Abstract
Medical cannabis can be considered a controversial substance. Despite its increased accessibility and use, healthcare professionals and general public struggle to assess the positive and negative effects of prescribed cannabinoids. Clinical benefits of marijuana are identified in numerous research studies. However, ethical issues arise as doctors question their professional obligation to provide competent treatment recommendations.
The patient-doctor relationship suffers as healthcare providers are discouraged from prescribing a treatment proven to relieve patients from pain and anxiety. Furthermore, by denying to provide suitable medicine, doctors seem to violate patients’ personal freedom as well as universal principles of non-maleficence and beneficence. Therefore, patients should have the right to request medical marijuana, and primary care providers have an obligation to inform them of such an option.
Introduction
Cannabis use for medical purposes has gathered much national attention in recent years. Some experts advocate for non-restrictive prescriptions of marijuana, while others argue that the safety and efficacy of cannabinoids are not researched enough to recommend them to patients. Extensive media coverage of such substances (focusing primarily on the benefits) leads to their widespread acceptance. Issues arise regarding patients’ disregard of possible risks and implications of utilizing the drug. Ethical nuances contribute to the problem as well. However, it is crucial to realize that even with the recent obsession with cannabidiol (CBD) and tetrahydrocannabinol (THC) 1 medicinal use of marijuana is not a new concept.
The historical significance of cannabis is not the primary focus of this paper, but it demonstrates the value of using marijuana for medical purposes by earlier generations. The origins of the drug trace back to the ancient world. People who lived in what is now Romania found a medical use for marijuana more than 5,000 years ago.2 It was also a well-known medicine in the United States in the 19th century. The first governmental limitations took place in 1937 as the Marihuana Tax Act was successfully passed on a federal level.3 Legal penalties and restrictions that followed contributed to the plant’s criminalization and further stigmatization.
Widespread administration of medical cannabis remains a matter of conflict between the conservative scientific community and numerous marijuana supporters. The opposition argues that all the research regarding CBD and THC is nonspecific as studies do not demonstrate possible long-term effects of consistent marijuana use. Statistical reports demonstrate “about 1 in 10 marijuana users will become addicted” (National Center for Chronic Disease Prevention and Health Promotion). Such numbers, however, are not representative of medical cannabis.
It can be argued that the normalization of medical marijuana use is a result of extensive, meticulous studies that have started to surface recently, and not media manipulation. THC, for example, has been shown to have “anti-inflammatory, neuroprotective, anti-nausea, appetite enhancing, and analgesic effects” (Clark et al., The ethics of medical marijuana: Government restrictions vs. medical necessity (an update), 2018, p. 2). Studies suggest that CBD can help with epilepsy, inflammation, chronic pain, etc.
According to Nadia Solovij, co-director of Australian Centre for Cannabinoid Clinical and Research Excellence (ACRE), “it is unlikely that medicinal cannabis used for specific medical conditions would be used sufficiently heavily for dependence or other adverse outcomes to develop” (as cited in Ribeiro, 2019). So, a 10 percent addiction rate mentioned earlier is not representative of medical marijuana use because it is associated with heavy, unregulated abuse of cannabinoid-containing substances.
Thesis
Considering how benefits of medical marijuana outweigh the potential dangers (either baseless or manageable), failure to inform patients of cannabis treatment or deny their request to explore such an option might be considered a direct violation of their autonomy and basic human dignity.
Case Study
Utilization of marijuana for chronic pain relief is one of the prominent focuses of scientists studying cannabinoids. Analgesic effects of marijuana have been explored in studies by Barth Wilsey et al. in 2015, Murali Kolikonda et al. in 2016, and numerous others. The New England Journal of Medicine presents a typical case of recurring pain (Caulley et al., 2018, p. 1575). Ms. Rothstein is a 31-year-old graduate student from London. She suffered an injury to her lower leg while playing soccer in a varsity soccer team. The accident happened when she was 24. Since then, she has been experiencing burning and aching in her right foreleg and foot.
Ms. Rothstein was diagnosed with complex regional pain syndrome. In order to relieve the pain, she has tried several treatments, including opioids, nerve stimulation and acupuncture, numerous salves, as well as behaviour modification. These options proved to be insufficient in alleviating her pain. They negatively affected her concentration, energy levels, and metabolism. Further concerns about developing an opioid addiction led to Ms. Rothstein inquiring about a possible medical marijuana prescription.
