Canada's uptake of medical assistance in dying (MAID) is roughly four to five times Oregon's per capita rate despite Oregon legalizing it two decades earlier, mainly because of provider infrastructure and access, not eligibility rules.
Wiebe estimates about 85 percent of Canadian MAID patients would also qualify under California's stricter six-month-terminal rule, so the gap isn't really about who's eligible. Instead she credits an organized national provider association that trained and supported doctors, government-run coordinating offices that connect patients to assessors quickly, and early positive media coverage that made the option visible to the public.
assisted-dying
Wiebe frames assisted dying as a direct extension of the same bodily-autonomy right that underlies reproductive choice, not a separate ethical category.
She draws an explicit line from the right to control reproduction to the right to control one's own death, arguing both rest on the same principle: a person's body is theirs to decide about, and outsiders (family, clergy, the state) shouldn't override that even when they disapprove.
bodily-autonomy
The 'demeaning to the disabled' objection to assisted dying gets the causality backward, according to Wiebe, who has used a wheelchair for over 30 years.
She argues devaluation of disabled people is a real and separate problem (she describes being talked about in the third person while sitting right there), but taking away a disabled person's right to choose their own death 'because they're disabled' compounds that devaluation rather than fixing it. She illustrates with two similarly ill patients whose vastly different financial resources changed how much they wanted to keep living, suggesting apparent 'choice' to die is sometimes really a poverty of support.
disability-and-identity
Dementia patients face a forced tradeoff: leave earlier than they'd otherwise want in order to remain legally eligible for an assisted death, because Canadian law requires the ability to consent at the moment of the procedure.
Once someone is deep enough into dementia to qualify as being in 'advanced decline,' they can no longer legally consent, so they age out of eligibility. Wiebe says she has this conversation constantly with dementia patients who are still lucid: they must decide to die 'early' to guarantee access, since only Quebec has an advance-consent law letting people pre-specify symptoms that should trigger a death later. Levitt connects this directly to economist Daniel Kahneman's 2024 assisted death in Switzerland, undertaken while still mentally sharp because he could not be sure of retaining the option later.
assisted-dying
A written pre-consent document (a living will for death) does not reliably override family objection in practice, even where legally recognized.
Wiebe says many doctors will not proceed with an assisted death against a family's wishes even when the patient's own advance directive calls for it, because doing so is professionally and legally risky for the doctor - so the patient's documented will can end up unenforced despite the law technically permitting it.
assisted-dying
Levitt argues assisted dying is straightforwardly cost-saving for the healthcare system, and society avoids discussing that argument even though it's real.
He notes enormous spending occurs in the last year of life on procedures that extend life marginally rather than on comfort care, which is comparatively cheap. He frames the taboo around discussing the cost angle as itself the anomaly: society readily accepts money-versus-quality-of-life tradeoffs everywhere else but treats money-versus-quantity-of-life tradeoffs, near death, as unspeakable.
healthcare-cost-tradeoffs
Wiebe reports that pressure or coercion toward assisted death, the central fear critics raise, essentially does not appear in her practice - if anything the pressure runs the other way, from religious family members pushing patients to continue living.
She screens explicitly for coercion as part of her assessment process and says she has never actually seen a patient pressured into choosing death; the cancellations she has witnessed were driven by family members persuading a patient to continue living, not the reverse.
assisted-dying
Countries where courts, not legislatures, establish the right to assisted dying end up with much broader access, because politicians facing re-election avoid touching the issue.
Canada's law originated from a constitutional court ruling that forced government action, whereas in New Zealand, Australia, and the U.K., the path has run through Parliament with repeated failed bills before (partial) passage. Wiebe attributes Canada's comparatively wide access to this structural difference in how the right was established.
assisted-dying
For patients themselves, death and dying are separable fears; most of Wiebe's patients are at peace with being dead but some remain anxious specifically about the process of dying.
She routinely asks patients what they believe happens after death and whether that scares them; most are unbothered by not existing but a minority fear the physical process itself, which she says is a distinct and separately worth naming source of anxiety, not synonymous with fear of death.
end-of-life-care
Very few of Wiebe's patients change their mind on the day of the procedure, and clinical complications during the procedure itself are under 1 percent.
