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Want to stay current with Arthur’s writing? Sign up to get an email every time a new column comes out.“The art of life lies in taking pleasures as they pass,” said the ancient Greek philosopher Aristippus, “and the keenest pleasures are not intellectual, nor are they always moral.” In other words: If it feels good, do it.Aristippus was a student of Socrates who founded a minor school of philosophy called Cyrenaicism. As Cyrenaic thinking evolved, it centered on two ideas. First, objective reality is unknowable, so we should pay attention only to our own subjective experience of that reality. Second, that experience should be as pleasant as possible, meaning that we should maximize immediate pleasure and avoid pain. Aristippus himself focused especially on the first part, pleasure—preferably involving young courtesans and old wine.Cyrenaic hedonism still pops up as a significant cultural influence from time to time, as it did during the hippie era in America. That pleasure-first principle sounds a bit quaint today, given all the talk of a sex recession and young people being less adventurous than they used to be. But another form of Cyrenaicism is currently very strong: the idea that besides seeking pleasure, we should avoid pain.The memetic way that such an idea can spread means that you may have fallen into this philosophy without even realizing it. This column is intended to help you recognize that possibility, and understand why it can be so damaging for your health and well-being—and how you can break free.[Arthur C. Brooks: There are two kinds of happy people]A Cyrenaic belief in hedonistic abandon might sound harmless and even fun until we grasp how pleasure works in the brain. Charles Darwin reasoned that pleasurable sensations, which are primal in the way they involve the brain’s limbic system, evolved to help us survive and pass on our genes. For example, humans crave highly caloric foods and fixate on attractive bodies because our brains are wired to give us a biochemical reward for acting in ways that prevent starvation and help us find mates.Unfortunately, although Mother Nature is good at making us desire what will keep us and our genes alive another day, she does not care at all whether we’re happy. That condition underpins why Mick Jagger sings, “I can’t get no satisfaction … ’cause I try, and I try, and I try.” Or, to put that more scientifically, the gap between wanting and liking is a major neurobiological disconnect. When you think of something that you are programmed to desire, your brain experiences a little spritz of dopamine, which makes you anticipate pleasure—wanting. But if the payoff is what you anticipated, no more dopamine is forthcoming, denying you much liking. In other words, the pleasurable experience has to be better than you expected in order to produce more dopamine. That generally means that you have to keep upping the dose of whatever pleasure you are pursuing, be it booze, candy, gambling, or pornography.Fruitless pleasure seeking thus easily leads to addiction and misery—what we might call the “Cyrenaic paradox.” If all you do is look for gratification, you will no longer find it. As the psychiatrist Anna Lembke, the author of Dopamine Nation: Finding Balance in the Age of Indulgence, puts it, “The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.”The Cyrenaic paradox works in an inverted way when it comes to suffering. Researchers have demonstrated that when people fear their physical pain and strive to minimize it at all costs, by pulling back from daily activities, the pain tends to remain chronic. This is sometimes called the “fear-avoidance model.” Patients who fear physical pain become hypervigilant and make efforts to elude it. This leads to inactivity and disability, and thus greater pain: The cycle continues and worsens. Say, for example, you hurt your back. Fearing the pain, you baby it and load up on analgesics. Through disuse, your back actually becomes weaker, leading to greater, more constant pain. Many studies have shown this pattern.This cycle of avoidance and worsening pain lies at the center of our drug-abuse epidemic. In the U.S., prescriptions for opioid analgesics to treat pain increased 104 percent from 2000 to 2010. This led to an explosion of opioid addiction and overdose deaths. At that point, crackdowns lowered the prescription levels, but overdoses continued to rise as black-market-opioid use grew.Obviously, pain treatment is necessary and appropriate for many people. The problem comes when this is the first line of defense because pain is considered something that must be eliminated, not a normal part of life to be managed. Just as pleasure seeking tends to make pleasure unattainable, a strategy of pain avoidance can make suffering worse.[Read: Pain doesn’t belong on a scale of zero to 10]The treatment of pain and the avoidance of pain are two very different things. To treat pain effectively requires losing your fear of it and your desire to expunge it as a result. Pain is an unavoidable part of life, and the most effective treatment in many cases involves learning to thrive despite some degree of it. If your back hurts, you may well find healthy ways to increase your mobility and lower your physical discomfort, but your treatment might also include learning to live with that discomfort and manage it at an acceptable level.So far we’ve been talking about physical pain, but mental pain works in a similar way. For example, people who experience depression do well to treat their symptoms, but striving to eliminate them typically makes them worse. According to recent research published in the Journal of Happiness Studies, a belief that happiness requires an absence of pain undermines happiness itself. Other scholars have found that mental-pain avoidance is positively correlated with suicide attempts among those who are depressed. Unfortunately, these mistaken views are reinforced by professionals who tell patients with any mental distress that their discomfort is a pathology, convincing them that they are ill and defective.Therapists and clinicians understand that pain is part of life. They advise their patients not to run away from their reality—and certainly not to self-medicate with recreational drugs and alcohol. This better understanding recognizes that only in facing one’s pain can one learn to live fully and treat it successfully. Particularly if you naturally have high levels of negative affect—if, in other words, you tend to have low moods—part of a full and good life might be accepting this fact about yourself.Several therapeutic treatments explicitly incorporate acceptance, and have proved successful. One is mindfulness-based cognitive therapy, in which patients learn that avoidance can be one of the causes of discomfort itself. This type of cognitive treatment teaches patients to accept their distress as painful but as neither catastrophic nor impossible to lessen. This is very similar to the Buddhist concept that suffering = resistance × pain, which implies that nonresistance is the beginning of effective treatment to reduce suffering. This therapeutic approach is also effective in the treatment of addiction, because it can help an addicted person accept their condition honestly, which facilitates a fuller understanding of the gravity of the problem and a greater capacity to stop using.Another treatment option that has achieved good results is known as acceptance and commitment therapy. Patients are encouraged to acknowledge and accept their pain, but then to shift their attention toward the positive aspects of their life. This technique relies on reversing our innate tendency to focus on what we don’t like rather than what we do—a phenomenon called “negativity bias.” When mental or physical pain is chronic, this evolutionary bias can make us one-track-minded about it, leading to avoidance behaviors and making things worse. Instead, we can recognize that pain is real, but also learn to focus on what is right in our life. For instance, I might wake up with a lot of pain, but I can shift my focus away from the pain to the facts that I wake up in a home where people love me and that I have a job I value.[From the October 2018 issue: How to live better, according to Nietzsche]In either its positive, pleasure-seeking or negative, pain-avoiding forms, Cyrenaicism is a mistaken model for human happiness. Rather than taking the advice of Aristippus, we would do better to follow that of his fellow Greek philosopher, Epictetus the Stoic. In his second-century ethical manual, Enchiridion, Epictetus wrote: “Don’t demand that things happen as you wish, but wish that they happen as they do happen, and you will go on well.”At the start, I called Cyrenaicism a “minor school of philosophy”; Stoicism is better known and far more influential, and justly so. But the larger point is that your philosophy matters—because it will help you exercise control over your life and your happiness. An attitude of acceptance rather than avoidance can empower you to treat your pain appropriately and manage your expectations about what a good life means. That, in turn, will enable you to learn and grow as a person—and truly savor your sweetest experiences.

