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The Ethicsof MedicalMarijuana:
GovernmentRestrictionsvs.
MedicalNecessity
PETER A. CLARK
e
I
HERE is a healthy debate raging in the medical
community about the increasing popularity of alternative medicine (also termed unconventional, com-
plementary, or integrative) in the United States (i).
It is estimated that 40% of the public is using someform of alternative medicine, which reflects the
,51eD
and
values in our culture today (z). The major critichanging needs
cism of these alternative therapies is that they have not been scientifically tested; therefore, their safety and efficacy has been called
into question. One such alternative therapy that is gaining prominence is the medical use of marijuana for treating pain, nausea, and
vomiting associated with chemotherapy, and severe weight loss associated with AIDS. Medical marijuana can be both a treatment in
itself, and it can be used to help patients withstand the effects of
accepted treatments that can possibly lead to a cure or amelioration
of their condition (3). As a result of its effectiveness, seven
states -California, Alaska, Arizona, Colorado, Nevada, Oregon, and
Washington have approved initiatives to make marijuana legal for
medical purposes. The stumbling block has been the Federal government, which has threatened to prosecute any physician who prescri'besmarijuana.
The Federal government's basis for threatening prosecution is that
marijuanais listed as a Schedule I drug under the I970 Uniform Controlled Substance Act. Possession of a Schedule I drug is illegal and
such drugs can only be utilized for research purposes. Attempts to
reassign marijuana to a Schedule II drug have been rejected by the
Drug Enforcement Administration (DEA) on the basis that "there
-
3
40
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was no scientificevidence showing that marijuanawas better than
otherapproveddrugsfor any specificmedicalcondition"(4). The Federal government'sobjectionto the medicaluse of marijuanais based
on a nationalpolicy of zero-tolerancetowardillicit drugs.The objection to legalizingmarijuanafor medical purposesis based on three
suppositions.First, the Clinton Administrationbelieves that marijuanais an illegaldrugwhich remainsunprovenin termsof safetyor
efficacy.Second,theycontendthatmarijuanais a "gatewaydrug"that
leads to more serious drug use. Third, legalizatonof marijuanafor
medicalpurposeswill send the wrong messageto the public, and in
particularto our children,namely that marijuanais acceptablefor
recreationaluse andevenbeneficial.Basically,the governmentbelieves
its argumentis groundedin logic. The argumentgoes this way: marijuanais an illegaldrug;no one shouldeveruse illegaldrugs;therefore,
no one should ever use marijuanafor any reason (S). The government'spolicy againstthe legalizationof medicalmarijuanahas been
challengedby medicalresearchers,physicians,and patientsbased on
its reportedeffectivenessas a therapyand becausethey believe the
government'sargumentis groundedin bad logic.
On March17,
I999,
the mostcomprehensive
analysisto dateof
the medicalliteratureabout marijuanawas issuedby a WhiteHousecommissionedcommitteeof ii independentscientistsappointedby
the Instituteof Medicine.The reportconcludedthat "the benefitsof
smokingmarijuanawere limitedby the toxic effectsof the smoke,but
nonethelessrecommendedthat the drug be given underclose supervision to patientswho do not respond to other therapies"(6). The
reportalso statedthat "therewas no evidencethat givingthe drugto
sick people would increaseillicit drug use in the generalpopulation.
Nor is marijuanaa 'gateway drug' that prompts patients to use
harder drugs like cocaine and heroin" (7). This government-sponsored study found solid scientificdata that indicates the potential
therapeuticvalue of marijuanain controlling some forms of pain,
alleviatingnausea and vomiting, treatingwasting due to AIDS, and
combatingmusclespasmsassociatedwith multiplesclerosis(MS)(8).
Neither does it increasedrug usage or lead to harderdrugs. Why,
then, is the Federalgovernmentprohibitingthis effectivedrug from
being prescribedby physiciansfor patients sufferingfrom specific
treatment side-effects?The ethical dilemma at the center of this
debatefocuseson whetherthe Federalban on the use of medicalmar-
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ijuanaviolates the physician-patientrelationship.Patientshave the
rightto expectfromtheirphysiciansfull disclosureand discussionof
all availabletreatmentoptions.Denyinga patientknowledgeof and
accessto a therapythat relievespain and suffering,especiallywhen
the patienthas a terminaldisease,violatesthe basicduty of a physician. Physiciansfind themselvesat the center of this controversy,
searchingfor a compromisebetweenmedicalnecessityand governmentrestrictions.
The purposeof this article,therefore,is threefold:first,to examine
the scientificdataregardingthe medicaluse of marijuana;second,to
give an ethicalanalysisof the argumentsfor and againstthe medical
use of marijuana;third,to determineif the ClintonAdministration
shouldmove to have marijuanareclassifiedas a ScheduleII drug so
that physicianscan legallyprescribeit to patientsas an alternative
medicaltherapywhichwill relievepain and suffering.
MEDICAL
USES
OF MARIJUANA
Marijuanacomes from the leaves and floweringtops of the hemp
plant, Cannabissativa, which grows in most regionsof the world.
The marijuanaplant contains over 460 known compounds,6o of
which are cannabinoids,compoundsuniqueto cannabis.The chief
psychoactivecompoundof marijuanais delta-g-tetrahydrocannabinol (THC) (9). Clinical findings have documented marijuana's
efficacyin treatingpain, neurologicaland movementdisorders,nausea of patientsundergoingchemotherapyfor cancer,loss of appetite
and weight (cachexia)relatedto AIDS,and glaucoma(io). The negativeeffectsof marijuanaincluderapidheartbeat,some loss of coordination,and impairedimmediatememory.In addition,the drugcan
adverselyaffectone'scriticalskills,includingthoseskillsnecessaryto
operatevehicles safely, such as judgmentof distanceand reaction
time (i i). Froma clinicalstandpoint,the positiveeffectswould seem
to greatly outweigh the negative effects in controlled situations.
