Are You Ready for a Glorious Sunset? (Ep. 217)

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(photo: Josep Ma. Rosell)

(photo: Josep Ma. Rosell)

Our latest Freakonomics Radio episode is called “Are You Ready for a Glorious Sunset?” (You can subscribe to the podcast at iTunes or elsewhere, get the RSS feed, or listen via the media player above. You can also read the transcript, which includes credits for the music you’ll hear in the episode.) The gist: we spend billions on end-of-life healthcare that doesn’t do much good. So what if a patient could forego the standard treatment and get a cash rebate instead?

Not long ago, we received an e-mail from a listener named Timothy Price:

Why don’t health insurance companies offer bonuses to patients who are willing to forego standard end-of-life medical care?  When a patient receives a terminal diagnosis, I have to believe that the healthcare companies have actuaries and data sets that would give them guidance on what the next 6-24 months of medical care would cost.  For patients willing to skip this type of care my idea is for a bonus according the following formula: immediate bonus = 50% of (actuarial underwriting of standard medical care – hospice care). The patient maintains control over the optionality, but an immediate benefit opens up to them (one last grand vacation, a lasting legacy for the next generation, etc).  The health insurer gets an actuarial gain and makes progress towards disincentivizing excessive consumption of health care in the final months of life.  Seems like a no-brainer to the economist in me (though my sociologist wife thinks I’m completely cold-blooded).

Whether you consider Price’s idea a no-brainer or completely cold-blooded probably says a lot about how you think about end-of-life healthcare costs and, more broadly, how we handle the end of life in modern society generally. Those are the themes we poke at in this episode. Among others, you’ll hear from:

+ Ezekiel Emanuel, the physician and medical ethicist at Penn who helped put together the Affordable Care Act. More recently, Emanuel outlined his end-of-life views in an Atlantic piece called “Why I Hope to Die at 75.”

+ Uwe Reinhardt, a healthcare economist at Princeton.

+ Thomas Smith, an oncologist and cancer researcher at Johns Hopkins.

+ A University of Chicago economist named Steve Levitt.

Which of these people do you think were most enthusiastic about Timothy Price’s proposal?

Mighty Casey

Outstanding idea. Too bad you didn't have any patients or family members with direct experience of how end of life actually unfolds. Clearly stating one's wishes has to be Step 1, with this idea about a payer bonus if one forgoes care other than palliative and hospice after a terminal dx.
The "life above all" cohort will do a full bore linear freak-out over this idea, of course - just witness the blowback that continues on Zeke Emanuel's Atlantic piece, where he gets tagged as the "Mengele of Obamacare" - but it makes so much human, and economic, sense.
A national conversation about end of life is WAY past its due date. But given that the American mind is overly influenced by "I'll be a millionaire soon" and "I'll live forever" dream-think ... I dunno as that conversation will happen soon. But there are points of heat on a map - like this - that reveal it to be rising a bit.

Nathaniel M. Herrera

"Let food be thy medicine and medicine be thy food." - Hippocrates | I am currently taking English Writing 302 at American River College with Laurette Buljan Fall 2015 and commenting on a Levitt and Dubner's Freakanomic blog is part of my Homework. Thank You @natanyofsho

Julien Couvreur

I'd be curious to hear more about why Uwe Reinhardt thinks that insurance companies don't have an incentive to control costs (20 minutes into the podcast). He suggests that the insurance company takes a cut of any transaction (3%), but without going into details.

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Most people will have health insurance no matter how high healthcare costs are. An individual insurance company has an incentive to keep its costs lower than the next company's, but when everyone's costs are the same, then it doesn't matter how high or low those costs are. Insurance company #1 costs about $600/month, Insurance company #2 costs about $600/month, Insurance company #3 costs about $600/month—and my employer, not me, decides which one I will be using.

Julien Couvreur

That would explain why the cost of insurance doesn't have much downward pressure, but does not explain why the cost charged by hospitals to insurances wouldn't have such pressure.

