but I'm relatively indifferent to life.

I think compared to other people, I worry less about the consequences of being dead.

But I have a lot of fears about the process of dying.

I don't like the idea of being dependent.

And I have a lot of complicated feelings around losing control.

But I want to ask you, because I've heard you say frequently that you love life.

And I think if I loved life, I would be really afraid of being dead.

Do you personally fear death?

Do you fear the process of dying?

Oh, no.

I mean, the process?

Yeah.

I get to see some people suffering so horribly and I don't want to be there.

Saying goodbye to your loved ones is really hard.

But like you, I believe that nothingness is what happens after I die and that's not scary.

So to speak very much like an economist, if you get a big positive out of everyday life and death is a payoff of zero, then you really don't want that.

You really don't want to be dead, right?

But it's interesting because I first started thinking about this.

Believe it or not, my grandparents died via a medically assisted suicide many years ago.

But the doctor who assisted them was actually my grandfather himself.

He was a retired doctor.

And I'm not sure if he prescribed himself two lethal doses before he retired or he was squirreling away in my grandmother's medicine.

She had lung cancer.

She was terminal with lung cancer.

But they decided to die together.

And so they, in their own home, took a lethal dose and and both died.

And it was interesting because it certainly made sense that my grandmother wanted to die.

She was very, very ill, very far along with lung cancer.

I mean, my grandfather was old.

He was in his 90s, but extremely healthy, mentally acute.

And he seemed to enjoy life more than just about anyone I had ever met.

And so for me, it was actually a transformative experience to understand that someone like him, who seemed to derive so much joy out of life would choose death over life.

And it actually was very freeing for me in that regard.

I suppose you experienced some of the same things yourself.

Being a provider, you've seen people who love life happy nonetheless to go.

Yes, absolutely.

Now, I'm sure you've thought a lot about your own end of life path, even more broadly.

For listeners, how would you advise them in thinking about their end of life?

What we talk about is what's really important to you, what matters to you most in your life.

Some people will say, I mean, I've even had somebody say, if I can't drive my car, then I don't want to be alive.

That's not something that most people would agree with.

And then there's the one, I don't want anybody to wipe my bum.

And that's something that a lot of people agree with until they actually get to that point.

And then a lot of people find out that caregivers are kind and that they can still enjoy visiting with their grandkids and that life still has pleasures.

So it wasn't the last point.

They decided that this would be unbearable and it turns out it's not.

So I tell people that

they should think about what it is that would be too much for them and

recognize that they might change their their mind.

Are you in favor of expanding the definition of who's allowed to use assisted suicide?

From your perspective of liberty and human rights, do you think that we should expand this?

Yes.

I mean, for Canada, the group of people right now who don't have the right are people whose main suffering comes from mental illness.

And that is slightly unfair.

The suffering from psychiatric illness can be horrendous.

Those people should be given their rights.

And there, I think, what people argue is that the sound mind is the question there, right?

Yeah, but that's separate.

We always have to assess that somebody is of sound mind.

And we can do that in somebody with cancer and depression.

We can do that with somebody in cancer and schizophrenia.

We are capable of assessing for competence.

And generally, people who have serious mental illness are competent to make decisions about their own lives.

There have to be different safeguards for people with mental illness, absolutely.

But it's still unbearable suffering for some people.

I agree that on a basic human rights basis, that should not be an exception.

I think when everybody has access and knowledge, more people would be choosing assisted dying.

I've been trying to put my finger on what felt odd about this conversation, and I finally managed to figure it out.

We just had a long conversation about death and dying that was completely emotion-free.

And that's extremely unusual.

Whether it's on this podcast or just talking with friends, I can't remember a conversation about dying that wasn't emotional.

But it does make sense sense to me why our conversation was so matter-of-fact.

It's because we both think as a matter of public policy that it is completely and totally obvious that medically assisted dying should be available to everyone.

I know when my time comes, I definitely plan to take advantage of it.

If I, like Danny Kahneman, happen to die in Switzerland, you'll know exactly why.

So, this is a point in the show where I welcome my producer, Morganant, Morganon, to tackle a listener question.

Hi, Steve.

So today we're going to continue our conversation on noise and randomness.

We've talked about this a couple of times in listener question segments at this point, most recently in the last episode with roboticist Ken Goldberg.

And he talked about the usefulness of noise and randomness, how they add it to their training data sets when they're training robots.

So robots are learning in an environment that mimics the real world.