However,despitereportedpositivemedicaleffects,the DEAhas marijuanaclassifiedas an illegalScheduleI drugwhichhas "nocurrently
acceptedmedical use." The DEA refuses to reschedulemarijuana
withoutan officialdeterminationof safetyandefficacyfromthe Food
and Drug Administration(FDA).TheFDA requirescontrolled,double-blindedclinicaltrials for reschedulingto occur.One reason for
the lack of clinicaltrialsis a roadblockwhich faces all herbalmedi-
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cines:the lack of a patentableproduct.The othermajorreasonis that
the governmenthas always requiredthat such clinical studies be
fundedfrom scarcegrantmoneycontrolledby the National Institutes
of Health (iz). Both restrictionshave discouragedresearchersfrom
studyingthe medicalbenefitsof marijuana.
Two forms of marijuanahave been used for medicalpurposes:a
syntheticform, dronabinol (Marinol?), which is taken orally, and
smoked marijuana.Both forms contain the psychoactiveingredient
THC. Marinol?, manufacturedby UnimedPharmaceuticals,Inc., is
a ScheduleII prescriptiondrug, approvedby the FDA in i985 for
treatmentof nausea and vomiting of cancerchemotherapypatients
who have not respondedto the conventionalantiemetictherapy.In
i992,
the FDA also approvedit for use in loss of appetiteand weight
loss relatedto AIDS (13). There are three majorconcernswith prescriptionMarinol?. First, some patients have complainedthat the
effects of the pill were too strongat first,then wore off quickly(14).
Second, Marinol? is very expensive, costing about $500 for one
hundred io-mg capsules. Third, it can be difficult for nauseous
patients to consume. Some patients fail to keep the pill down long
enoughfor it to be effective(I 5). It has beenarguedthat smokedmarijuana,on the other hand, is substantiallymore effective.The THC
in aerosolform in the inhaledsmoke is absorbedwithin secondsand
is deliveredto the brainrapidlyand efficiently,as would be expected
of a highly lipid-solubledrug. Maximum blood concentrationsare
reachedaboutthe time smokingis finishedandthen rapidlydissipate.
Psychopharmacologiceffects peak at 30 to 6o minutes. The clear
advantageof smokedmarijuanais the rapidonset and dissipationof
effects,becausethe patientis able to self-titratethe dose. In addition,
the plant contains many other compounds (including about 6o
cannabinoids) that may produce some additional benefits (i6).
Oncologistswere among the first medicalprofessionalsto advocate
for the medicaluse of smokedmarijuana.Reactingto a DEA suggestion that only a "fringegroup"of oncologistsacceptedmarijuanaas
an antiemeticagent, a randomsurveyof the membersof the Ameri-
can Societyof Oncologywas conductedin I990.
Morethan IOOO
oncologistsrespondedto the survey;44% reportedthat they had recommendedmarijuanato at least one patient.Smokedmarijuanawas
believedto be more effectivethan oral dronabinol(Marinol?) by the
respondents.Of those who believedthey had sufficientinformation
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to compare the two drugs directly,44% believed marijuanawas more
effective and I 3 % that Marinol? was more effective (I 7). In addition, the cost of marijuana is considerably cheaper. "The cost of producing cannabis is about a dollar an ounce, and medical distribution
would add at most a few more dollars. There are about 6o marijuana
cigarettes in an ounce, and the average dose is one cigarette or less"
(I8). On a cost-effectiveness analysis, smoked marijuana is more
effective and less costly that Marinol?.
Despite the medical benefits of smoked marijuana, there are also a
number of medical risks associated with this drug. First, it is difficult
to determine the effective dosage of smoked marijuana,since the concentration of the active ingredient, THC, varies according to the particular plant and how it is grown. Second, nonconclusive studies have
shown that THC both suppresses macrophages and human T-lymphocytes and enhances macrophage secretion of interleukin-i (i9).
These are critical components of the immune system and could seriously jeopardize AIDS patients who used marijuana. Other studies
emphasize the potential for toxic compounds in marijuana smoke,
which include harmful cannibinoids, gases, and other particulates.
Studies have shown that marijuana tar contains 50% more phenols
than does tobacco tar (zo). Finally, marijuana can also be contaminated by microorganisms and fungi, which can cause possible infections by pathogenic organisms. There have been reported cases of
marijuanasmokers contracting pulmonary fungal infections. In addition, adulterants such as pesticides and fertilizerscan compromise the
purity of the marijuana (zi). To combat these risks, various methods,
such as filtering marijuana in water pipes and vaporizing the marijuana, have been shown to remove certain toxins and to deliver a
higher cannabinoid-to-tar ratio than do cigarettes or pipes. In addition, sterilizing the marijuanaby dry heat (300 degrees F) kills spores
and fungi (zz). These risks can be minimized further if the supply of
marijuana is grown under government-regulated conditions rather
than by illicit sources.
Scientificresearchon the medical effects of marijuanahas been limited due to the stipulation that all studies must be funded by the
National Institutes of Health. Since I978 the Federalgovernment has
provided zo patients with medical marijuana under a compassionate
investigational new drug program. The Institute of Drug Abuse pays
the University of Mississippi to grow a consistent, reliable source of
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research-gradecannabis.This is an unadulteratedand standardized
form of marijuanawithout contaminantsor pesticides.A North Carolina manufacturerreceives$6z,ooo a yearfrom the Federalgovernment to roll the marijuanacigarettesand ship them FederalExpress,
in sealed tins of 300 each, to the patients'doctors and pharmacists.