From learning a new skill to prompting federal legislation, here are some of the ways people's lives were affected by the NPR Network's journalism this year.

These last days of the year can feel weird. When I was about 7, Los Angeles public schools shifted to a “year-round” schedule. The effect, for my elementary school, was a shorter summer break (boo), and an extra-long winter break (also, it turned out, boo). That year, my parents enrolled me in “winter camp,” which was like summer camp but less fun. It was an El Niño year, and the constant rain turned the swimming pools into an unwholesome shade of green. I honestly don’t remember what we did with most of our days; probably we made a lot of lanyards and argued with one another. In an effort to mix things up, the camp arranged a whale-watching trip for us (January is gray whale season in Southern California). But as soon as we got out to sea, an enormous storm kicked up, buffeting our boat to such a degree that every camper except for me threw up. Lest you think I was spared: My clothes became so waterlogged in the rain that my pants fell down in front of everyone. We did not see any whales. All of this is to say that winter break can be weird for kids: There are often family visits and holiday celebrations, but it’s also a time when school is out, the weather is bad, and there’s not always much to do. In a lot of places, there’s no longer enough snow for the winter activities of yore — you really cannot build a snowman out of wintry mix. One year, I took my older kid on a desperate trudge to the dollar store in subfreezing temperatures just to get out of the house. Things can get rough. I have no advice for the short, strange days at the end of the year other than to honor them in whatever way you can. We celebrate Christmas in my family, so my kids will be opening presents this week, and then probably strewing pieces of them liberally about the house. My 2-year-old keeps exclaiming, “It’s Halloween!” and then, when corrected, quietly lamenting, “Halloween all done.” I get it — I like Christmas fine, but I kind of prefer Halloween, too. Whether you’re celebrating anything or not, remember that these are the darkest days of the calendar, and whatever happens with the weather or everything else, the days are already getting longer. Maybe get some sleep, if you can. Take your kids out to look at the night sky — Venus is really good this month and is not a drone. If they are reasonably quiet, take them birdwatching. I’ll be skipping Thursday, January 2, but I’ll be back with you on January 9. A big thank you to everyone who’s been reading (and sending in questions, podcast recommendations, and stories about kids hibernating in nests of toys) these last few months, and I’ll see you in the new year! What I’m reading School districts are preparing for potential immigration crackdowns from the Trump administration, by hosting seminars for families on their legal rights and training staff on how to respond if ICE agents show up at school. The 74 has a roundup of charts that defined education in 2024, including data on pandemic learning loss and kids’ smartphone use. Ulta Beauty has started selling mystery balls with toy versions of beauty products inside, possibly as a way of courting the coveted Sephora tween demographic. We are contractually allowed to continue reading our Christmas books until December 31, at which point my husband will sequester them for the next 11 months. My little kid especially enjoys Pick a Pine Tree, a sweet rhyming story about tree decorating, and How Does Santa Go Down the Chimney?, which (spoiler) fails to answer that age-old question. From my inbox I’ve gotten a lot of questions about Australia’s move to ban kids from social media, and in the new year, I’ll be looking into the pros and cons of such bans. As I report on that, I’d love to hear from you: Have the kids in your life experienced any positive effects from social media? We hear so much about the negatives that I’m very curious about the flip side. Get in touch at anna.north@vox.com.

Mikal Bridges spent much of this Knicks season before the holidays — too much, probably — as the “but.” As in, yes, the new-look Knicks are shaping up to be a legit contender with an unreal offense and a defense that’s creeping into the top half of the league, and yes, the Karl-Anthony Towns trade...

President-elect Trump floated Wayne Gretzky as the prime minister of Canada and it appeared his wife was watching as she shared the post on her own social media.

LeBron James and Austin Reaves each put in stellar performances to lift the Lakers to a thrilling victory over Stephen Curry and the Warriors.

No flights were affected.

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After Donald Trump reiterated the idea that the U.S. purchase should Greenland, social media posts suggested Denmark had responded in kind.

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Los Angeles Lakers star LeBron James had a message for the NFL as it continued to encroach on the NBA's day, which has been Christmas for years.

The "Look What You Made Me Do" singer did not attend the tight end's game against the Pittsburgh Steelers in Pennsylvania on Wednesday.

Mississippi man Timothy Wayne Tillman has been charged with the murder of his wife, Dawn Marie Tillman.

Local Chinese authorities have stepped up efforts to encourage women to consider having more children, including through controversial cold-calling campaigns.

Make no mistake what President-elect Trump is doing is negotiating a new treaty for the Panama Canal and hence, a better deal for the American people.

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Joan Benoit Samuelson's victory in the marathon at the Los Angeles Games helped change the perception of women as athletes and competitors.

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"If a neighbor had one, or one would come on the television, she would lose her mind with excitement," mom Rebecca Pfeiffer said.

