Ethical issues involving medical use of marijuana
The medical use of marijuana is a reality in many states and appears to be gaining traction, notes Abraham Nussbaum, MD, MTS, an assistant professor of psychiatry at the University of Colorado School of Medicine in Denver.
"Bioethicists and clinical ethicists can help pose questions about this system and how it affects the contemporary physician-patient relationship," says Nussbaum. "There is no room for Reefer Madness-style propaganda. But there is always room for sober assessments of what occurs when a physician recommends the medical use of marijuana."
A primary ethical concern is whether it is possible for the benefits of medical use of marijuana to exceed its known risks, and whether it should be recommended without the usual protections afforded to patients, according to Nussbaum.
"While the past decade has seen a dramatic increase in research about the medical use of marijuana, the evidence base for its benefits remains quite limited," says Nussbaum. The published trials are compromised by their small sample sizes, heterogeneous populations, lack of active comparators, differing exclusion criteria, differing concentration, and subjective outcomes, he says, in contrast to the published studies of marijuana’s risks, which are larger, longer-lasting, better-controlled for confounders, and have clearer outcomes.
"Given the state of the medical evidence, physicians can make a strong argument that the medical use of marijuana should be studied rigorously," he says. "However, no compelling ethical grounds exist for physicians recommending the medical use of marijuana outside of current regulations."
It is well-known that there are medical marijuana clinics staffed with physicians who perform cursory histories and physicals and issue prescriptions for medical marijuana, says Katrina A. Bramstedt, PhD, a clinical ethicist and associate professor at Bond University School of Medicine in Australia, and former faculty in the Department of Bioethics at Cleveland (OH) Clinic Foundation.
"Do these physicians put profit above proper medical practice?" she asks. "Also, state laws can be very generous’ in their specification for what conditions medical marijuana can be prescribed." For example, in California [Proposition 215] the list of indications includes "other chronic or persistent medical symptoms."
"This is an open window to nearly anything, and patients who are merely drug-seeking can be very creative in fabricating an illness to satisfy prescribing criteria," says Bramstedt.
In the setting of clinical ethics consultation, ethicists can recommend referrals to pain team specialists, palliative care specialists, and integrative medicine specialists for patients with refractory symptoms such as pain, nausea, muscle spasms, and wasting, says Bramstedt. "Clinical ethicists can also play a role in the design and conduct of clinical trials which test medical marijuana," she adds.
Another ethical concern is what happens to the patient-doctor relationship in medical marijuana programs, says Nussbaum. Since many major healthcare systems will not allow physicians to recommend a substance that is not approved by the Food and Drug Administration and not distributed by hospitals or pharmacies, many of the physicians recommending the medical use of marijuana operate on the margins of the medical community, he explains.
While some recommendations for medical marijuana do occur in the context of an established physician-patient relationship, the available evidence suggests that most recommendations occur in a relationship focused on the recommendation of marijuana, adds Nussbaum. "Many physicians advertise that they specialize’ in medical marijuana recommendations," he says. "These arrangements narrow the physician-patient relationship to the provision of an otherwise illicit substance."
While the medical marijuana lobby is well-funded and well-organized, the opposition is poorly funded and disorganized, so the public conversation is imbalanced, says Nussbaum.
"The issue is clear: Marijuanais not a medicine, and cannot be prescribed by a physician," says Robert L. DuPont, MD, president of the Institute for Behavior and Health in Rockville, MD. "Doctors do not recommend’ medicines to patients to buy all they want from whomever they want and suggest that they take all thatthey want of it."
Medicines are purified chemicals that are approved in specific doses, based on scientifically determined efficacy, safety, and purity, says DuPont, and come from pharmacies where they are dispensed to individual patients on legal physicians’ orders to be used for specific periods of time, for specific reasons, and in specific amounts.
"None of that simple, common standard applies to medical’ marijuana,’" says DuPont, noting that the American Society of Addiction Medicine recently issued a white paper opposing medical marijuana because it fails to meet this standard.1
Autonomy is issue
Clinician-patient discussions about the risks, benefits, and alternatives to marijuana should include these items, says Gary M. Reisfield, MD, assistant professor and chief of pain management services in the Divisions of Addiction Medicine and Forensic Psychiatry at University of Florida College of Medicine in Gainesville:
- A presentation of the evidence base for specific potential medical benefits of marijuana in specific medical conditions;
- A discussion of pharmacologic and nonpharmacologic alternatives to marijuana;
- General and patient-specific risks of marijuana.
Bioethicists can help clinicians develop a framework for determining the limits of patient autonomy in medical marijuana decisions, advises Reisfield, and how autonomy relates to children and adolescents, the mentally ill, pregnant women, individuals with substance use disorders, and individuals who take psychotropic medications.
"In some medical conditions, and in some patients, the therapeutic effects of marijuana can exceed or augment the effects of currently available prescription medications," notes Reisfield. "And, of course, beneficence also applies to considering therapies that are commensurate with our patients’ preferences and values."
Nonmaleficence imposes an obligation on clinicians to refrain from doing harm, and there are several potential harms associated with cannabis and additional harms associated specifically with the smoked form of the drug, notes Reisfield. "It’s apparent to me that many physicians are aware of some of the potential benefits of marijuana, but fewer are well-informed about the downsides of the drug," he says.
Reisfield says that one of the biggest ethical challenges he sees presently is physicians’ ready accession to patient demands for marijuana recommendations. "There is a lack of a big-picture view of the implications of blithely making medical’ decisions based on changing social and political realities, rather than scientific evidence or meaningful empirical data," he says. "I’ve heard highly credentialed physicians dismiss the risks of recommending the use of a flower’ that has been used medicinally for millennia."
The reality is that despite its widespread and growing use and social acceptance, marijuana poses real and serious dangers, says Reisfield, including that nearly 10% of users will, at some point, meet criteria for addiction. "Many patients seeking physicians’ medical marijuana recommendations have pre-existing marijuana use disorders. The recommendation will give legitimacy to their drug use," he says.
Physicians must be mindful about using the authority of their medical degrees in recommending marijuana as a medicine, says Reisfield, "both in general and with regard to the unique patient sitting on their examination table."
1. The American Society of Addiction Medicine. The role of the physician in "medical" marijuana. 2010.
- Robert L. DuPont, MD, President, The Institute for Behavior and Health, Rockville, MD. E-mail: BobDuPont@aol.com.
- Abraham Nussbaum, MD, MTS, Assistant Professor of Psychiatry, School of Medicine, University of Colorado, Denver. E-mail: Abraham.Nussbaum@dhha.org.
- Gary M. Reisfield, MD, Assistant Professor and Chief, Pain Management Services, Divisions of Addiction Medicine and Forensic Psychiatry, Department of Psychiatry, University of Florida College of Medicine, Gainesville. Phone: (352) 265-5404. E-mail: email@example.com.