Eachparticipantwas givena letterfromthe FDA authorizingthemto
use this illegal substancethat can bringa Federalprisonterm of five
years. In
I99I,
the Federal government terminated this program,
which was the only legalway to obtainaccessto marijuana.This program was terminated, in the government's opinion, because too many
people becameawareof it andwere askingfor accessto medicalmarijuana supplies. Twelve individualswere receivingmarijuanacigawhen the programwas
rettesin I99I and theywere "grandfathered"
terminated.Since that time, four individualshave died from AIDS,
and the remainingeightcontinueto receivetheirsupplyof marijuana
cigarettes (23). The government'shope is that this program will
quicklydisappearthroughattrition.To allow some to have accessto
medicalmarijuanawhile others are deniedseemsa graveinjusticeto
many and placesthe Federalgovernmentin a precarioussituation.
In February1997, the National Institutesof Health releasedits
reporton the resultsof an expertpanelthat was convenedto investigate the therapeuticpotential of marijuanaand to identify future
research avenues that would be most productive. The panel of
expertsidentifiedfive areaswhere therewas at least a suggestionof
therapeuticvalue of marijuanaand for which furtherstudywas indicated. The five areas were: (i) stimulates appetite and alleviates
cachexia, (z) controls nausea and vomiting associatedwith cancer
chemotherapy,(3) decreasesintraocularpressurefor those suffering
from glaucoma,(4) analgesia,and (S) neurologicand movementdisorders are relieved.The group also concluded that more extensive
studies were needed to fully evaluatethe potential of marijuanaas
supportivecare for cancerpatients.Suggestedareasof study were a
smoke-freedelivery system of marijuana'sactive ingredientTHC,
effects of marijuanaon the lungs and immunesystem, and the dangerous byproductsof smokedmarijuana(24).
On March I7, I999, a panelof I I independentexpertsat the Institute of Medicine released the most comprehensiveanalysis of the
medicaluses of marijuanato date. This two-yearstudy was ordered
and financedby the White House Office of National Drug Control
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Policy.The reportcautionedthat the benefitsof smokingmarijuana
were limitedbecausethe smoke in itself is so toxic. Yet at the same
time, the panelof expertsrecommendedthat marijuanabe given,on
a short-termbasis underclose supervision,to patientswho did not
respondto other therapies.The panel believedthat becauseof the
toxicity of the smoke, the true benefitsof marijuanawould only be
realized when alternative methods like capsules, patches and
bronchialinhalerswere developedto deliver more active components,calledcannabinoids,withoutthe harmfuleffectsof the smoke.
The researchersrecommendedthat the governmentshouldtake the
lead in developingmoreeffectivecannabinoiddrugs.However,realizing this would take yearsto develop,the panel recommendedthat
peoplewho did not respondto othertherapybe permittedto smoke
the
marijuanain the interim.In additionto these recommendations,
reportalso containedsome new findingsabout the effects of marijuanaon variousmedicalconditions.In additionto the usefulnessof
medicalmarijuanain treatingpain, nausea,and weight loss associated with AIDS, the report concludedthat despite popular belief,
marijuanawas not useful in treating glaucoma. Marijuanadoes
reduce some eye pressureassociatedwith glaucoma;however,the
effectswere short-term,and did not outweighthe long-termhazards
of using the drug. In addition,the study found therewas little evidencethat marijuanahad any effecton movementdisorderssuch as
Parkinson'sdisease of Huntington'sdisease, but it was effectivein
combating the muscle spasms associatedwith multiple schlerosis
(25).
As a resultof thismedicalresearch,sevenstateshaveapprovedballot initiativesmakingmarijuanalegal for medicalpurposes(z6). In
the NovemberI996 elections,ArizonavoterspassedPropositionzoo
by a vote of 65% to 35 % and CalifornianspassedPropositionzi 5
by a vote of 56% to 44%. Theseendorsementsof the medicinaluse
of marijuanaforcedthe Federalgovernmentto respondpublicly.The
Arizonameasuremandatedthat the prescribingphysicianmustdocument that scientificresearchexists which supportsthe use of a
ScheduleI substancefor this purpose,must receivewrittenconsent
from the patient, and must obtain the writtenopinion of a second
physicianthat the prescriptionis appropriate.The majorconcernof
the Arizonapropositionwas that it allowed physiciansto prescribe
any ScheduleI drug.To rectifythis, the Arizonalegislaturein April
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I997
amended the law to apply only to FDA-approved drugs (27).
The California measure, entitled the Compassionate Use Act of I996,
amended the Health and Safety Code "to allow a patient or primary
caregiver (person who has consistently assumed responsibility for the
housing, health, or safety of the patient) to grow or possess marijuana for medical use when the drug is recommended by a physician
who has determined that the patient's health would benefit from its
use in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief. The physician's recommendation may be oral
or written. No prescription or other record keeping is required" (z8).
The problem is that physicians are fearful of writing prescriptions
because the Federal government has threatened to prosecute them.
Attorney General Janet Reno announced that physicians who complied with the California law would be new targets of Federal law
enforcement, and threatened physicians with loss of their registrations with the DEA and with exclusion from participation in
Medicare and Medicaid (29). In April 1997, Judge Fern Smith of the
U.S. District Court granted a preliminary injunction prohibiting the
DEA from carrying out its threats against California physicians and
encouraged the litigants to try to work out a reasonable settlement.
The settlement allowed physicians to discuss the option of medical
marijuana as part of the First Amendment protection of physicianpatient communication, but physicians could not assist in obtaining
the illegal substance for the patient (30). In addition, the Federal government has moved to shut down the Cannabis Buyer's Clubs in California that were providing and distributing the standardized marijuana grown without any contaminants or pesticides to individuals
with a medical need for the drug. Because marijuana remains a Schedule I drug, there is no regulated pharmacy system for marijuana; thus
there is no control on its purity or strength. The result is that those
suffering from AIDS, cancer, MS, etc., are being forced either to seek
out black-market marijuana which contains various contaminants or
to rely on other medications that have proven to be ineffective. This
is one of the major arguments for seeking a change in classification of
marijuana to a Schedule II drug so that it could be prescribed and
obtained through controlled and regulated channels. The fear of the
Federal government is that reclassifying marijuana to a Schedule II
drug will open the door to the slippery slope that could lead to the
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legalizationof marijuanaandsendthe wrongmessageto ourchildren
about drugs.This fear,while havingno scientificbasis,is real to the
people who feel it. But from an ethical point of view, is not the
demonstratedreliefthat medicalmarijuanacan provideto those sufferingfromvariousillnessesthe greatergood?