Protesters march for victims of gun violence. 2024 defied the worst expectations for firearm violence in the US. If you follow the news about gun violence in America, you know that there’s a lot to be pessimistic about. Guns were already a major public health concern when the pandemic hit and the murder rate skyrocketed. The surge in homicide in 2020 and 2021, research has shown, was best understood as a surge in gun violence, with firearms-related deaths counting for the majority of the increase. Not all communities suffered equally: In 2020, 61 percent of victims of gun homicide were Black, with the largest increases among boys and men ages 10–44. The following year, according to the Gun Violence Archive, the number of mass shootings — shootings in which four or more people, not including the shooter, are shot and injured or killed — reached 689, up more than 50 percent from the number of mass shootings in 2018. And then the Supreme Court issued a ruling that functionally allowed all Americans to carry weapons in public. Coming on the heels of an awful rise in gun violence, experts warned that it would almost certainly get worse. But that hasn’t really happened. Some of the worst-case scenarios, based on the recent trends around gun violence, haven’t yet come to pass. To be clear, the United States still has exceptionally high levels of gun violence. The country has more guns per capita than any other nation on Earth, and a messy patchwork of laws that make regulation extremely difficult. For those reasons, the country is still incredibly vulnerable to seeing more gun-related deaths in the future. But we’re so used to bad news about gun violence, and the fact that Republicans refuse to pass better gun regulations, it’s easy to feel like the issue is hopeless and tune out. So it’s important to acknowledge that in some key ways, this year was better than the last — and that 2024 was an important step in the right direction. The US saw less gun deaths in 2024 Murder likely fell at the fastest rate ever recorded this year, according to crime data analyst Jeff Asher — which is particularly impressive when you consider that murder fell at the fastest rate ever recorded last year, too. Those numbers will almost certainly be revised somewhat, but the overall picture is unlikely to change. Because the large majority of homicides in the United States are firearm-related, it’s safe to attribute the decline to a reduction in gun deaths. And it’s manifested as big, double-digit reductions of murders in cities that have long suffered from the epidemic of gun violence, including Baltimore, New Orleans, Philadelphia, and Washington, DC. It’s hard to overstate just how meaningful that is. As Asher notes, “the rapid decline in murder has led to more than 5,000 fewer murder victims this year compared to the 2020 to 2022 years.” The pandemic-era murder spike, in other words, appears to be over. What happened? Experts are careful not to attribute the rise and fall of murder to any single cause. But the return to work and school following pandemic disruptions and closures, and a renewed effort at gun violence reduction in many US cities, supported by federal funding, almost certainly helped. Whatever the reason, the outcome is thousands of lives saved. The outbreak of political violence that wasn’t One of the crucial concerns gun and political violence researchers had going into 2024 was whether we’d see an outbreak of unrest following the presidential election. The concern was not unfounded. Recent studies have shown that a small but worrying number of Americans increasingly believe that a more violent era of American life is coming. A smaller percentage of those people say that violence is justified for political reasons, and that they are willing to participate in political violence. Then, in July, a gunman shot at President-elect Donald Trump during a campaign rally in Butler, Pennsylvania, and came hair-raisingly close to striking his head (instead, according to investigators, the bullet grazed Trump’s ear.) Two months later, another man attempted it again — though that time the Secret Service were able to respond before he opened fire. “The set of circumstances most likely to produce political violence in this country in the next few months are a closely contested election, with momentum swinging to Democrats, and with high-profile instances of political violence having already occurred,” political violence researcher Garen J. Wintemute told Vox after the first assassination attempt. The polls showed a close election, up until the very end. Trump repeatedly attacked the legitimacy of the electoral process. And the memory of January 6, 2021, when the then-president incited a mob to a violent, armed insurrection at the US Capitol to protest his election loss, was fresh in everyone’s mind. But it didn’t happen — perhaps because the election wasn’t a long, drawn-out fight, and perhaps because Trump won. Whatever the reason, the US came back from what seemed like the brink of a dangerous moment. That’s not to say the country couldn’t find itself there again, and soon. The recent shooting of United Healthcare CEO Brian Thompson, and the lionization of his alleged killer, Luigi Mangione, have revealed there may be more openness to political violence in the American public than previously realized. And research of mass shooters show that when a shooter receives lots of public attention, it tends to inspire copycats. In 2024, though, the worst fears about election violence didn’t come to pass. And it’s not just political violence. Though a student in Wisconsin killed a classmate and a teacher in December, overall, mass shootings also appear to have declined in 2024, from 656 incidents in 2023 to 491 in 2024. No one is exactly sure why — but it’s undeniably a good thing. The scourge of ghost guns eases The assassination of Thompson in December was newsworthy for a number of reasons, one of them being that it appeared to be the first high-profile killing using a ghost gun — in this case, one that the alleged shooter 3D printed himself. Ghost guns don’t have serial numbers, which make them difficult for law enforcement to track where they came from. For that reason, they’re especially appealing for people looking to commit crimes and not get caught. They’ve become a huge problem in recent years, with the number of such weapons being recovered from crime scenes increasing a staggering 1,083 percent between 2017 and 2021. Many of these guns were not printed at home, like Mangione’s apparently was, but instead were sold as easy-to-assemble kits online. Just one ghost gun manufacturer was responsible for 88 percent of the guns recovered during that time. The government moved quickly to address the problem. In 2022, the Biden administration said that the ghost gun kits and their receivers (or frames) were subject to the same federal regulations as regular guns — meaning, they needed a serial number. The rule was challenged in the courts, but it appears that the Supreme Court is likely to uphold the law, which the government says is necessary for cracking down on the untraceable guns. Meanwhile, the gunmaker responsible for most of the guns showing up at crime scenes was hit with lawsuits. It appears they have since shut down. According to an analysis by The Trace, the numbers of ghost guns being recovered from crime scenes are now falling in several cities. Of course, the United States still has too many guns — and a regulatory system that resembles Swiss cheese. As long as that’s the case, the country will likely deal with elevated levels of gun deaths. But the developments this year show that the situation isn’t hopeless. Meaningful attempts to address gun violence and regulate firearms do work — and can save lives.