Doctors need to decide whether to prescribe medical cannabis to the patient or to discourage her from cannabinoid use. In this case study, Dr. Edgar Ross advises the patient to try other evidence-based treatments (Caulley et al., 2018, p. 1577). He argues that multidisciplinary therapy might suit Ms. Rothstein best as cannabinoids’ safety and efficacy are not clearly identified. Sedation, dysphoria, and dizziness are some of the side effects that are associated with excessive marijuana use. Dr. Ross also mentions that it is especially hard to establish a safe dose for the patient when there are so few standards and regulations regarding CBD and THC utilization for medical purposes.
Systematic government restrictions might be a reason why necessary research is limited, and standardization of medical policies remains an issue for patients and doctors. Keeping in mind the available research as well as the historical significance of the plant, it is right to assume that utilization of marijuana medicinally is, in fact, effective and safe. Dr. Ross himself states that “cannabinoid compounds are almost certainly safer than long-term opioid therapy” (Caulley et al., 2018, p. 1577). Cannabis proved to be a viable option for patients disappointed in traditional treatments, according to Dr. Caplan (Caulley et al., 2018, p. 1576). Moreover, research in both animals and humans has demonstrated positive effects regarding pain alleviation and patient safety.
From an ethical standpoint, the doctor treating Ms. Rothstein does not only need to provide her with necessary scientific findings but recognize their duty to practice medicine without violating her autonomy. By discouraging the patient from a non-traditional but still effective and safe (as proven earlier) treatment, the doctor discredits the main principles of medical practice. Any medical professional should remember to prioritize patients’ needs and not to neglect the concepts of non-maleficence and beneficence. Successful treatment can be formulated only by making the burden/benefit assessment. In this case, chronic pain relief, avoiding opioid addiction, and managing the side effects from other drugs outweigh possible inconveniences associated with CBD/THC.
Research Material
Medical
Controversies surrounding the efficacy, safety, and addictive properties of marijuana arise in the scientific community. Several studies have been conducted in recent years that provide medics with the necessary information on the nature of the plant, its benefits and potential risks. Utilization of marijuana as a replacement for opioid treatments is one of the major focuses of researchers as well.
Some medical professionals question the effectiveness of CBD and THC. As a result, they become hesitant about recommending marijuana derivatives to their patients. Multiple double-blind placebo studies have shown that regulated concentrations of CBD and THC reduce pain intensity. Analgesic efficacy of vaporized cannabinoids was demonstrated in a controlled laboratory experiment. Wilsey et al. showed an improvement in pain severity when participants inhaled dosages of 2.9% to 6.7% delta-9-tetrahydrocannabinol compared to visually similar placebo drugs (2016, p. 990).
Using patients’ charts and a systematic survey, another group of researchers determined that patients with severe nausea responded much better to marijuana than other anti-nausea medications, including diphenhydramine and metoclopramide.4 Studies prove that medical marijuana is, in fact, an effective drug when it comes to treating severe pain, gastroenterological conditions, as well as epilepsy (Kolikonda et al., 2016, p. 25).
Some side effects associated with marijuana include anxiety, psychotic episodes, and memory loss.5 However, they are primarily caused by severe dosages of the drug usually taken for recreational purposes. Torres-Moreno et al. conducted a systematic review and meta-analysis of medicinal cannabinoids’ efficacy, tolerability, and sensitivity and stated that “the analysis of serious adverse events did not show statistical significance” (2018, p. 16). They demonstrated that all the possible risks and implications are not serious enough to be scientifically significant. It is safe to conclude that current research findings show that systematic, regulated use of medicinal cannabis is safe.
Some healthcare professionals and patients consider marijuana a ‘gateway drug’ (a drug that leads to the use of more addictive, dangerous substances). However, higher, unregulated dosages of CBD and THC have been linked to addiction, and not systematic medicinal use that is required for treatment. Moreover, cannabis proved to be an effective treatment option for patients suffering from Opioid Use Disorder (OUD).
According to Clark et al., there is strong evidence that encourages using medical cannabinoids “as an adjunctive treatment to assist patients struggling with OUD and opioid withdrawal, or possibly even as a primary treatment modality” (Is medical marijuana a viable option for opioid replacement therapy?, 2019, p. 6). Given all the presented evidence, it is apparent that medical cannabis is an efficient and well-tolerated drug if used systematically, under medical supervision.
Legal
Due to the nation-wide struggle with OUD and massive amounts of social pressure, administration of medical marijuana 6 has been a controversial topic among lawmakers and government officials. The issue is further complicated by extreme differences between federal and state regulations. Under the Controlled Substances Act of 1970, for example, marijuana is classified as a Schedule I drug, which prohibits its use (medical, recreational) for anything other than research. However, some states started to implement their own laws regarding the legality of cannabis. As a result, 33 states have legalized the use of marijuana for medical purposes.7 Such regulations contradict federal laws and therefore, pose a question: which entity holds more power, the federal government or state authorities?
