Initially, I really didn’t take to Dr. Jean Marmoreo, perceiving her as over-confident and even brassy, but I came to appreciate her informative book, finding it considerably more nuanced than Stefanie Green’s This is Assisted Dying, which came out in March 2022. Both Marmoreo and Green were at the forefront when medically assisted death became legal in Canada in 2016—Green on the west coast of Canada, Marmoreo in the Greater Toronto Area. Since Marmoreo’s book is the more recent, it covers new developments in Medical Assistance in Dying—aka MAiD, an acronym I loathe, as it suggests to me tidying up the unwanted mess of chronically or terminally ill people. I’ll add here that I am no fonder of the euphemistic term Marmoreo consistently uses—“provision”— which only sounds like a way to avoid stating what these doctors actually do: euthanize patients. Marmoreo notes that in the Netherlands, they’re more straightforward: it’s acknowledged there as killing people. I prefer that directness.

In her book, Marmoreo does some of the usual things you see in medical memoirs. She presents a wide range of case studies. She also talks about assessments, criteria, the approval process, the procedure itself, and the thorny matter of assisted death for patients in cognitive decline. What interested me about her story is the perspective she brings to the subject. Marmoreo has been a family doctor for over 40 years. She’s now 80–still very sharp and physically fit—but aware that her own time on earth is drawing to a close. It’s unclear to me if she still has a medical practice outside of providing medically assisted death. But my point here is: she has spent years caring for her patients. She knows them, their struggles, how they’ve coped with challenges in the past—in short, their stories. The fact that she assesses and ends the lives of people she does not know well greatly concerns her, and it’s taken an emotional toll. She had hoped that over time Canadian family physicians, like Dutch GPs, would incorporate assisted death into practices where longterm relationships with patients have been established. Family doctors in the Netherlands can expect to perform an average of five euthanasias over the course of their careers. The Dutch, acknowledging the emotional burden of ending someone’s life, have ensured that doctors have some opportunity to recover after the procedure. They do not go into their offices and clinics the day following an assisted death. Unfortunately, 85% of assisted deaths in Canada are performed by physicians who are essentially strangers to patients. This is the inverse of what happens in the Netherlands, where only 15% of euthanasias are performed by physicians not known by the patient, and 85% by family doctors.

Before Marmoreo began performing assisted deaths, she created and followed a learning program, shadowing palliative care doctors in both urban and rural settings. This has proved to be invaluable when it comes to assessing patients. She describes cases in which she intervened to find supports and resources for patients in order to give them extra quality time, but she openly acknowledges the frustration and distress she has felt when services—community, home care, mental health, and medical—can’t be drawn on because there are none to be had. This is particularly true in rural areas and in the northern parts of Ontario. There have been several recent articles in the Canadian press about patients who are opting for euthanasia because they cannot get the home care they require. Some people who request an assisted death are really doing so out of loneliness or concerns about finances, but other health conditions (which they probably could in fact live with if supported) get them approved. They are euthanized. In one case Marmoreo was involved with, the Ontario Coroner’s office had “questions” about the death.

In 2023, Canada will likely be extending medical assistance in dying to the mentally ill. There’s talk, too, of allowing mature minors to request it, and having it performed on infants with serious disabilities. In short, Canada is fast becoming the nation with the most liberal euthanasia laws in the world. Is this a good thing? I tend to think not. If it’s so easy to kill people, why bother developing support services? The Canadian medical system is a mess. It’s no exaggeration to say it’s in crisis. This past summer, a number of emergency departments were shut down on weekends due to staffing issues. There are unacceptable wait times for diagnostic imaging and surgeries. Many family doctors and specialists have found they prefer doing “telemedicine” over actually seeing and examining patients. (Thanks, Covid.) Ending lives could become a cost-effective solution. I’m not being facetious. It’s happening now. Is more of that really where we want to go?

Marmoreo is one tough cookie. Even so, she acknowledges that ending people’s lives involves carrying an emotional burden. It can lead to “moral injury”, a term I first encountered in Francisco Cantú’s The Line Becomes a River, an account of his time as a border patrol officer. I do not deny that euthanasia is sometimes a blessing—in cases where there’s intractable pain and suffering, for example. However—and I’ve mentioned this before—I’ve personally experienced (and been taken aback by) the callousness of veterinarians who routinely euthanize animals. Is that where we want to go? Physicians carrying out this procedure so frequently that they wall off their humanity and become hardened?

While I might intellectually understand why a medical professional feels committed to doing this work, I admit that on an emotional level I don’t fully understand what makes these doctors tick. A practice, such as Stefanie Green’s for example, exclusively dedicated to ending people’s lives concerns me. I worry about the effect on the physicians and on the patients and families they serve. ( )