When the South Korean drama Squid Game hit Netflix in 2021, the show became a bona fide cultural phenomenon. The story of people in debt competing to the death for a massive cash prize looked like nothing else on television, juxtaposing candy-colored children’s games with horrifying hyper-violence. Squid Game soon turned forest-green tracksuits into a trendy Halloween costume. It helped enter the word dalgona—the sugary treat used in one of the contests—into the pop-culture lexicon. It was parodied on Saturday Night Live. For weeks after I watched, I couldn’t get the murder doll’s song during the first contest, Red Light, Green Light, out of my head.The second season, now streaming, begins where the first ended: with the game’s latest winner, Seong Gi-hun (played by Lee Jung-jae), choosing not to board the plane out of South Korea that would have reunited him with his family. Instead, he threatens Hwang In-ho (Lee Byung-hun), the tournament’s supervisor known as the “Front Man,” over the phone. As he hails a cab, Gi-hun warns In-ho that he’ll find him and stop the games—but In-ho is unperturbed. “You will regret your decision,” he coolly replies.I began having regrets of my own as I made my way through Season 2. Gi-hun’s revenge quest is, for the most part, the opposite of thrilling. The show’s tedious opening hours depict him as a recluse who has hired a collection of incompetent men to find the games’ slap-happy recruiter (Gong Yoo). They’re monitoring every subway station in Seoul in the hopes of coming across him, but none of Gi-hun’s employees knows exactly what their target looks like. Gi-hun isn’t a reliable boss either; he’s too paranoid to visit the stations himself. Even teaming up with Hwang Jun-ho (Wi Ha-joon), the police detective who discovered that the Front Man was his own brother last season, to track down the island where the competition took place yields a monotonous search. Without the sadistic games going on, the show lacks momentum.[Read: In Netflix’s Squid Game, debt is a double-edged sword]And then—and this is only a spoiler if you haven’t seen a single trailer—Gi-hun winds up back in that tracksuit, reliving his worst nightmare. It’s a neat trick: Season 2 withholds the deadly events just long enough for viewers to yearn for their return, making them wonder whether they’re actually on the protagonist’s side. As a result, when the games do begin, they make for an even uneasier watch than before. Season 1 framed the tournament as a straightforward allegory for the punishing trap of financial distress, rendering even the greediest characters as sympathetic to an extent. Season 2 isn’t as totalistic; it further blurs the lines between the show’s victims and perpetrators. The series displays a meaner, more critical streak toward the cash-poor participants this time around. It emphasizes how, as much as the capitalistic system may push people to do rash things for money, the players themselves work to uphold such values. Thornier questions arise: Is it possible to overcome cruelty, avarice, and selfishness? And if not, do the players actually deserve to live?To Gi-hun, the answer to both questions is a resounding “yes”—but the show seems to revel in countering his perspective whenever it can. Even before this season’s competition begins, Squid Game argues that individuals will chase financial gain above all else with an interminable scene in which the games’ recruiter mocks unhoused people for choosing lottery tickets over food. Gi-hun reenters the competition in an effort to dismantle it from the inside and save his fellow players, but the show immediately underlines the futility of his attempt, with a fresh, brutal round of Red Light, Green Light. In-ho, too, toys with Gi-hun’s belief in the goodness of humanity by ordering players to vote on whether to end the bloodbath at the end of each trial; if they do, they walk away with far less cash than they could have if they continued on, because every death improves their chances of landing the jackpot. These deliberations unfold over and over, and they’re not especially fun to observe: Gi-hun sees each election as an opportunity to convince players that, together, they can defy both the temptation of the prize money and the game makers. Each time, he fails.Still, the show’s latest lineup of trials allows it to return to form. Each contest is more diabolical and intriguing than those Gi-hun had experienced in his first go-round. The violence is more over-the-top, the visuals more absurd. And unlike Season 1’s hopscotch-like glass bridge and biscuit-carving challenge, which relied mostly on a person’s individual luck, Season 2’s selections are more dependent on interpersonal skills from the start, requiring the players to form alliances and rivalries right away. As such, the contests themselves help expand the new characters beyond their initial archetypal trappings: The pregnant player proves to be an asset. The wallflower being bullied by the obnoxious rapper has a callous side. One of the ubiquitous pink-suited soldiers might even care about the competitors. In Squid Game, people tend to reveal who they really are at their most desperate.[Read: What happens when real people play Squid Game?]In-ho seems to hope that by playing the games again, Gi-hun will discover a surprising side to himself as well—and that doing so will break his spirit. The series shines most when the two share scenes, because they’re diametrically opposed in their worldviews: In-ho is convinced that people are inherently heartless, while Gi-hun insists that they can choose to be good.When the season finale wrapped up with yet another cliff-hanger, however, I found myself wondering whether the story had progressed at all. Squid Game was meant to be a limited series; the first season’s ambiguous ending simply underlined Gi-hun’s Pyrrhic victory. These new episodes just emphasize the foolishness of his bravery, forcing him—and a batch of other players I’ve come to root for—to undergo freshly excruciating tests. The show’s bleakness has always been quite torturous to absorb, even if I couldn’t help but keep watching. But in Season 2, the gloom comes not only from the violence. It comes from the show’s overindulgence in proving its own protagonist wrong.

"The restrict-and-splurge cycle of budgeting gets you nowhere," writes personal finance expert and journalist Dana Miranda.

It was an uphill battle for climate action in 2024, with glimmers of hope amid halting progress.

The Times' Sports reporting staff selects their favorite story from 2024, a showcase of stories that hold a special place with 17 writers.

A bunch of slumping star players proved to be contagious and ignited a team-wide collapse for the Rangers, who spent Christmas in the basement of the Metropolitan Division because of it. 

Here are The Post's pro wrestling awards for 2024.

Choose between the Kansas City Chiefs winning the Super Bowl, the Summer Olympic Games in Paris, France, or LA Dodgers Shohei Ohtani becoming the first MLB player ever with 50 home runs and 50 stolen bases in the same season.

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A trio of reports on environmentally responsible business practices shows executives and investors leaning into sustainability despite the ESG pushback.

