Is the federal government trying to play doctor?
Is the federal government trying to play doctor?
State marijuana initiatives focus on pain control
While marijuana’s medicinal use has been debated in hospital corridors for years, the California ballot earlier this year approving its prescriptive use and President Bill Clinton’s high-profile rejection of that vote have propelled the issue to the national center stage.
Caught in a deafening volley of accusations of overblown political correctness and violations of patient rights and physician autonomy, bioethics professionals are trying to make sense of the highly charged ethical debate over use of this and other illegal drugs to manage pain.
As more voices in the medical community weigh in, the debate shows no signs of quieting. In January, New England Journal of Medicine editor Jerome P. Kassirer, MD, wrote: "I believe that a federal policy that prohibits physicians from alleviating suffering by prescribing marijuana for seriously ill patients is misguided, heavy-handed, and inhumane."1
Kassirer urges the federal government to rescind its prohibition against medical use of marijuana, change the drug’s status from Schedule I to Schedule II, and "regulate it accordingly." His editorial accused the government of using "reflexive ideology and political correctness" rather than compassion for the terminally ill in making policy decisions.
Clinical ethics professionals interviewed by Medical Ethics Advisor say the real issue is neither politics nor compassion, but rather beneficence. "The larger question may be whether the government can justify regulation of any substance that a physician thinks may benefit a patient," says Sandra H. Johnson, JD, LLM, former president of the Boston-based American Society of Law, Medicine, and Ethics (ASLME).
Marijuana may cloud a bigger issue
Johnson says the marijuana debate may dovetail with physician-assisted suicide arguments about patient autonomy and professional judgment. But she worries that the question of access to an illegal drug such as marijuana may detract from the much larger question of access to legal drugs for pain management, she says.
As the co-chairperson of last fall’s national conference on legal constraints on effective pain relief, Johnson says, "We can’t put all of these substances into one pile and assume that they are all the same." Opiates such as heroine and morphine can be used legally in some circumstances to alleviate cancer pain.
The ASLME conference on pain management found that many physicians are reticent about prescribing these medicines for pain management because of the stigma of addiction attached to them. Yet there are many differences between the proposed use of marijuana and the current legal use of opiates.
"There is an entire body of knowledge on the usefulness and effects of taking these other drugs but we have no empirical data on marijuana," says Johnson. Legally controlled opiates also are strictly regulated, but the California initiative does not specify how the delivery of the drug will be regulated.
Many physicians say they could not support legalization of marijuana or any other drug until they know whether it is safe and works best to alleviate symptoms of terminal diseases such as cancer and AIDS.
"Right now there is a great deal of rhetoric about efficacy, but we have no idea whether marijuana would be safe and whether it is more effective than other drugs now used," says Daniel Icenogle, MD, JD, a Madison, WI, physician in private practice and a consultant on ethics and health law.
"It seems the problem is that we don’t know what the science of this drug is, making its use currently unjustified," echoes Jon Merz, JD, PhD, a faculty member of the Center for Bioethics at the University of Pennsylvania in Philadelphia. "If marijuana truly is an effective treatment for some patients, it raises ethical concerns about why the drug has never been studied for medical use."
One physician argues that even if marijuana is found to be helpful, legalization would present a "dual effect" ethical dilemma. "Many of the proponents for making marijuana legal are people who simply want to get high," asserts Geoffrey E. Moore, MD, assistant professor of medicine in preventive cardiology and a member of the ethics committee at the University of Pittsburgh Medical Center.
Science first
The American Medical Association (AMA) and the California Medical Association late last year issued statements opposing the California initiative and a similar Arizona measure based on lack of scientific evidence that the drug is medically beneficial.
"We urge federal funding of research to determine the validity of marijuana as an effective medical treatment," says AMA President Daniel H. Johnson, MD. "The AMA urges physicians to prescribe effective, legal medications available to compassionately treat disease and relieve pain."
The Chicago-based physicians’ group supports evaluation of the therapeutic uses of "non-inhaled preparations of cannabinoids (marijuana) through well-designed scientific studies" and argues that research is needed to determine the consequences of long-term marijuana use.
Physicians seeking to treat patients with marijuana argue that the federal government has refused to conduct research on its effectiveness.
A synthetic version of the drug (Marinol) is available in pill form and has proven effective for treating cancer patients with extreme nausea and vomiting and patients with AIDS-related wasting syndrome. Proponents of using smokable marijuana say that method offers better dose control and easier use for severe vomiting.
Another advocate for effective use of pain control views the marijuana debate as "an example of political correctness." Fenella Rouse, executive director of the Mayday Fund in New York City, cautions health care professionals "not to get caught up in an anti-drug hysteria." The philanthropic organization is dedicated to relieving pain and its consequences and sponsors educational programs on pain management.
Reference
1. Kassirer JP. Federal foolishness and marijuana. N Engl J Med 1997; 336:366.
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