Julien Couvreur

Regarding Ezekiel Emanuel's discussion of Obamacare and death panels, yes, trade-offs are inevitable. But I think there is a big difference between government imposing a certain trade-off, and individuals and their families making trade-offs.

Of course, the issue becomes complicated as government starts to tax, redistribute and manage healthcare services. As economist Ludwig von Mises said, intervention begets intervention. Something that once was a local and personal decision becomes a political, one-size-fits-all, tug of war.


Being from the UK, where we have universal healthcare, I find the whole discussion on a glorious sunset bizarre. Uwe Reinhardt provided the example of the German doctor that refused to instruct expensive end of life care; that's because doctors in countries with universal healthcare have to make budgetary decisions as well as healthcare decisions. There is a need for a pragmatic approach to healthcare.
Correct me if I'm wrong, as thankfully I don't have experience of paying for healthcare in the US. In the US many people need health insurance to receive the kind of expensive end of life care you discuss in the podcast. A lot of the contributors to your podcast and the comments below highlight the ethical and legal issues of a patient, or their family, making the decision to end life. But if a patient doesn't have the right health plan, the decision to instruct end of life care has already been made and there is no Glorious Sunset.


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Most Americans have some kind of financial coverage. Most relevantly, most end-of-life care is paid for through Medicare (because it is for disabled people and older people). Medicare is paid for by taxpayers like the NHS, only without the NHS's limits on what will be paid for. Medicare pays the lowest amount for each service that they can get away with, but they will pay for a nearly infinite number of services.

Mark Laurel

I'v just listened to your podcast on end-of-life care, and I want to thank you for bringing attention to a difficult subject. It's close to home for me, because my paternal grandparents had significant illnesses that bankrupted them with medical costs in their final years. Just this past month, my siblings and I had the advanced directives conversation with my father, whose cancer has become aggressive.

In both cases in my family, there were and are hard financial choices to face. Personally, I would welcome an option that would allow for palliative care and would enable me to leave a positive financial legacy for my family, a choice that is not open to me at present. Alas, I agree with the arguments that such a plan is not feasible, although I do I applaud the physicians who take time for informing patients of their choices and directing their final care.

Some of us who live in poverty do not see a chance for a graceful death. We receive medical care in a patchwork system that drains our mental, emotional, and financial resources. Perhaps my desire for a 'glorious sunset' simply reflects my longing to help my family escape what has sometimes been a devastating twilight.

In any case, an excellent podcast.


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This doesn't seem to different from critical illness insurance, which already exists. You could have an option to convert your health insurance plan to a critical illness insurance plan.

Also, the option is not just "die alone, uncared for, in pain". You could actually spend some of the lump sum money on the healthcare that you actually want.




After listening to this podcast, which hit very close to home, I found myself saying yes a lot. My husband passed away last year from grade 3 brain cancer. He was 32, I was 31. Never once did they mention palliative care, they gently said that he could stop the treatment any time, but that was it. I love his doctors and don't want to detract from the amazingly difficult and sensitive job that they do. But they didn't talk about death, as a result we didn't talk about it. I think that I was waiting for the doctors to say something more to acknowledge that he was dying. They never did. He was still on chemotherapy until two weeks before he died from pneumonia. Another point I wanted to bring up is the rebate proposition that was discussed. I always let my husband make his own medical decisions, it was his body after all. But in this situation I know that he would have made a decision I wouldn't have been able to handle. He definitely would have taken a rebate, if it meant that I was taken care of. I would have felt as though he sacrificed time in order to ensure my comfort. I know many stories of widows who blew through their inheritance because they didn't want it haunting them anymore, or others who never touch it because it was blood money. So being the person left behind, I would gladly trade minutes with my husband for any amount of money. Which then brings up quality of life. I knew that at some point his quality of life would get so bad that I would wish for his death, for him. It sounds horrible and I would never have thought I could feel or think something like this. But it happened three weeks before he passed. His treatments made everything burn his mouth and he couldn't eat, it made the muscles in his legs so weak he couldn't stand, it affected his bowel movements in a very uncomfortable and painful way, and he could no longer see because of where the cancer was in his brain. His brain was still there, he was still there, but his body made it so he couldn't enjoy anything. I wouldn't wish that on my worst enemy. Which is why I understand why Brittany Maynard moved to a state where she could choose to end her life. I would like to think that if Dan chose that path, I would have supported it. Its such a difficult thing to even comprehend, let alone put yourself in that situation, so I really will never know. Anyways, this is the perspective of a person who stood by her husband through 12 years of cancer treatments and watched helpless as he died in her arms. I normally don't comment on things, but this podcast resonated so deeply with me that I had to comment, even if it was just to clear my head of these thoughts.