This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get early access to member-exclusive stories every month, join the Vox Membership program today. The sharp decline in child mortality rates is one of the great global success stories of the past several decades.  In 1990, nearly 13 million children died before their fifth birthday, primarily from infectious diseases or complications during birth. By 2022, that number had fallen by more than 50 percent, meaning that today, about 8 million fewer children are dying than were some 35 years ago.  Overall development improvements, alongside a handful of targeted public health interventions — ensuring that skilled health care workers are present during childbirth, improving access to clean water, providing postnatal care, and expanding vaccination, to name a few — have helped ensure far more children live to see their fifth birthday and beyond.  Yet despite that progress, around 5 million children younger than 5 years old still die prematurely each year, with about 80 percent of those deaths occurring in sub-Saharan Africa and southern Asia. And progress to reduce child mortality has slowed in recent years. Between 2015 and 2022, child mortality rates fell by only 2 percent, down from about 4 percent between 2000 and 2015. But one surprising intervention — periodically distributing antibiotics prophylactically to young children en masse — could help further reduce child mortality rates in some of the worst-affected countries. A study published in August examined children in Niger, a country in West Africa with one of the highest child mortality rates in the world. Researchers found that twice-yearly mass distributions of an antibiotic to children between the ages of 1 and 5 reduced child mortality by 14 percent.  If this sounds too good to be true — significant reductions in child deaths simply by giving them basic drugs designed to fight bacterial infections — it may be. This intervention around one major health challenge — childhood mortality — is somewhat controversial because it seems to directly run against another major health challenge: the rise of drug-resistant infections. Such infections, which are caused by the overuse of antibiotics, claim an estimated 1 million lives every year, a number that could nearly double by 2050.  “If you increase the amount of antibiotic exposure in the population, you are guaranteed to increase the risk of having drug resistance,” said Gautam Dantas, a professor at Washington University’s School of Medicine who studies the human microbiome and antimicrobial resistance. These drug-resistant pathogens can spread around the world, creating a public health threat for everyone.  And there’s another question: While the positive results show promise, no one is exactly sure why giving antibiotics to children who have no overt sign of infection but still live in high-risk areas reduces overall child mortality in the community. Given the unknowns and potential to contribute to global drug resistance, the World Health Organization in 2020 strongly recommended against mass antibiotic distribution as a universal intervention. Instead, the agency suggested that public health officials pursue the intervention only in places where under 5 mortality is greater than 80 children per 1,000 births. In 2022, only 10 countries recorded under 5 mortality rates higher than this threshold.  The scientists who study and advocate for the mass distribution of antibiotics are well aware of these issues. The essential question: How does one weigh saving children’s lives against fueling another deadly health threat?  A safety net of antibiotics The idea of mass distributing antibiotics to reduce child mortality has its origins in control programs for a specific disease: trachoma. Trachoma is a bacterial eye infection that can lead to visual impairment and irreversible blindness.  Though the disease has plagued humanity for at least 10,000 years, by the early 20th century it had become a serious scourge, infecting anyone from soldiers to boarding school students. But the disease was wiped out in most developed countries in the 1950s and 1960s following the invention and widespread use of antibiotics, especially azithromycin.  But trachoma has persisted in about 50 countries, mostly in poor, rural areas of Africa, Asia, the Middle East, as well as Central and South America. About 2 million people today have blindness or visual impairment caused by trachoma and another 103 million are considered at risk of contracting the disease.   In communities where trachoma is still a problem, the disease prevalence is high, ranging from 60 to 90 percent. Because trachoma became so widespread, the World Health Organization in the early 1990s recommended that health officials treat everyone in an affected community with the antibiotic azithromycin, whether or not they had been diagnosed with the disease. The thinking was that treating the entire community with an antibiotic would reduce the amount of bacteria circulating in the community, thus reducing transmission — much like mass vaccination is used to curtail viral outbreaks.  In the early 2000s, researchers started noticing that mass distribution of azithromycin not only reduced trachoma, but also seemed to reduce overall child mortality. Scientists running a trachoma control study in Ethiopia hypothesized that because azithromycin was effective against other infectious diseases, including respiratory and diarrheal diseases and malaria — all leading causes of childhood death in the country — mass distribution of the drug might help save children’s lives.  Other public health scientists probed this idea further by conducting mass antibiotic distribution trials in places where trachoma wasn’t found.  In one 2018 study known as the MORDOR trial (MORDOR stands for Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance, French for “Oral Macrolides to Reduce Deaths with an Eye on Resistance”), researchers randomly selected more than 1,000 villages across Malawi, Niger, and Tanzania to either receive the mass distribution of azithromycin or a placebo intervention. Children who were between one month and five years in the intervention villages received a small dose of azithromycin twice a year for two years.  At the end of the study, in communities where children had received the antibiotic, the overall annual mortality rate was lower — by about 3 percent in Tanzania, 6 percent in Malawi, and 18 percent in Niger — compared to the villages that received a placebo. The drop in mortality was even greater, about 25 percent, among the youngest children, those between 1 and 5 months old. While the results are promising, researchers still do not fully understand how mass azithromycin distribution reduces child mortality. One explanation is that the intervention works in a similar way as it does in trachoma-endemic settings, but instead of providing communities a blanket of protection against merely the Chlamydia trachomatis bacterium that causes trachoma, it bestows protection against a wider range of bacteria, including the ones that cause the common respiratory diseases and diarrheal diseases that can kill young children in poor countries.  “It may not be just that you get lucky and you treat a kid that happens to be sick that week,” said Thomas Lietman, a professor at the Proctor Foundation at the University of California, San Francisco who has led studies on trachoma and was the senior author of the 2018 and 2024 child mortality studies.  “We think it’s that we’re reducing the pathogen load in the community. And one of the reasons we think this is because there appears to be an indirect effect. In other words, you receive benefit just by your community being treated.” The cost of saving lives Even during these early trials, researchers were concerned about how giving antibiotics to kids might fuel another massive global challenge: antimicrobial resistance, the process by which bacteria evolve the ability to evade antibiotics. It’s simply a matter of evolution: the more that antimicrobials are used, the more opportunities pathogens have to develop resistance to them. If that process continues long enough, it will eventually render these critical, life-saving medicines ineffective.  At the same time, most major drug developers have turned away from making new antibiotics. That means our stores of effective antibiotics are dwindling. If left unchecked, researchers predict that some 2 million people might die from drug-resistant infections by 2050, making it a leading cause of death. But people won’t just die from drug-resistant infections. Life-saving surgeries and treatments such as chemotherapy, which massively damage the immune system, will become much riskier because it will be harder to prevent infections.. In its antibiotic stewardship guidelines, the Centers for Disease Control and Prevention recommends that health care workers only prescribe antimicrobials if they know what pathogen is causing a patient’s illness. But the idea of mass distributing antibiotics to reduce childhood mortality runs entirely counter to that.  “We’re taught in every health care field not to give antibiotics non-specifically; yet that’s exactly what we’re doing here,” Lietman said. “We’re giving antibiotics to children whether or not they’re sick, whether or not they have a particular pathogen.” However, it is unclear what impact mass distribution interventions have on drug resistance. After the MORDOR trial, researchers conducted follow-up studies where they collected swab samples from the children who received the antibiotic during the study and those who did not. Among children who participated in the study in Tanzania, researchers reported that there was no significant difference in the number of azithromycin-resistant strains of two types of bacteria between the two groups. Yet in Niger, researchers found that children who received the antibiotic harbored more drug-resistant strains.  Other studies, though not all, that have assessed drug resistance in the wake of mass distribution campaigns for trachoma control have documented measurable but short-lived increases in drug-resistant bacterial strains.  Regardless of whether and to what extent mass antibiotic distribution contributes to drug resistance, the intervention uses a small fraction of the total antibiotics consumed worldwide either by humans or livestock animals. In the 2018 MORDOR study, children received about 20 milligrams per kilogram of body weight which equates to about 360 milligrams for a 40-pound child or a total of, at most, 36 kilograms of antibiotics for the roughly 100,000 children that received the intervention across four distributions.  Compare that to, say, the 6.2 million kilograms of medically important antibiotics sold for use in livestock operations in the US in 2022. Perhaps it would be more effective to reduce antibiotic use in agriculture than target relatively miniscule antibiotic use during an intervention that saves children’s lives. But there may be other consequences to mass antibiotic use. A series of studies conducted mostly in the US and Europe have linked antibiotic use in childhood with an increased risk of developing obesity, attention deficit hyperactivity disorder, asthma, and other lifelong disorders.  Still, it is important to note here that these studies are looking at a very different population than children in Niger who face a high risk of dying before they turn 5. Some research suggests the link between antibiotic use and obesity and other disorders may be related to alterations in the gut microbiome, but it remains unclear exactly how antibiotics might cause poor health outcomes and what role other lifestyle factors might play. And those factors could be entirely different in a country like Niger or Tanzania than in the US.  “Right now, the benefit outweighs the harm,” Dantas said. “Yes, you may encode some burden elsewhere, but you’ll save the life of a child.” It’s hard to argue that saving thousands — if not millions — of children’s lives doesn’t outweigh future threats of drug resistance or a possible heightened risk of developing chronic diseases. There are plenty of other ways to address the public health challenges posed by antibiotic resistance and chronic diseases that don’t put the lives of some of the poorest children in the world at risk.  And there is one conclusion that is undeniable: If millions of young children were dying every year in the US, parents would demand that every possible intervention be used — whatever the future consequences. 