ETHICAL
ANALYSIS
Society,in general,has alwaysrecognizedthat in our complexworld
thereis the possibilitythat we may be facedwith a situationthat has
two consequences-one good and the other evil. The time-honored
ethicalprinciplethat has beenappliedto thesesituationsis calledthe
principleof double effect. As the name itself implies, the human
action has two distincteffects. One effect is the intendedgood; the
other is the unintendedevil. As an ethical principle,it was never
intendedto be an inflexiblerule or a mathematicalformula, but
ratherit is to be usedas an efficientguideto prudentmoraljudgment
in solving difficultmoral dilemmas(3 i). The principleof double
effect specifiesfour conditionswhich must be fulfilledfor an action
with both a good and an evil effectto be ethicallyjustified:
i) The action, consideredby itself and independentlyof its
effects,mustnot be morallyevil.Theobjectof the actionmust
be good or indifferent.
z) The evil effectmust not be the meansof producingthe good
effect.
3) The evil effectis sincerelynot intended,but merelytolerated.
4) There must be a proportionatereason for performingthe
action,in spiteof the evil consequences.(3z)
The principleof doubleeffectis applicableto the issue of whether
it is ethicalfor a physicianto prescribemarijuanafor medicalreasons
becauseit has two effects, one good and the other evil. The good
effect is that smokedmarijuanais more effectivethan conventional
therapiesin helpingpatientswithstandthe effectsof accepted,traditionaltreatmentswhichcan bringabouta cureor the ameliorationof
their condition. The evil effect is that marijuanasmoke has toxic
effectsand as a ScheduleI illegaldrugit has beenarguedit couldlead
to more seriousdrug abuse and send a wrong messagethat illegal
drug use is safe and even condoned.To determineif it is ethicalfor
physiciansto prescribemedicalmarijuanafor patientsas a medical
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therapy,this issue will be examinedin light of the four conditionsof
the principleof double effect.
The firstconditionallows for the medicaluse of marijuanabecause
the object of the action, in and of itself, is good. The moral object is
the precisegood that is freelywilled in this action.The moralgood of
this action is to help treatpain, nausea,severeweight loss associated
with AIDS, and to combat muscle spasms associatedwith multiple
sclerosis,that cannot be treatedadequatelyby traditionalmedicines.
The immediategoal is not to endorse,encourageor promote illegal
drug use. Rather,the directgoal is to relievepatientsof their unnecessary pain and suffering (33). The second condition permits the
medical use of marijuanabecause the good effect of relievingpain
and sufferingis not producedby means of the evil effect. The two
effectshappensimultaneously.The thirdconditionis met becausethe
direct intention of medical marijuanais to give patients suffering
fromlife-threateningillnessesrelieffromthe effectsof acceptedtreatments that could cure their medical condition. Recent studies have
shown that medical marijuanais more effectivein controllingpain
and nausea from chemotherapytreatments, and in boosting the
appetitesof AIDSpatientsso as to combat wasting, than any of the
traditionalFDA-approvedmedications.To denya physicianthe right
to discuss,recommend,andprescribemarijuanato patientsis a direct
violation of the physician-patientrelationship.To make an informed
decisionabout their treatment,patientshave the rightto expect full
disclosureand discussionof all availabletreatmentoptionsfromtheir
physicians.Failureto do this violates the patient'sright of informed
consent (3 4).
The hypothesizedforeseenbut unintendedconsequencesof legalizing medicalmarijuanaare twofold. First,the smoke from marijuana
is highlytoxic and can cause lung damage.The intentionof smoked
marijuanais not to cause more health problemsbut to remedythe
effects of existing treatments.Second,some membersof the Clinton
Administrationbelievethat legalizingmedicalmarijuanamay lead to
usage of harderdrugs,and may be seen as condoningand encouraging recreationaldrug use. Nevertheless,this has not been proven to
be true. The March I7, I999 report by the Instituteof Medicine
found no evidencethat the medicaluse of marijuanawould increase
illicit use in the generalpopulation,nor was it a "gatewaydrug"that
would lead to the use of harderdrugs like cocaine or heroin (35).
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According to bioethicist William Stempsey, M.D., the government's
belief that "the availability of drugs on the street is a function of the
availability of prescription drugs is wrong. Morphine and other narcotics are available at present only by prescription, and there is no
widespread abuse of these drugs"(36). In addition, a I994 survey in
the New YorkTimes found that I7% of current marijuanausers said
they had tried cocaine, and only o.z% of those who had not used marijuana had tried cocaine. Ethicist George Annas points out that there
are two ways to interpretthis study. One way is to conclude that those
who smoke marijuana are 85 times as likely as others to try cocaine;
another way is that 83% of pot smokers, or five out of six, never try
cocaine (37). If GeneralBarryMcCaffrey,the Director of the Office of
National Drug Control Policy, is worried that the legalization of medical marijuana will send the wrong message to our children about
drugs, then Boston Globe columnist Ellen Goodman asks a good
question: "What is the infamous signal being sent to [children] . . . if
you hurry up and get cancer,you, too, can get high?" (38). Will some
people view the legalization of medical marijuana as the condoning
and encouraging of marijuanafor recreationaldrug use? The answer
is "yes." But this is not the direct intention of legalizing medical marijuana. The direct intention is to relieve pain and sufferingthat cannot
be relieved by presently approved medications.This misinterpretation
of the legalization of medical marijuanacan be correctedthrough public education. Finally,the argumentfor the ethical justificationof marijuana for medical use by the principle of double effect focuses on
whether there is a proportionately grave reason for allowing the foreseen but unintended possible consequences. Proportionate reason is
the linchpin that holds this complex moral principle together.
