S9 Ep27: The right to choose to die

Content note: this episode discusses assisted dying, end-of-life choices, and suicide. Some listeners may find the content distressing.

In April 2024, Daniel Kahneman — one of the most influential psychologists of the twentieth century — emailed his close friends to say goodbye. He was 90 years old, his kidneys were failing, his mental lapses were increasing, and he had decided it was time to go. He flew to Switzerland to end his life at an assisted dying clinic there, because New York, where he lived, did not permit it. Thirteen American states currently allow medical assistance in dying; most require a terminal diagnosis with death expected within six months. Canada, Belgium, and Switzerland allow it on broader terms. The UK introduced a bill to parliament, but it failed to pass. The debate on whether we have the right to end our own lives has not been resolved.

This week Tim Phillips talks to Al Roth of Stanford University about how economics can contribute to the debate on medical aid in dying (MAID). Roth, a Nobel Prize laureate, has written a new book that argues this, and similar debates, often miss the key insight: the binary choice of “allow” versus “ban” rarely reflects reality. For example, in the United States, he explains that physicians in jurisdictions where assisted dying is illegal are familiar with the practice of administering doses of drugs that will relieve pain, but also end life.

Roth's argument is not that assisted dying is always right. It is that a moral position that ignores the costs of a ban is not more ethical — it is less honest. Economists, he says, bring one specific thing to this debate: the insistence that trade-offs be made explicit.

The book discussed in this episode:

Roth, Alvin E. 2026. Moral Economics: What Controversial Transactions Reveal about How Markets Work. Basic Books. Published 21 May 2026.

To cite this episode:

Phillips, Tim, and Alvin Roth. 2026. “The right to choose to die." VoxTalks Economics (podcast).

Assign this as extra listening. The citation above is formatted and ready for a reading list or VLE.

About the guest

Alvin Roth is the Craig and Susan McCaw Professor of Economics at Stanford University. He was awarded the Nobel Prize in Economics in 2012, shared with Lloyd Shapley, for the theory of stable allocations and the practice of market design. He is one of the architects of modern matching market design, having redesigned the systems used in the United States to match medical residents to hospitals and students to schools. A previous book, Who Gets What — and Why, was published in 2014.

Research cited in this episode

Repugnant transactions is Alvin Roth's term for a class of transactions that are controversial not because no one wants to engage in them — that would be disgust — but because some people do want to engage in them and others believe they should not be allowed to, typically on moral or religious grounds. The key feature is that the objectors suffer no direct externality from the transaction; their objection is to the thing happening at all, regardless of whether it affects them. Roth's examples across the book include medical aid in dying, kidney sales, paid blood plasma donation, surrogacy, and access to certain drugs. The policy implication is that repugnant transactions, unlike ordinary market failures, cannot be resolved by standard economic tools; they require explicit engagement with the moral contest and careful mechanism design to decide what is permitted, to whom, under what conditions.

Oregon's Death with Dignity Act (1997) was the first US state law permitting physician-assisted dying. It requires a terminal diagnosis with death expected within six months, confirmation from two physicians, a waiting period, and self-administration of the medication by the patient. According to the 2024 report of the Oregon Health Authority, assisted dying accounts for roughly 0.9% of all deaths in Oregon; many patients who obtain a prescription never use it. Oregon's 27 years of data make it the most-studied model for the policy, and its take-up rates and population demographics have informed both advocates and critics in other jurisdictions.

Ezekiel Emanuel and vulnerable populations: A 2016 paper by physician and bioethicist Ezekiel Emanuel and co-authors examined the demographics of patients who access assisted dying in jurisdictions where it is legal and found no evidence that vulnerable populations — defined by disability, age, mental illness, or socioeconomic status — accessed it at higher rates than the broader population of dying patients. Roth cites this as evidence against the argument that legalisation creates pressure on the vulnerable to choose death, while noting that this population-level finding does not rule out individual cases of pressure.

The Hippocratic Oath is the earliest recorded professional commitment by physicians not to participate in assisted dying. Roth notes that Hippocrates formulated the oath in the fifth century CE, and that the very inclusion of a prohibition on helping patients die implies the practice was already occurring — physicians were being asked to do it. The religious objection — that decisions about life and death belong to God — and the medical objection — that a physician's role is to save life, not end it — have both been consistent features of opposition to assisted dying across more than two millennia.

The Canadian Supreme Court decision (Carter v. Canada, 2015) struck down Canada's criminal prohibition on physician-assisted dying on the grounds that it infringed Canadians' constitutional rights to life and to security of the person. The court's reasoning included the counterintuitive argument that denying access to assisted dying could cause people to end their lives earlier and less safely — while still capable of doing so — out of fear of being unable to later. The Canadian framework that followed is more permissive than US state laws: it does not require a terminal diagnosis but instead an irremediable condition causing intolerable suffering. Canada has since debated, and repeatedly delayed, extending the framework to mental illness as a sole underlying condition.

Mechanism design is the field of economics concerned with designing rules, institutions, and processes to achieve desired outcomes, particularly in settings where participants have private information or conflicting interests. Roth is one of its leading practitioners. In the context of assisted dying, mechanism design asks: who can apply, through what process, verified by whom, with what waiting periods, and with what safeguards against coercion or mistaken diagnosis? The differences between Oregon's model (terminal diagnosis, self-administration, annual reporting), Canada's model (irremediable suffering, physician or nurse practitioner administration permitted), and Switzerland's model (available to non-residents) are, in Roth's framing, different mechanism designs with measurably different outcomes.

More VoxTalks Economics episodes

In February, Tim spoke to Martin Ellison and Julian Ashwin about what decisions seniors will take about their later years and whether policy can accommodate both their abilities and their needs. Listen to The Economic Consequences of Living Longer.