The Supremacy Clause establishes federal power as the “Law of the Land” which legally enables federal officials to enforce their policies regarding marijuana across all the states (U. S. Const. art. VI, § 2). In reality, the government cannot allocate enough resources for federal regulators to manage that. In addition, the public opinion makes it potentially politically challenging to go against state decisions. Because of how interconnected state and federal powers are, it is impossible for the federal government to oppose states’ decisions without any negative consequences for both.
The recent decline of social stigmatization of marijuana as well as extensive research regarding its efficacy and safety led to 16 CBD-based drugs being approved by the Food and Drug Administration (FDA). It resulted in the Drug Enforcement Administration (DEA) classifying CBD as a Schedule V substance, drugs that are considered to have the lowest risk of harm and abuse (2018, p. 1312). It was a noticeable shift and proved that “the evolution of marijuana-related legislation reflected trends in public opinion in regards to the use of the substance” (Clark et al., The Ethics of medical marijuana: Government restrictions vs. medical necessity (an update), 2018, p. 6).
Ethical
Two major issues arise as cannabis administration becomes more and more normalized in the medical field. Firstly, doctors are faced with the benefit/harm dilemma concerning the prescription of effective, but potentially harmful drugs. Non-maleficence and beneficence become the main principles for medical professionals to navigate by. Furthermore, social and political biases often affect how they present information regarding the plant to their patients.
Beneficence and non-maleficence can be ensured by recommending cannabis “only for conditions where the evidence base is well-established” (Glickman & Sisti, 2019, p. 2). Substantial research has demonstrated that medical benefits of cannabinoids (anti-seizure, anti-inflammatory, analgesic effects) outweigh potential risks.8 Therefore, to deny patients “access to such therapies is to deny them the dignity and respect all persons deserve” (Clark et al., The Ethics of medical marijuana: Government restrictions vs. medical necessity (an update), 2018, p. 9). Doctors’ unwillingness to discuss cannabinoid therapy contradicts the key concepts of medical practice that require medics to seek the well-being of their patients.
Cannabis opposers are rightfully concerned with the quality of the information provided by doctors, who might not be competent enough to present potential physiological and psychiatric risks of the drug. Medical marijuana should be regarded as “a complex class of therapies that must be managed and adjusted in collaboration with individual patients” (Glickman & Sisti, 2019, p. 3). Doctors must be familiar with all the latest research and specific standards regarding marijuana use in order not to harm their patients.
Position
Objective Norm
Principlism is a common ethical approach used in clinical ethics to solve moral dilemmas concerning a patient’s life and health. The focus of this paper is moral implications and considerations about medical marijuana administration. Should doctors advise medical cannabis to patients or discourage them from using it instead? The best way to resolve such a dilemma is through the application of specific ethical principles, including autonomy, beneficence, non-maleficence, and justice. It is arguably the most practical and concise ethical framework when it comes to confusing real-life situations.
Moral Principles
Any patient has a right to autonomy which means they can self-determine their treatment 9 without any persuasion or coercion from medical professionals. However, it is crucial for patients to be informed of all the possible risks, implications, and not just benefits. Thus, keeping in mind numerous evidence-based studies, doctors should not disfavor the option of medical cannabis, but instead, provide patients with all the necessary information for them to make a reasonable decision.
Medical practice requires doctors to act in accordance with the concepts of non-maleficence and beneficence. They are obligations to avoid and prevent harm as well as promote good to their patients. In order to do that, medical professionals need to assess the case presented to them, including its risks and benefits (burden/benefit analysis). In the case of medical marijuana, potential good outweighs potential harm as research consistently demonstrates the safety and efficacy of the plant. Societal judgment, legal implications, and minor side effects (far less aggressive than those associated with other drugs) can be considered reasonable and manageable for prospective patients.
Without fair risk-benefit distribution, doctors’ choices cannot be ethically correct, according to principlism. Hence, the concept of justice is introduced. Primary care providers have a professional obligation to justify their decisions. Successful chronic pain alleviation, epilepsy recovery, stress relief, replacement of opioid treatments affect the patient’s quality of life much more than any possible risks might.
Theological Conclusion
Based on established moral principles in medical practice as well as evidence-based research, cannabinoid prescription might be a viable option for patients struggling with eating disorders, sleep deprivation, epilepsy, and other conditions. Withholding necessary information from patients violates their rights and contradicts the principles of beneficence and non-maleficence, which are essential in practicing medicine.