Proportionate reason refers to a specific value and its relation to all
elements (including premoral evils) in the action (39). The specific
value in legalizing medical marijuana is to relieve pain and suffering
associated with treatment for life-threateningillnesses. The premoral
evil (33), which can come about by trying to achieve this value, is the
foreseen but unintended possibility of the potential harmful effects of
the smoke and the possibility that some may view this as condoning
and even encouraging illegal drug use. The ethical question is: does
the value of relieving pain and suffering outweigh the premoral evil
of the potential harmful effects of the smoke and the possibility of
scandal? To determine if a proper relationship exists between the
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specific value and the other elements of the act, ethicist Richard
McCormickproposesthree criteriafor the establishmentof proportionate reason:
The means used will not cause more harmthan necessaryto
achievethe value.
z) No less harmfulway exists to protectthe value.
3) The meansusedto achievethe valuewill not undermineit. (40)
i)
The applicationof McCormick'scriteriato the legalizationof medical marijuanasupportsthe argumentthat there is a proportionate
reasonfor allowingphysiciansto prescribemarijuana.First,the most
comprehensivescientificanalysisto date by the Instituteof Medicine
cautioned that the benefits of smoking marijuana were limited
becausethe smokeitselfis toxic, but recommendedthat it be givenon
a short-termbasis, under close supervision,to patientswho do not
respondto other therapies.The possible damageto an individual's
lungsis a legitimatehealthconcern;however,the patientswho would
benefitfrom the smokedmarijuanaare sufferingfrom cancer,AIDS,
MS, etc. Many of these conditions are terminaland the treatments
they are undergoingalso have toxic effects-chemotherapy, radiation, the AIDScocktail,etc. The point is that the benefitof the treatments outweighsthe burdens.The focus should be on encouraging
the Federalgovernmentto direct its researchresourcestoward the
developmentof alternativemethodsof deliveringcannabinoidsin the
form of patches,capsulesand bronchialinhalers.In this way the toxicity could be eliminated. The Institute of Medicine study also
reportedthat there was no evidencethat prescribingmedical marijuana would increaseillicit drug use or that it is a "gatewaydrug"
that promptspatientsto use harderdrugslike cocaineor heroin.Second, at present,there does not seem to be an alternativemedication
that is as effectiveas smokedmarijuana.Thousandsof patientswho
have smoked marijuanaillegallyfor medicalpurposeshave attested
to its effectiveness.Those patientswho were and are involvedin the
government-sponsoredcompassionatecare program also attest to
smokedmarijuana'seffectiveness.In addition,scientificstudieshave
shown that Marinol? is less effective, more difficultfor nauseous
patients to consume, and more expensive than smoked marijuana.
There are also other approvedantiemeticdrugs or combinationsof
these drugswhich have been shown to be effectivein relievingpain
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and suffering in some cancer patients (4I). However, for others these
medicationshave provenineffective.To date, the only therapythat
relieves their nausea and vomiting is smoking marijuana.Third,
smoking marijuanafor medical reasons does not underminethe
value,which is the reliefof pain and suffering.Many of the patients
who would use medicalmarijuanaaresufferingfromterminalconditions and are undergoingtherapiesthat have serious side-effects.
Sincethis seemsto be the only therapyto date that relievesthe pain
and sufferingof thesepatients,one can argueconvincinglythat it is a
concernthat legalizmedicalnecessity.The ClintonAdministration's
ing medicalmarijuanacould lead to the possibilityof the slippery
slope in regardsto druguse is a real fear.But, this has not occurred
with otherprescriptionpsychoactivedrugs(e.g., morphine,codeine,
cocaine,etc.) andthereis no evidenceit would occurwith marijuana.
Therefore,it is ethicallyjustifiedunderthe principleof doubleeffect
for the Federalgovernmentto legalizemarijuanafor patientswho do
not respondto traditionaltherapies.Seriouslyill patientshave the
rightto effectivetherapies.To deny them accessto such therapiesis
to denythemthe dignityand respectall personsdeserve.The greater
good is promotedin spiteof the potentialevil consequences.
CONCLUSION
After reviewingthe pertinentscientificdata it is clear that there is
morethan sufficientevidenceto warrantthe ClintonAdministration
to authorizethe DEAto reclassifymarijuanaas a ScheduleII drugso
that it can be used for medicalpurposes.As a ScheduleII drug,the
governmentwill be able to properlyregulatethe use of marijuanaso
thatpharmacies,in conjunctionwith physicians,can providepatients
with unadulteratedand standardizedforms of marijuana.Unless
marijuanais regulatedby the propermedical and pharmaceutical
authorities,thereis the possibilitythat those seekingrelieffrompain
and sufferingwill be forced to resort to black-marketmarijuana,
which could lead to legal prosecution and could jeopardize their
health and safety. The philosophy guiding this position is one of harm
reduction.With the appropriatelegal and medicalcontrolsa proper
strategycould be formulatedto identifyand reducehealthhazards
facing those individualswho use smoked marijuana(42). To deny
physiciansthe right to prescribeto their patients a therapy that
relationrelievespainandsufferingis to violatethe physician-patient
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ship. Patientshave the right to expect full disclosureof all possible
treatment options from their physicians, so that they can make
informedmedical decisions regardingtheir health. Physicianshave
the medicalresponsibilityto provideadequaterelief from both pain
and sufferingin orderto give their patientsan acceptablequalityof
life. Failureto offer an availabletherapythat has provento be effective would violate the basic ethical principle of nonmaleficence,
which prohibitsthe inflictionof harm,injury,or death, and is related
to the maximprimum non nocere ("aboveall, or first,do no harm"),
which is widely used to describethe duties of physicians.To allow a
patientto sufferneedlessly,when this sufferingcan be relieved,is to
do direct harm to the patient. Scientificdata has shown that the
benefitsof medical marijuanafar outweigh the burdens.However,
there is a need for continuedresearchboth in regardsto maximizing
marijuana'stherapeuticeffectsand minimizingits adverseeffects.