And I jumped on on that example he gave.

It caught me off guard because in economics, we essentially never want to pollute our data sets to add noise back into it.

And so we asked listeners at the end of that episode, did they have other cases where adding noise would make things better?

Because for me, it was kind of like a revelation that that was something that could be valuable.

The listeners rode in with a ton of examples from machine learning, computer security, game design, physical therapy, neuroscience.

Apparently, noise and randomness are useful in hand grinding telescope optics, training virtual assistants like Siri and Alexo.

And then one of my favorites is a small example from a listener named Colette who works in aviation.

And she says that adding noise and randomness into wind and gust modeling for stability and control analysis for aircraft is really useful.

Yeah, of all the questions we've ever posed to listeners, I think this is the one where I was most impressed, where the answers were so thoughtful and presented in such a kind and constructive way.

I learned a lot from them.

Academic economists almost always are looking backwards.

We're trying to explain the past rather than to predict the future.

We don't need to add noise.

Really, the common theme among almost all of the listeners was if you're trying to build a prediction model, you can be too confident if your data are too clean.

You can overfit the data.

And so noise is a way of offsetting that.

What were some of the standouts for you?

So, my single favorite email that we got, Morgan, came from a listener named John, and it was very short.

It was essentially two sentences.

He said, The obvious case to me where randomness is critical is natural selection.

Without it, there's no life.

And that's really a great point because if you take a very naive view, you might think, well, the easiest way to reproduce is just to replicate yourself, right?

And some primitive organisms do that, and it's really cheap energetically.

You don't have to find a match to mate with.

And it seems like that would be a good strategy naively, but what is clearly shown through the history of life is that this mixing of chromosomes.

So when the male and the female reproduce, they split their DNA and each get half of it.

And that leads to a lot of randomness in what comes out the other side.

And of course, genetic mutations are also doing that same thing.

So that was a case where I really kicked myself.

And I thought, God, how did I blow it when we answered that first question and not get something as important, as obvious as natural selection?

Well, another one that I was surprised by that I also think you probably should have thought of was about how randomness is useful in game theory.

We had a listener named Barney write in about how in many games, there's something called mixed strategies that can benefit a player.

And a mixed strategy example for Barney was penalty kicks in soccer or football.

Can you explain how noise and randomness is useful in that setting?

Well, I certainly know a lot about penalty kicks in soccer.

I've written academic papers on it.

The idea is that if you always kick to the left, then the goalie will always jump to the left.

So you can't always play the same strategy, even if you're better at kicking the ball to the left than to the right.

And so you have to mix up what you do.

Sometimes kick left, sometimes kick right.

And I actually read Barney's email over and over because my initial reaction was: no, no, there's a very big difference between adding noise and mixed strategies because a mixed strategy is just inherent to the problem.

But the more I thought about it, the more I realized that that is really just a prediction problem.

It's a problem where you're trying to make it hard for your opponent to predict.

And so, despite my deep resistance to Barney's point, in the end, I had to give in and say, Yeah, that's actually a rare case in economics where we're trying to do prediction and the principles are exactly the same.

So, hats off to Barney for changing my mind on something that I've thought about a lot.

Listeners, thank you so much for writing in on this topic.

If you missed the first part of our conversation about noise and randomness, you can listen to our episode with roboticist Ken Goldberg.

It's called Can Robots Get a Grip?

If you have another question or thought for us, please send us an email.

Our email address is pima at freakonomics.com.

That's p-im-m-a at freeconomics.com.

We read every email that's sent, and we look forward to reading yours.

In two weeks, we're back with a brand new episode featuring economist and criminologist Jens Ludwig.

Jens has a brand new book out that offers a radical new take on how to tackle crime in America.

Luckily, neither the neighbor or I had a gun in that moment, but sometimes someone does, and a tragedy results.

I think a lot more of the gun violence problem in America than we've appreciated is driven by fast thinking rather than slow thinking.

As always, thanks for listening, and we'll see you back soon.

People I mostly admire is part of the Freakonomics Radio Network, which also includes Freakonomics Radio and the Economics of Everyday Things.

All our shows are produced by Stitcher and Renbud Radio.

This episode was produced by Morgan Levy and mixed by Greg Ripon.

We had research assistance from Daniel Morrick's Rabson.

Our theme music was composed by Luis Guerra.

We can be reached at Pima at freakonomics.com.

That's P-I-M-A at freakonomics.com.

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