Podcast Summary: "Does Death Have to Be a Death Sentence? (Update)"
Podcast: People I (Mostly) Admire
Host: Steve Levitt (Freakonomics Radio + Stitcher)
Guest: BJ Miller, palliative care physician and author
Original Air Date: May 31, 2025 (encore of 2021 conversation)
Overview
In this episode, Steve Levitt engages in a profound conversation with Dr. BJ Miller, a physician specializing in end-of-life care, about society’s flawed relationship with death and how we can vastly improve the dying experience. Miller, who became a triple amputee at 19, brings personal and professional insights to his advocacy for a more humane, honest, and supportive approach to dying. Their discussion ranges from the need for “death education” in schools, the problems with medicalized death, the benefits of hospice and palliative care, and personal reflections on grief, loss, and authenticity.
Main Themes and Discussion Points
1. Why We Need "Death Ed" in Schools
- Levitt suggests that our curriculum is missing life-relevant topics like dying, sparking a discussion on when and how to teach about death.
- Miller's response:
- Children inherently understand death if adults don't interfere.
- Empathy and acceptance of death should be discussed openly from a young age.
- Quote:
"Death is everywhere... All you have to do is turn a little attention to it."
— BJ Miller [05:38]
2. Medicalization and Detached Approaches to Death
- Miller describes how modern medicine treats death as a failure or problem to be solved:
- Death often occurs in hospitals designed to fight death at all costs.
- This leads to missed opportunities for connection and acceptance at end-of-life.
- Patients often endure aggressive treatments that offer little benefit and decrease quality of life.
- Quote:
"All of this is just gummed up what is otherwise a very natural phenomenon that is dying and death."
— BJ Miller [09:14]
3. The Costs—Emotional and Financial—of the Traditional Model
- Levitt shares his sister’s agonizing end-of-life experience in the hospital, highlighting how the system’s rules can strip dignity and connection from dying.
- Miller calls these lost moments “a tragedy on top of sadness.”
- The pair note that hospice and palliative care not only improve quality of life but are significantly less costly.
- Quote:
"We collected data that both the hospice and palliative care interventions actually save the system money, save people money, improve quality of life, lower pain, lower depression, lower anxiety."
— BJ Miller [17:51]
- Quote:
4. Societal and Institutional Barriers to Better End-of-Life Care
- Fear of public perception (“death panels”) hinders rational policy change.
- Quote:
"Once you put the words ‘death panel’...around a piece of legislation, it was more than dead and killed conversation for years."
— BJ Miller [19:31]
- Quote:
- There’s a “collusion” in health care to prolong life at any cost, often contrary to genuine patient wishes.
- Miller identifies four pillars for change:
- Society’s attitudes
- Infrastructure and alternative care settings
- Medical education reform
- Policy and incentives
5. Alternatives: The Zen Hospice Model
- Miller contrasts the sterility of hospitals with the warmth and comfort of hospice homes:
- Emphasis on autonomy, peace, family, and the aesthetics of dying.
- Quote:
"The environment of care itself was part of the therapy versus part of the thing you're trying to tune out."
— BJ Miller [15:13]
6. Personal Experience, Loss, and Resilience
- Miller describes his life-changing accident at 19, and how exposure to disability (through his mother) and a shift to art history helped him reconstruct his identity.
- Art, philosophy, and modern perspectives on aesthetics informed his acceptance and self-embrace.
- Quote:
"I can choose how I see myself. I have some power here."
— BJ Miller [34:07]
- Quote:
7. Conversations About Grief and the Power of Authenticity
- Levitt recounts the loss of his one-year-old son, Andrew, and the struggle people have in knowing what to say to the bereaved.
- Miller emphasizes that authenticity and vulnerability, not perfect words, are what heal.
- Quote:
"It's less about the words you choose and more about the spirit behind the words."
— BJ Miller [38:23]
- Quote:
- Authentic gestures—rooted in honesty and care—are universally meaningful.
8. Practical Tools: "A Beginner’s Guide to the End"
- Miller’s book aims to be for death what “What to Expect When You’re Expecting” is for childbirth—an accessible, practical guide for patients and families.
- Quote:
"The reason why we titled it that way is in some ways to turn your attention to the fact that you're mortal. Wrap your head around that. And in some ways, that's where the living starts."
— BJ Miller [41:31]
- Quote:
9. Updates & Miller’s Current Work (2025)
- Miller’s organization, Metal Health (Mettle Health), has grown, offering support and navigation for serious illness, disability, and end-of-life challenges.
- Their mission is to bridge practical and existential needs, helping people see “life and death as part of a whole, a natural cycle.”
Notable Quotes
-
On the need for death in education:
"Death ed seems to make sense. Death is even probably more... I don't know what's more pervasive, sex or death? ...I've gone into schools, third through sixth graders, to have conversations about death... All the adults had to do in a sense was get out of the way. These kids inherently knew what to do."
— BJ Miller [03:42–04:58] -
On medicalization and the importance of proportionality:
"I want to remind ourselves that the medical system, medical inventions, they're there for us to use, not the other way around. This is part of the problem with technology. It ends up ruling our lives, even though it's promised to make our lives easier."
— BJ Miller [12:55] -
On the Zen Hospice alternative:
"Peace and quiet when you want it, music when you want it. Smells coming from a kitchen. ... The building itself, the environment of care itself was part of the therapy..."
— BJ Miller [14:24] -
On confronting grief and difficult conversations:
"There isn't a perfect thing to say... What I think is really the most important, what is really actually healing, is authenticity."
— BJ Miller [37:31–38:23] -
On making peace with mortality:
"Turn your attention to the fact that you're mortal. Wrap your head around that... In some ways that's where the living starts. That's when you appreciate time."
— BJ Miller [41:31]
Key Timestamps and Segments
- [03:42-05:46] — Miller on why “death ed” belongs in schools and the innate wisdom of children
- [07:29-09:23] — What typical dying looks like in the medical system vs. the idealized experience
- [09:58-10:30] — Levitt’s personal story of his sister’s hospital death
- [12:55-14:13] — Miller’s alternative vision: proportional medicine and meaningful conversations
- [14:24-15:29] — Description of the Zen Hospice Project’s atmosphere
- [17:49-18:57] — Economics of dying: why palliative/hospice care saves money, and why insurance companies hesitate
- [19:00-20:49] — "Death panel" controversies and the politics of end-of-life reform
- [21:16-21:57] — Usage stats of hospice and why care still comes too late for many
- [22:05-23:21] — The experience and challenge of telling patients death is near
- [29:52-36:49] — Miller’s accident, adjustment to disability, role of art history, and impact on identity
- [37:28-39:49] — Advice for handling grief and difficult conversations: embracing vulnerability and authenticity
- [39:49-41:56] — BJ Miller’s book "A Beginner’s Guide to the End"
- [43:29-45:17] — Miller’s organization Metal Health: mission and updates
Conclusion
This episode challenges listeners to rethink how we approach death—not as a medical failure or something to be feared, but as a natural, communal, and meaningful aspect of life. Through stories, critique of systems, and personal experience, BJ Miller and Steve Levitt argue for more compassion, authenticity, and honesty around dying. Miller’s unique outlook—shaped by his own disability and career—provides practical hope for reforming end-of-life care, with a belief that doing so will enrich not just our dying, but our living.
Resources
- Book: A Beginner’s Guide to the End by BJ Miller and Shoshana Berger
- Organization: Mettle Health
- Related: Zen Hospice Project, UCSF Cancer Center
Summary prepared by a podcast summarizer (2024).