The Clinton Administrationmade a significantstep in the right
directionwhenit announcedon May zi, I999, that it wouldease
restrictionson medical marijuanaresearchby selling governmentgrown marijuanato researchersand allowing them to secure their
own researchfunding.In the past, only a handfulof researcherswere
investigatingthe benefitsof marijuanabecausethey had to show not
only that theirresearchwas of high quality,but also that it was more
important than competing applications for National Institutes of
Health funding.Now, accordingto ChuckBlanchard,chief counsel
for the WhiteHouse Officeof National DrugControlPolicy,"aslong
as you are willing to show that it is high-qualityresearchand also
provideyourown funding,you can haveaccessto medicalmarijuana"
(43). This new developmentwill not only lead to furtherassessment
of the effectivenessof medicalmarijuanaand developmentof purified
forms of cannabinoids,but could lead to the developmentof new
deliverysystemsthat would allow patientsto benefitfrom the active
ingredientsof marijuanawithout sufferingthe toxic side-effects.
The Federalgovernment'sannouncementthat it was easingrestrictions for studieson medicalmarijuanawill have long-termbeneficial
effects.However,it will do little to help those sufferingat the present
time. The regulationsissuedsaid, "thegovernmentdid not intendto
approvesingle-patientrequestsfor marijuana,becausethey did not
producescientificinformation"(44). GeneralMcCaffrey,afterreviewing the reportissuedby the Instituteof Medicinethat his agencyhad
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commissioned,stated that the analysiswas a superbpiece of work
underadvisement.But
and that he would take the recommendations
he also went on to say that "therewas enormousconfusionin law
enforcementabout how to handle this issue and we've got people
with mischievousagendasat work" (45). This confusioncould be
eliminatedand safeguardsput in placewith the reclassifyingof marijuanato a ScheduleII drug. To legalizemedicalmarijuanawill go
policy of zero tolerancetoward
againstthe ClintonAdministration's
illicit drugs,but the benefitsit will providefor those sufferingfrom
devastatingdiseaseswould surelyoutweighthe possibleburdens.
The quality of life of those sufferingfrom cancer,AIDSwasting
syndrome,multiplesclerosis,etc. should concernall of us, but particularlythe Federalgovernmentand the medicalprofession.Recent
studieshaveshownthat one reasonpublicopinionhas becomemore
suicideis becausemedicalprofessionals
tolerantof physician-assisted
have not adequatelymanagedthe pain and sufferingof those with
terminalillnesses.Medicalmarijuanahas beenprovento be another
valuabletherapyin the war againstterminalillnesses;however,until
the Federalgovernmentrecognizesthis as a reality,many terminal
patients will continue to suffer needlessly.The result will be an
suicideis the
increasein the public'smindsetthat physician-assisted
only option for those who want to die with dignityand respect.The
fight againstdrug abuseis importantbecausemany lives are lost to
drug addiction.But the fight againstthe effects of devastatingdiseases impactsa substantiallylargernumberof Americans.Medical
marijuanamay be justthe weaponphysiciansneedto meetthe challenge of those people'spain and suffering.It appearsthe Clinton
Administrationhas placedpoliticsand appearancesaheadof science
andhealthcareconcerns(46). Theappearanceof scandalandthe fear
of beingaccusedby a RepublicanCongressof beingweak on drugs
must not stand in the way of provenscientificevidence.The quality
of human lives hangs in the balance.If the dignity and respectof
everyperson'slife is a priorityfor this Administration,then it is time
to standup for thosewho arethe mostvulnerable.Thismeansreclassifying medicalmarijuanaas a ScheduleII drug, becausefor some
patientsit is trulya medicalnecessity.
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**Postscript: On SeptemberI3, I999, the United States Court of
Appealsfor the Ninth CircuitorderedJudge CharlesBreyerof FederalDistrictCourtto reviewa I998 decisionthat closedthe Oakland
Cannabis Buyers Cooperative for violating antidrug laws. The
Appeals Court said that JudgeBreyerhad not given enough considerationto the possibilitythat marijuanawas an indispensabletreatment for people served by the club-including patients with AIDS
and cancer-and thus potentiallyprotectedas a "medicalnecessity."
The AppealsCourtdid not vacatethe injunctionagainstthe Oakland
club, but it did suggest that Judge Breyeramend the injunctionto
allow marijuanaclubs to resumeservicefor patientswho can prove
that cannabisis a medicalnecessity(47).
NOTES AND REFERENCES
i.
Alternativemedical therapiesare functionallydefinedas interventions
neithertaughtwidely in U.S. medicalschools nor generallyavailablein
U.S. hospitals. For a more detailed analysis, see David M. Eisenberg,
Roger B. Davis, SusanL. Ettneret al. "TrendsIn AlternativeMedicine
Use In The United States, I990-I997,"
Journal of the American Medical
Association z8o (November II, I998): I569.
z. The reasons for this popularity are a rise in prevalence of chronic disease,
an increase in public access to worldwide health information, reduced
tolerance for paternalism, an increased sense of entitlement to a quality
of life, declining faith that scientific breakthroughs will have relevance
for the personal treatment of disease, and an increased interest in spiritualism. For a more detailed analysis, see Wayne B. Jonas, M.D. "Alternative Medicine-Learning From The Past, Examining The Present,
Advancing To The Future," Journal of the American Medical Association
z8o (November ii, I998): i6i6. See also, P. Starr. The Social Transformation of American Medicine. San Francisco, CA: Harper Collins Publishers, i98z: 5I4; A. Furnham and J. Foley. "The Attitudes, Behaviors,
And Beliefs Of Patients Of Conventional vs. Complementary (Alternative) Medicine," Journal of Clinical Psychology so (I994): 458-69; and
J. A. Astin, "Why Patients Use Alternative Medicine: Results Of A
National Study," Journal of the American Medical Association 279
(I998): I548-53.