Conclusion
A long history of criminalization and stigmatization serves as a challenge for the medical community to start recommending marijuana. However, with all the evidence-based research that establishes anti-inflammatory, anti-seizure and analgesic effects of medicinal cannabis, it would seem illogical and unethical to exclude it from discussions about possible treatment options. The risks are reasonably manageable, so the plant can be considered safe to use.
More research is needed to provide medical professionals with all the right information regarding the dosages and legal procedures. Doctors need to remember their obligation to act following the principles of beneficence and non-maleficence. In the case of medical marijuana 10, it is crucial not to violate patients’ autonomy and personal dignity and allow them to make conscious decisions regarding their health based on doctors’ informed advice.
- Two substances that are both derived from the cannabis plant.
- See Bridgeman & Albazia (2017) for more information.
- See Mcallister (2019) for an insightful examination of the Marihuana Tax Act of 1937.
- See Zikos et al. (2020) for more detailed information about diphendyhydramine and metoclopramide.
- See Alexander (2019) for a thorough analysis of the side effects associated with long-term marijuana use.
- Marijuana is still legally considered an illicit substance.
- Including 11 states where recreational use of cannabis is allowed.
- See Caulley et al. (2018), Kolikonda et al. (2016), Torres-Morreno et al. (2018) for more evidence-based examinations of the benefits of marijuana.
- Usually based on their doctor’s recommendations.
- The drug proven to be both effective and safe.
References
Alexander, S. (2019). SP0147 Ethical issues in medical cannabis use. Annals of the Rheumatic Diseases, 78(2). Web.
Bridgeman, M. B., & Albazia D. T. (2017) Medicinal cannabis: History, pharmacology, and implications for the acute care setting. Pharmacy and Therapeutics, 42(3), 180-188. Web.
Caulley, L., Caplan, B., & Ross, E. (2018). Medical marijuana for chronic pain. The New England Journal for Medicine, 379(16), 1575-1577. Web.
Clark, P. A., Dubensky, J., Evans, A., Bhatt, H., Ayala, A., & Umapathy, S. (2018). The ethics of medical marijuana: Government restrictions vs. medical necessity (an update). The Internet Journal of Law, Healthcare and Ethics, 12(1), 1-12. Web.
Clark, P. A., Mamo, G., Schadt, S., Gulati, S., Minupuri, A., Dubensky, J., Krupadev, A., Shah, R., Zheng, S., Noain, J. S., Fick, C., Nguyen, O., Laird, P., Gulati, R., Fontana, M., Rodriguez, P., Clifford, G., McDermott, S., Patrick, H.,… Davis, J. (2019). Is medical marijuana a viable option for opioid replacement therapy? Journal of Addiction and Dependence, 5(1), 1-18. Web.
Drug Enforcement Administration. (2018). Schedules of controlled substances: Placement in schedule V of certain FDA-approved drugs containing cannabidiol; corresponding change to permit requirements. Department of Justice, 1308-1312. Web.
Glickman, A., & Sisti, D. (2019). Prescribing medical cannabis: Ethical considerations for primary care providers. Journal of Medical Ethics, 1-4. Web.
Kolikonda, M. K., Srinivasan, K., Enja, M., Sagi, V., & Lippmann, S. (2016). Medical marijuana for epilepsy? Innovations in Clinical Neuroscience, 13(3-4), 23-36. Web.
McAllister, W. B. (2019). Harry Anslinger saves the world: National security imperatives and the 1937 Marihuana Tax Act. The Social History of Alcohol and Drugs, 33(1), 37-62. Web.
National Center for Chronic Disease Prevention and Health Promotion. Is it possible for someone to become addicted to marijuana? Web.
Ribeiro, C. (2019). Medicinal cannabis: The hype is strong, but the evidence is weak. The Guardian. Web.
Torres-Moreno, M. C., Papaseit, E., Torrens, M., & Farré, M. (2018). Assessment of efficacy and tolerability of medicinal cannabinoids in patients with multiple sclerosis. JAMA Network Open, 1(6). Web.
U. S. Const. art. VI, § 2.
Wilsey, B., Marcotte, T. D., Deutsch, R., Zhao, H., Prasad, H., & Phan, A. (2016). An exploratory human laboratory experiment evaluating vaporized cannabis in the treatment of neuropathic pain from spinal cord injury and disease. The Journal of Pain, 17(9), 982–1000. Web.
Zikos, T. A., Nguyen, L., Kamal, A., Fernandez-Becker, N., Regalia, K., Nandwani, M., Sonu, I., Garcia, M., Okafor, P., Neshatian, L., Grewal, D., Garcia, P., Triadafilopoulos, G., & Clarke, J. O. (2020). Marijuana, ondansetron, and promethazine are perceived as most effective treatments for gastrointestinal nausea. Digestive Diseases and Sciences. Web.