This story was originally published in The Highlight, Vox’s member-exclusive magazine. To get early access to member-exclusive stories every month, join the Vox Membership program today. The pod looked like a tanning bed from another planet: a human-sized chamber, white and sparkly purple with a clear glass door, resting on an inclined platform. Previously, it had been on display in public exhibitions, but now it was in Schaffhausen, in a large park in northern Switzerland, near the border with Germany.  A woman stood in front of it, under a dense canopy of trees. She wore a white fleece jacket, dark pants, and flip-flops. It was late September 2024, and the air in this part of the country had become cool. The woman, a 64-year-old American whose name has not been made public, had come to the Alpine country, to this place of vineyards and rolling meadows and mountain views, to end her life. It was a private decision that, paradoxically, would have global implications for the debate over end-of-life care and whether people have a right to medically assisted suicide. For more than 25 years, Switzerland has been a destination for people who want a medically assisted suicide, thanks to the country’s longstanding and liberal law regarding the practice. Each year, the number of people choosing assisted suicide in the country grows; in 2023, that number reached more than 1,200. Most people who end their lives in Switzerland are elderly or have an incurable illness, though a person can sometimes get approval for an assisted suicide under other circumstances. And though the majority who die this way are citizens, Switzerland is one of the few countries that also allows foreigners to travel there for the purpose, a practice critics have derided as “suicide tourism.”  The country’s largest assisted suicide nonprofit, Exit, takes only citizens and permanent residents. But other prominent organizations, including Dignitas and Pegasos, accept foreigners. People who are interested reach out to the groups online and apply for membership, which provides counseling and guidance around end-of-life care. Those seeking a medically assisted death are required to have consultations with a doctor associated with one of the organizations. After determining that the person is eligible, of sound mind, and, when applicable, has considered their full range of treatment options, the doctor writes a prescription for sodium pentobarbital, the same substance used for pet euthanasia and many lethal injection executions in the US, to be used at a later date chosen by the patient. The doctor is not allowed to administer the medication themselves. That practice is known as euthanasia, which is not legal in the country because it is considered “deliberate killing.” Instead, they provide the medication to the patient, who, in the presence of the doctor or an aide for one of the organizations, either swallows it or takes it with a gastric tube or an intravenous infusion.  The entire process, for foreigners, costs about $11,000 and usually takes a couple of months.  Had the American woman chosen to end her life under the standard Swiss protocol, it probably wouldn’t have been controversial. She reportedly had skull base osteomyelitis, a rare and painful inflammatory condition that is often fatal if untreated. She told the group helping her that her adult children fully supported her decision. But she wasn’t there to end her life the standard way. Instead, she was about to become the first person to try a controversial new method for suicide, using a technology that would roil public debate over assisted suicide in Switzerland and capture attention around the globe.  She would use the Sarco pod, an invention of Philip Nitschke, a strident right-to-die advocate. Nitschke hopes that the 3-D printed pod, with a name that’s short for sarcophagus, will revolutionize the practice of voluntary assisted death by taking doctors out of the picture.  The Sarco, he has said, doesn’t require a lengthy screening process or thousands of dollars. Rather than relying on sodium pentobarbital, a person who wanted to use the pod could buy nitrogen. They would lie down inside the pod, resting their head on a neck travel pillow. Then, they would close the door and push a button. The chamber would fill with nitrogen gas, and oxygen levels would quickly drop below levels humans need to survive.  As a method of execution in the US, nitrogen hypoxia has been highly controversial. Earlier this year, UN experts raised concerns that the execution of Alabama death row inmate Kenneth Eugene Smith using nitrogen gas could constitute “torture,” and the state is currently being sued by another inmate alleging the practice is cruel and unconstitutional. Right-to-die advocates, though, say that when administered properly, it’s a relatively painless death because people exposed to high levels of nitrogen quickly lose consciousness. The American woman entered the chamber just before 4 pm, according to Dutch newspaper de Volkskrant, which had a photographer in the woods of Schaffhausen before and after the death to document the scene. To protect against the possibility that they might be accused of foul play, Nitschke and his colleagues also set up two video cameras to record. Then Nitschke went across the border to Germany, possibly to avoid the risk of arrest. The only person who remained with the woman at the scene the entire time was Florian Willet, a colleague of Nitschke’s who co-founded The Last Resort, an organization to promote the Sarco pod’s use in Switzerland.  Seconds after entering the pod, the woman pressed the button to release the gas. Willet waited with her, monitoring her vital signs on an iPad and relaying them to Nitschke over the phone. After confirming her death, Willet called the police — a standard practice after an assisted suicide in Switzerland.  Typically, police examine the scene to verify that there are no signs of foul play.  But this wasn’t a typical death. Police arrested Willet, his attorneys, and the de Volkskrant photographer nearby on suspicion of “inducing and aiding and abetting suicide,” according to Reuters.  More than eight weeks later, Willet remained in jail, with police investigating the woman’s death as a possible “intentional killing.”  And Switzerland, a country that has for decades maintained a public consensus in support of assisted suicide, has been confronted with a series of questions that have implications for one of the most significant moments of every person’s life: To what extent should people have the right to determine when and how they die? What are the moral and philosophical implications for a society that sanctions the practice of medically assisted suicide? How does a nation handle the need for the safety of vulnerable people while also protecting their dignity and individual rights?  Switzerland isn’t the only country that allows assisted suicide. Other nations, including the Netherlands, Belgium, Luxembourg, Colombia, Spain, and Canada, also permit the practice, which some advocates call medical aid in dying (MAID) to differentiate it from the usual connotations of the word “suicide.” In late November, the British Parliament took the first step to pass a bill that would legalize assisted dying for some terminally ill patients. In some countries, the law goes further than it does in Switzerland, allowing voluntary euthanasia, where doctors can administer lethal doses for patients who can’t or don’t want to do it themselves. Belgium and the Netherlands, for example, allow physician-assisted euthanasia for mental illnesses if a doctor determines that the condition creates unbearable suffering. What constitutes unbearable suffering, though, is inherently subjective and open to interpretation. The number of deaths via euthanasia in both countries has grown considerably in recent years; the same is true of Canada, which recently passed some of the world’s most liberal euthanasia laws. Critics worry that the easy availability of assisted death creates incentives for people to see it as the only solution to their suffering, even when there might be effective treatments. They also worry about a “slippery slope” where doctor might approve assisted suicide for more and more reasons, ultimately resulting in suicides for non-medical reasons being enabled by law. The United States does not permit euthanasia, but physician-assisted suicide is legal in 10 states, including California, Oregon, and Washington. According to a Gallup survey earlier this year, 71 percent of Americans believed that a doctor should be able to administer a euthanasia drug if requested by a patient or their family member, and nearly the same amount supported physician-assisted suicide for people with terminal illnesses.  