3. George J. Annas, "Reefer Madness-The Federal Response To California's Medical-Marijuana Law," The New England Journal of Medicine
337 (August 7, I997): 439.
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4. Ibid., 438. The following findings must be made to place a drug on
Schedule I: "(A) The drug .
.
. has a high potential for abuse; (B) The
drug ... has no currentlyaccepted medical use in treatment in the United
States;and (C) there is a lack of accepted safety for use of the drug under
medical supervision." Part A for a Schedule II drug is identical; the other
requirements are "(B) The drug .
.
. has currently accepted medical use
in the United States ... and (C) Abuse of the drug ... may lead to severe
psychological and physical dependence." Ibid.
5. William E. Stempsey, M.D. "The Battle For Medical Marijuana In The
War On Drugs," America 23 (April i i, i998): I4.
6. Sheryl Gay Stolberg, "For A Very Few Patients, U.S. Provides Free Marijuana," The New YorkTimes, I9 March 1999, A-Io.
7. Sheryl Gay Stolberg. "Government Study On Marijuana Sees Medical
Benefits," The New YorkTimes, i 8 March I 999: A- i. See also, Janet E.
Joy, Stanley J. Watson, Jr., and John A. Benson. Marijuana And Medicine: Assessing The Science Base (Washington, D.C.: Institute of Medicine, March I999): 99.
8.Joy et al., 3.
9. Lester Grinspoon, M.D., and James B. Bakalar.Marijuana, The Forbidden Medicine. New Haven, CT: Yale University Press, I993: I-2.
io. There has been considerable research done in understanding how
cannabinoids exert their cellular effects. "Two kinds of cannabinoid
receptors have been identified: CB-i and CB-z. CB-i receptors are present widely in the brain. An endogenous ligand for this receptor system is
the arachidonic acid derivative, anandamide, and there is some evidence
that the cannabinoid-receptor system is part of the natural pain control
system distinct from the endogenous opioid system. Small clinical studies indicate that THC has some analgesic activity in patients with cancer
pain, but there is a narrow therapeutic window between doses that produce useful analgesia and those that produce unacceptable central nervous system effects. Defining the naturally occurringcannabinoid-receptor system is good reason to pursue researchinto selective analogues that
may enhance therapeutic effects and minimize adverse effects." See Jane
B. Marmor, M.D. "Medical Marijuana," WesternJournal of Medicine
i68 (I998): 542. See also, W. A. Devane, L. Hanus, A. Breuer,et al. "Isolation And Structure Of A Brain Constituent That Binds To The
Cannabinoid Receptor," Science 258 (I992): I946-49.
i i. United States Department of Health and Human Services, "Investigating
Possible Medical Uses Of Marijuana," March 25, I999: I-2.
I2. John M. McPartland and Patty Pruitt, "Medical Marijuana And Its Use
By The Immunocompromised," Alternative Therapies 3 (May I997):
39. It should be noted that the DEA has rejected proposed protocols
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accepted by the FDA. "The clinical trial devised by D. I. Abrams et al.,
has been approved by the FDA (as well as the California Research Advisory Panel, the institutional review board of the University of California,
and the scientific advisory board of the San Francisco Community Consortium). Unfortunately, the protocol was rejected by the DEA and the
National Institute of Drug Abuse. Political disingenuity involved in this
rejection has frustrated members of Congress" (Ibid., 39-40). Five years
later, Dr. Abrams of the University of California at San Francisco finally
obtained approval and a $978,000 National Institutes of Health grant.
"Even then, Dr. Abrams said he had to mask his true research interest.
Although he wanted to examine the effects of marijuana on the weight
loss associated with AIDS, he pitched the study as one that would look
at potentially toxic interactions between marijuana and standard AIDS
medications. 'We designed a study that would appeal to the group of
people funding the grant."' Sheryl Gay Stolberg. "Restrictions Ease For
Studies On Marijuana As Medicine," New York Times, zz May I999:
A-I I.
I 3. United States Department of Health and Human Services, z.
I4. Stolberg. "Restrictions Ease For Studies On Marijuana As Medicine":
A- II.
I 5. Peter Gwynne. "Medical Marijuana Debate Moving Towards Closure,"
The Scientist 7 (March I8, I997): I.
i6. Marmor: 54I. See also, I. B. Adams, and B. R. Martin. "Cannabis: Pharmacology And Toxicology In Animals And Humans," Addiction 9I
(I996):
I585-I6I4.
Annas: 438. See also, R. E. Doblin and M. A. Kleiman, "Marijuana As
Antiemetic Medicine: A Survey Of Oncologists' Experiences And Attitudes," Journal of Clinical Oncology 9 (i 99 i): I 3 I4-I9.
I8. Grinspoon and Bakalar: I50.
I9. For a more detailed analysis, see, G. S. Rachelfsky and G. Opedz, "Normal Lymphocyte Function In The Presence Of Delta-g-THC," Clinical
Pharmacology Therapy (I977): 44-46; G. A. Cabral and K. FisherStenger, "Inhibition Of Macrophage Inducible Protein Expression By
Delta-g-THC," Life Science 54 (I994): I83 I-44; and W. Zhu, C. Newton, Y. Daaka, et al. "Delta-g-tetrahydrocannabinol Enhances The
Secretion On Interleukin i From Edotoxin Stimulated Macrophages,"
Journal of Pharmacological Experimental Therapy 270 (I994):
17.