Paul Williamson

Quite an interesting pod cast. As an intensive care unit nurse, clearly, we are in need of useful guidance for helping people endure and end-of-life diagnosis.


I realize I'm coming very late to this, but: there is a vast difference between "advanced directives," having doctors discuss advanced directives with patients, and what is meant by the term "death panel." The former is the individual making decisions about his/her own end of life care in advance. The latter is government bureaucracy making decisions about an individual's care. Government bureaucracy decision-making for an individual vs. individual decision-making for him/herself. Allowing the two to be equated like you did makes it appear that you're taking part in a political cheap shot.


I disagree. I thought he was very fair.


The one issue I see with the proposal to split the money between the insurance company and the patient is: where are the lines? If an elderly person refuses cancer treatment and receives a payment instead, could I refuse treatment for a broken limb and get a cash payment? What's the difference? How would the lines be drawn? Would this allow room for fraud of the insurance companies by a patient and doctor that are in collusion?


Having been raised on a farm and developing a utilitarian attitude about the life and death of domesticated animals, exposed me to death in a way that most in a modern urban/suburban existence never contemplate when young. The urban dweller may have been a participant in the sterile death of a euthanized pet, a beloved family member for some, but not in a way that causes them to contemplate there own mortality.

I also have the privilege of being a physician. I trained in internal medicine but could never have conscientiously practiced the discipline due to my abhorrence at the expense of end of life care in the mid 1980's. I chose to work initially in occupational medicine, a field that focuses on injury and disease prevention as well as rehabilitation and return to as functional a life as possible after injury. Even later I chose to study and pursue osteopathic manipulative medicine as a means of promoting health and function on an individual level without the medical legal pressures of satisfying the comptrollers of medical management, the patient and sometimes their attorney, the employer, and the insurer.
My opinion is that at some point we all have a responsibility to die. It is selfish of individuals afraid of death to feel that society owes them as much medical care as they can consume. I believe it is foolish for guilt ridden family members to make decisions for a dying relative based on the guilt they feel for ill will or lack of intimacy, by trying to make it up to the incapacitated individual wearing their death by demanding that everything be done for their family member (as opposed to to their family member)
Death used to be a fact of life 100 years ago. Children died of childhood diseases, multiple generations lived in the same residence and dying was part of the family experience. I am not longing to go back to the era before antibiotics, Teenagers probably believed they would live forever. Others had a chance to develop perspective.

We will all die. There will be another generation to take our place. The world cannot hold all the people that want to live forever and all that will yet be born. The idea that we will "win the war on cancer" or prevent all cardiac disease and stroke is misguided. Something is going to get us someday and as we acknowledge our future death, we can ponder what makes life meaningful now and in the near future.

I support measures to improve and provide quality of life as well as all the traditional goals of public health. The goals of big insurance, big pharma, and big hospital systems are not necessarily in line with the needs of humans or humanity; yet those entities determine healthcare policy and maybe even influence the ethical arguments defining rationing as a horrible thing.
Thank you for the discussion. It was fair and rational and thought provoking.