Erika Preisig, a family physician and founder of the organization Lifecircle, which helps foreigners come to Switzerland for assisted suicide and advocates for other countries to legalize it, says the issue is going to become more important as more baby boomers reach the end of their lives.  “They will not let others decide how they have to die. They will decide themselves,” says Preisig, who is a member of that generation. “This will raise the percentage of assisted dying all over.”  But even with widespread support, the practice is still controversial in the US and elsewhere. The American public, despite supporting legalization, is more divided on the morality of doctor-assisted suicide. It’s opposed by the Catholic Church and other Christian organizations, which believe the practice goes against God’s will. Some disability rights advocates have argued fiercely against it, saying that it allows medical professionals to offer disabled people death rather than finding ways to improve their lives. The American College of Physicians (ACP) also opposes medically assisted dying on the grounds that the practice is incompatible with a doctor’s duty as a healer who takes the Hippocratic Oath, promising to do no harm.  “[T]he focus at the end of life should be on efforts to prevent or ease suffering,” the ACP’s president said in 2017. Partly as a result of those disagreements, Americans have different rights regarding assisted suicide depending on which state they live in. That’s led some Americans, including the woman who used the Sarco pod, to come to countries like Switzerland to end their lives. The birthplace of Calvinism and an intellectual center of the Protestant Reformation, Switzerland has a long history of bucking the dogma of the Catholic Church and charting its own moral and philosophical path. Famously neutral during the World Wars, and now home to world governing bodies like the United Nations and the World Health Organization, the country can appear to be a tightly regulated place like many other Western European countries.  In reality, it’s a society built on compliance with social and cultural norms moreso than government regulations. Political scientists point to it as among the most libertarian societies on earth, and Switzerland is consistently ranked as the number one country in the Human Freedom Index report put out by the Cato Institute, a libertarian think tank.   Assisted suicide is no exception. The practice has been permitted in Switzerland longer than in any other country. In 1942, the government put into effect a statute outlawing abetting assisted suicide for “selfish purposes,” like gaining access to an inheritance, but otherwise, it wasn’t explicitly banned — which meant that, by omission, assisting suicide for non-selfish purposes was technically legal. To this day, the 1942 statute is the only law explicitly referring to assisted suicide. In an email to Vox, the prosecutor in charge of the case confirmed that Willet was arrested under suspicion of breaking this law. In place of those laws, requirements for obtaining a medically assisted suicide were developed by doctors and codified into guidelines maintained by Switzerland’s medical professional organizations. The regulations are nonbinding, but disobeying them can in theory lead to professional sanctions. In practice, this has meant that the doctors are regulating themselves.  “We have one of the most liberal systems in the world,” Yvonne Gilli, the president of the country’s professional association for doctors, told Vox in an email. For most of the medical community, the desire seems to be to keep it that way. “We would therefore do well to leave doctors in a central role in assisted suicide,” Gilli wrote.     In a small, relatively homogenous nation of just under 10 million people, assisted suicide has never been quite the culture war issue it was in the United States in the 1990s and early 2000s, when Dr. Jack Kevorkian, a right-to-die advocate nicknamed “Dr. Death” by the media, filmed himself performing a voluntary euthanasia and sent the video footage to 60 Minutes, intentionally triggering a trial that would result in his conviction for murder. In 2011, a referendum that proposed a ban on assisted suicide in Zurich, the country’s most populous canton or state, was rejected with 85 percent of the vote. That high level of public support has allowed assisted suicide organizations to operate with relatively little friction and without much public debate, even as demand increases. According to a long-term study of assisted suicides in the country from 1999-2018, the total number of physician-assisted suicides doubled every five years.  “Suicide assistance has been quite calm. The Swiss assisted suicide organizations were under the radar; there wasn’t much discussion about them,” says Bernhard Rütsche, a professor at the University of Lucerne and an expert on assisted suicide in Switzerland. “They care for their reputation. The whole branch of suicide assistance has been shaken up with this new method, and they don’t like that, quite understandably.” The intervention of Nitschke and his Sarco pod threatens to upend the status quo.  In 1996, Nitschke became the first doctor in the world to help a terminally ill patient die legally by assisted suicide in Australia. A decade later, he and his partner Fiona Stewart published The Peaceful Pill Handbook, a guide that provides information about methods of assisted suicide and describes the process of obtaining one in Switzerland.  Nitschke, according to Katie Engelhart’s book The Inevitable: Dispatches on the Right to Die, began his work believing that patients with terminal illnesses should have the right to choose an end to their suffering. But as his advocacy deepened, his thinking evolved. Why should doctors like him be the one to make the decisions? Why should doctors get to determine what counts as extraordinary suffering and what doesn’t?  Over time, Nitschke came to believe that the right to die should be entirely in the hands of individuals and not medical professionals. The deeper his advocacy became, the more he clashed with other members of the medical community. He burned his medical license in 2015 after a protracted battle with Australia’s medical board. He also became more critical of mainstream MAID groups that focus only on the sickest patients.  He takes issue with the Swiss system, which he has said is too deferential to doctors and too expensive. “We are convinced that no money should be charged for an assisted death. Especially when you realize that it is already very expensive for foreigners who wish to die to travel to Switzerland,” Nitschke said of his organization, Exit International, in a recent interview. (Exit International, which is not related to the Swiss group Exit, pointed to statements on their website and declined to be interviewed before deadline.) Nitschke approaches end-of-life issues with the zeal of a libertarian techno-futurist. In interviews, he’s spoken about a future where the Sarco pod’s blueprints are posted online, allowing anyone to 3-D print one anywhere in the world. He has said that AI could replace doctors in assessing whether a person meets the criteria to end their life. “We really want to develop that part of the process so that a person can have their mental capacity assessed by the software, rather than … spending half an hour with a psychiatrist,” Nitschke told Wired. Nitschke’s unapologetic belief that people should be able to choose how and when they die, combined with his confrontational style, has made him a lightning rod for controversy, leading some of the doctors who support assisted dying to think that he does more harm to their cause than good.  “Nitschke wants to give everybody, without thinking, the possibility to die. For me, this is unethical,” says Preisig, the founder of Lifecircle. “This is very bad for Switzerland. It’s a big problem for us.” Leaders of other assisted suicide organizations have also been critical.  The debate over the Sarco pod has even reached the Swiss government. Nina Fehr Düsel, a member of the Swiss National Council (which is similar to the US Congress), has made a motion for the National Council to discuss assisted suicide in the coming months. She’s also asking her colleagues to consider banning the Sarco pod explicitly.  “I don’t want to overregulate this,” Fehr Düsel, a member of the populist right-wing Swiss People’s Party, which controls the most seats in the federal assembly, tells Vox. She has concerns about the use of nitrogen, which is at this point cheap and easy to obtain in the country. In general, she says, the organizations that are already established in the country should be left alone. “We already have these two longstanding organizations and that is enough,” Fehr Düsel says. For others, the Sarco pod case has merely exposed the extent to which assisted suicide is operating without clear legal guidelines. “We need some regulation that ensures that autonomy is safeguarded and capacity is properly assessed, and the means for suicide assistance — the instruments and the medications — are safe and comply with human dignity,” says Rütsche, the professor at the University of Lucerne.  According to Rütsche, the government should codify the existing standards doctors have established, with laws around the assessment of someone’s capacity, obligations to provide information and counseling to make sure the decision is well considered, requirements for how the process takes place (including what drugs and devices are allowed and what aren’t), and oversight for the assisted suicide organizations — with the ability to ban a group for flouting the guidelines.  Whether Switzerland moves forward with a new law remains to be seen. But the Sarco pod’s future seems more certain.  Police confiscated the pod at the scene of the woman’s death. In November, Schaffhausen prosecutor Peter Sticher confirmed to Vox in an email that one person remained in police custody regarding the investigation. Willet, according to The Last Resort’s website, has been held in jail for two months.  Holding someone that long on suspicion of abetting a suicide for selfish purposes is highly unusual. But in late October, de Volkskrant, the Dutch paper, reported another reason that may explain Willet’s long detention: According to court records, a forensic doctor told investigators the woman was found with injuries to her neck, raising the possibility that Willet was the subject of an “intentional killing” investigation. “The allegation of a [killing] is simply not true, and I’d guess everyone involved knows this,” says Andrea Taormina, the lawyer for the photographer who was detained after the woman’s death. “There are no facts that would indicate differently. This is mainly an allegation brought forward simply to raise the stakes in this procedure.” De Volkskrant, which had access to and reviewed the camera footage, said in their report that nothing on the recording showed Willet opening the pod or doing anything to disturb the woman.  Ultimately, after 70 days in detention, Willet was released in early December. Exit International and The Last Resort, Nitschke’s organizations, celebrated Willet’s release. “The allegation of intentional homicide was, and remains, absurd,” it said in a statement.  But in response to an email, Sticher told Vox that both investigations remained open. “All persons are still under investigations, for aiding and abetting a suicide for selfish purposes and for intentional homicide,” Sticher wrote. “But we had no more reasons to keep this last person in custody.” While the drama brought by the Sarco pod’s use is exceptional, the broader debate shouldn’t be.   According to a UN report from 2023, the world population of people over 65 is expected to double, from 761 million in 2021 to 1.6 billion in 2050. In 25 years, people over 65 will make up 1 in 6 people on Earth — part of a global trend toward aging. Thanks to legalization in several countries, many of these people now know that physician-assisted suicide is an option. Assisted suicide remains rare, both globally and in the US. But as more attention is paid to it, the moral, philosophical, and political questions that the case prompted will only become more urgent.  In Switzerland, where assisted suicides are still a relatively small percentage of overall deaths, supporters say it’s important to maintain that right. “Modern medicine is keeping people alive longer and longer. This is why there are more and more very old people, and therefore more and more medical problems towards the end of life,” Marion Schafroth, the president of Exit, said in an email. “Human support for suicide is certainly not morally wrong. It serves the dignity and self-determination and safety of those who wish to die.” Even if they don’t ultimately choose assisted suicide, says Preisig, the founder of Lifecircle, it’s important for people who are seriously ill to know they have the option. “People are not afraid of death, they’re afraid of unbearable suffering,” she says. “When they know they could [die] if they wanted to, then they lose this fear of unbearable suffering. This is the most important point for me.” Still, other countries, like Canada, are grappling with serious concerns about whether the criteria for approval is expanding too quickly, enabling or even encouraging people who aren’t suffering to end their lives.  Canada’s Medical Assistance in Dying (MAID) program is a primary example for critics of what can go wrong. When MAID was first legalized in 2016, Canada had strict criteria: It was only to be used to end unbearable suffering in patients whose conditions were advanced and whose impending death was reasonably foreseeable. In 2021, following a court ruling, the government removed the criteria that a death be reasonably foreseeable. Stories emerged of people who had been approved for euthanasia who didn’t have terminal illnesses. Health care workers have said they’re struggling with the ethical implications arising from people requesting euthanasia not for incurable illnesses but because they’re on government subsidies, were recently widowed, or are dealing with chronic but nonfatal conditions like obesity. And in October, a Canadian committee found that people had received approval for euthanasia for reasons such as social isolation.  Some disability rights groups in Canada are challenging the country’s expanded MAID laws in court. “We are witnessing an alarming trend where people with disabilities are seeking assisted suicide due to social deprivation, poverty, and lack of essential supports,” a leader of the group, Inclusion Canada, said in a statement in September. “This law also sends a devastating message that life with a disability is a fate worse than death, undermining decades of work toward equity and inclusion.”  The controversies around these cases, like the Sarco case, are raising uncomfortable questions for which there might not be easy answers. A legalized assisted suicide program without strong guardrails runs the risk of creating opportunities for abuse. Among those who decide to die via assisted suicide will likely be complicated people with complicated motivations, some of which might not seem reasonable to others. On the other hand, in countries where assisted suicide is illegal, people often find other ways to end their lives. (The leading cause of suicide deaths in the United States is not a new technology like the Sarco pod but a much older one: guns.)  How governments balance the need to protect their citizens’ rights while also safeguarding the most vulnerable among them is a real conundrum. Switzerland found a balance, but the Sarco pod threatened to upset it. Restoring the balance is more than just a major imperative. It’s a matter of great moral significance — and of life and death. 

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