The rare cancellations she has seen were driven by outside religious pressure rather than the patient's own doubt. Medically, she says the process (a sedative followed by a high-dose general anesthetic, then rocuronium and bupivacaine) works reliably within about five minutes and complications are almost entirely limited to minor IV placement issues.
end-of-life-care
Books referenced
Thinking, Fast and Slow - Daniel Kahneman - Referenced when Levitt discusses Kahneman's own 2024 medically assisted death in Switzerland, noting Kahneman was the founder of behavioral economics.
Companies
Canadian Association of MAiD Assessors and Providers - Organization Wiebe helped found in 2016 to train, support, and set care standards for doctors providing medical assistance in dying across Canada.
Vancouver General Hospital - The hospital where Wiebe practiced and where palliative care doctors initially turned their backs on her for providing assisted deaths.
Techniques and frameworks
Waiver of final consent (Audrey Parker's Amendment) - Canadian legal mechanism letting a patient pre-consent to an assisted death if they lose capacity before a chosen date, named for a patient who died early rather than risk losing capacity before Christmas.
Advanced consent for dementia (Quebec-only) - A detailed legal document, unique to Quebec within Canada, that lets a person specify in advance the dementia symptoms that should trigger an assisted death even if they later appear content.
Summary
Steve Levitt talks with Ellen Wiebe, a Canadian physician who has provided medical assistance in dying (MAID) to over a thousand patients since 2016, when she and a colleague trained in the Netherlands and performed the first MAID case in Canada outside Quebec. The conversation opens on the mechanics: how Canada's law came from a 2015 constitutional court ruling rather than legislation, why Canada's uptake rate is roughly four to five times Oregon's despite Oregon legalizing decades earlier (Wiebe credits provider infrastructure and access over eligibility differences), and what the procedure itself actually involves - a sedative, a high-dose general anesthetic, and drugs that stop breathing and the heart, typically complete within about five minutes with under 1 percent complication rates.
The middle of the episode turns to the ethical and philosophical case for assisted dying. Wiebe, herself disabled and using a wheelchair for over 30 years, roots her argument in bodily autonomy, tracing a direct line from reproductive rights to end-of-life rights. She pushes back hard on the "demeaning to the disabled" objection, arguing that removing a disabled person's choice compounds their devaluation rather than protecting them, and illustrates with two similarly terminal patients whose radically different financial resources shaped how much they wanted to keep living. Levitt raises the economic argument directly - that assisted dying saves money that would otherwise go toward marginal life-extending care in the last year of life - and both agree society treats this as an unspeakable tradeoff even though it's straightforwardly true and analogous to tradeoffs made everywhere else.
A significant thread covers dementia, the hardest case for the law as currently written: because eligibility requires the ability to consent, patients with early dementia face pressure to choose death earlier than they'd otherwise want, before they lose the legal capacity to request it. Levitt connects this to economist Daniel Kahneman's own 2024 assisted death in Switzerland, undertaken while he was still mentally sharp because he couldn't be certain the option would remain available once his decline became obvious to others. Wiebe describes Canada's imperfect workarounds - the "waiver of final consent" (Audrey Parker's Amendment) for patients with a fixed near-term decline, and Quebec's more detailed (Canada's only) advance-consent law for dementia specifically - while noting that even documented advance wishes often go unenforced in practice because doctors are reluctant to act against family objections.
Wiebe also directly rebuts the common fear that patients are pressured or coerced into choosing death, saying she screens for coercion as standard practice and has essentially never seen it; if anything, pressure she's witnessed runs the other direction, from religious family members urging patients to keep living. The episode closes on a personal note from Levitt, who shares that his own grandparents died via a jointly chosen assisted death decades ago (his grandfather, a retired physician, self-administered the process), and reflects that the conversation with Wiebe was unusually unemotional for a topic this weighty - which he takes as evidence that both of them see the policy question as settled and obvious, even if the broader public debate isn't there yet.
A shorter closing segment with producer Morgan Levey revisits a prior listener-question thread on the value of noise and randomness in prediction and design, prompted by listener emails covering natural selection, mixed strategies in game theory (penalty kicks), aviation gust modeling, and machine learning training data.
Notable Quotes
"I've 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?'" - Ellen Wiebe
"It's human right. That is my basis. We have the right to control our own bodies... And that just translates directly into how you manage your life at the end." - Ellen Wiebe
"You have to actually be willing to leave early." - Ellen Wiebe, on the tradeoff dementia patients face to remain legally eligible for an assisted death
"We just had a long conversation about death and dying that was completely emotion-free. And that's extremely unusual... 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." - Steve Levitt