I334-39.
zo. McPartland: 4I.
zi. Ibid., 4I-42.
22. Ibid., 42-43.
23. Stolberg. "For A Very Few Patients, U.S. Provides Free Marijuana":A-iO.
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National Institute on Drug Abuse, Report to the Director. Bethesda,
MD: National Institutes of Health, Workshop on the Medical Utility of
Marijuana, I997.
25. Stolberg. "Government Study Of Marijuana Sees Medical Benefits":Ai, A-i9.
z6. It should be noted that in November I998, the District of Columbia had
a ballot referendumwhich contained a proposal to legalize medical marijuana, but Congress intervened and prevented the vote from being
counted. Stolberg. "Government Study Of Marijuana Sees Medical
Benefits":A-i9.
27. Nancy T. Lantis. "California,Arizona Laws Permit Medical Use of Marijuana," AmericanJournal of Health System Pharmacy 54 (January 1 5,
24.
I997):
Iz6.
z8. Ibid.
z9. Attorney General Reno stated, "Federallaw still applies ... U.S. attorneys in both states will continue to review cases for prosecution and
DEA officials will review cases as they have to determine whether to
revoke the registration of any physician who recommends or prescribes
so-called Schedule I controlled substances. We will not turn a blind eye
toward our responsibility to enforce federal law and to preserve the
integrity of medical and scientific process to determine if drugs have
medical value before allowing them to be used," Annas: 436-37.
30. Ibid., 347.
3 I. Joseph Mangan, S.J. "An Historical Analysis Of The Principle Of Double Effect," Theological Studies io (March, 1949): 41.
3 2. Gerald Kelly, S.J. Medico-Moral Problems. St. Louis, MO.: The Catholic
Health Association of the United States and Canada, 1958: 13-14.
33. It should be noted that some might argue that smoking marijuana by
itself, independently of its effects, is morally evil. This implies that certain actions in themselves are intrinsically evil and to do them is always
morally wrong. However, when one enters the realm of a "moral"
action, one is speaking of an action qualified by intention and circumstances. So unqualified actions can only be called "premoral actions."
For a more detailed analysis, see Richard M. Gula. Reason Informed By
Faith: Foundations Of Catholic Morality. New York: Paulist Press,
Premoral evil refers to the lack of perfection in anything
I989: 270-7I.
whatsoever. As pertaining to human actions, it is that aspect that we
experience as regrettable, harmful, or detrimental to the full actualization of the well-being of persons and of their social relationships. For a
more detailed description, see Louis Janssens. "Ontic Evil And Moral
Evil," in Readings In Moral Theology, No. I: Moral Norms And
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Catholic Tradition, ed. C. F Curran and R. A. McCormick. Ramsey,
N.J.: Paulist Press, I979: 6o.
34. Annas: 437.
3 5. Stolberg: "Government Study Of Marijuana Sees Medical Benefits":A-i.
36. Stempsey: i6.
37. Annas: 438. See also, Christopher Wren. "Phantom Numbers Haunt
The War On Drugs," New York Times, zo April I997: E-4.
38. Annas: 438.
39. James J. Walter. "Proportionate Reason And Its Three Levels Of Inquiry:
Structuring The Ongoing Debate," Louvain Studies io (Spring, I984):
32.
40. McCormick's criteria for proportionate reason first appeared in Richard
McCormick. Ambiguity In Moral Choice. Milwaukee, WI: Marquette
University Press, I973. He later reworked the criteria in response to criticism. His revised criteria can be found in Doing Evil To Achieve Good,
eds. Richard McCormick and Paul Ramsey. Chicago, IL: Loyola University Press, I978.
4I. Examples include drugs called serotonin antagonists which include
ondansetron (Zofran) and granisetron (Kytril), used alone or combined
with dexamethasone (a steroid hormone); metoclopramide (Reglan)
combined with diphenhydramine and dexamethasone; high doses of
methylprednisolone (a steroid hormone) combined with droperidol
(Inapsine); and prochlorperazine (Compazine). National Institute on
Drug Abuse: z.
42. McPartland & Pruitt: 44.
43. Stolberg: "Restrictions Ease For Studies On Marijuana As Medicine":
A-i I.
44. Ibid.
45. Stolberg: "Government Study Of Marijuana Sees Medical Benefits": AI9.
46. Ethan Nadelmann, director of the Lindesmith Center, which backed initiatives in California and Arizona to make marijuana legal for medical
use, believes the easing of government restrictions on the study of medical marijuana has exposed the government's intentions over the past zo
years. He states, "It's an implicit acknowledgment that the Government
has blocked research into medical marijuana for explicitly political reasons for the last two decades." Ibid.
47. Reuters. "Court Ruling A Boost For Marijuana Clubs." New York
Times, I4 September I999: A-i9.
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ABSTRACT
Marijuana is listed by the Drug Enforcement Agency (DEA) as an illegal
Schedule I drug which has no currently accepted medical use. However, on
March I7,
I999,
ii
independentscientistsappointedby the Instituteof
Medicine reported that medical marijuanawas effective in controlling some
forms of pain, alleviating nausea and vomiting due to chemotherapy, treating wasting due to AIDS, and combating muscle spasms associated with
multiple sclerosis. There was also no evidence that using marijuana would
increase illicit drug use or that it was a "gateway" drug. Despite this evidence the DEA refuses to reclassify marijuana as a Schedule II drug, which
would allow physicians to prescribe unadulterated and standardized forms
of marijuana. After reviewing the pertinent scientific data and applying the
principle of double effect, there is a proportionate reason for allowing physicians to prescribe marijuana. Seriously ill patients have the right to effective
therapies. To deny patients access to such a therapy is to deny them dignity
and respect as persons.