Should Physicians “Prescribe” Cannabis?
An ethical analysis
Over the last decade, medical cannabis has moved from the fringe to the mainstream—at least in some states. Nearly 900,000 Americans were registered cannabis patients in 2017, which is more than a ten-fold increase since 2009. By the end of 2020, over two-thirds of states and the vast majority of Americans will live in a state with legal access to either medicinal or recreational marijuana. Despite the rapid changes in the legal status and evidence supporting the use of cannabis to treat a range of conditions, physicians and trainees remain ill-equipped to recognize and advise patients who may benefit medical cannabis. Meanwhile, pockets of opposition continue to perpetuate misinformation and historic canards about cannabis—that “pot” is a gateway drug, that it kills brain cells, or that it erodes intelligence, to name a few.
In a new paper published in the Journal of Medical Ethics, we argue that expanded access to medical cannabis has prompted an urgent need for physicians (and primary care doctors in particular) to develop competency to recommend and manage cannabis for appropriate patients. This requires normalizing cannabis and recognizing the significant associated risks involved. In large part, we build on well-established principles within bioethics, adapting them to the idiosyncratic history and status of cannabis in the U.S.
Few drugs share cannabis’s unique social and cultural position in the U.S. While cannabis was widely used for physical ailments as early as the 1850s, racially charged anti-drug policies marginalized it from the 1930s onward. Since then, it has become the most widely used illicit drug. Since the 1950s, marijuana gained a polarized status—either harmless or deadly, socially acceptable or morally inexcusable.
Both the anti-drug stigma of prohibitionists and blasé attitude of some legalization supporters have stifled reasonable discourse about the medical uses of cannabis. The current federal treatment of cannabis as a Schedule I drug—i.e., having no accepted medical use—conflicts with the medical literature. A comprehensive review by the National Academies of Science, Engineering, and Medicine on the medical uses and risks of cannabis concluded there is substantial evidence that cannabis is effective for treating chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis symptoms. Compared to existing treatments, cannabis often is a more cost-effective option as well. There is also moderate evidence that cannabis is effective for several other conditions, including sleep apnea.
Physicians should be willing to recommend cannabis for conditions with substantial or moderate evidence. Refraining from doing so due to stigma is indefensible. By the same token, a state’s decision to count a condition as medically qualifying should not be sufficient grounds for recommendation. Physicians should be wary advocating cannabis use for conditions with a limited evidence base, such as post-traumatic stress disorder, even if it is a legally qualifying condition.
Like any medication, cannabis presents certain risks. We raise concerns about the link between cannabis use and onset of serious mental illness and the risk of abuse among children and adolescents. Given the dose- and age-dependent manner of risk, prudence should be a guiding principle when managing cannabis use, and its use in pregnant women, people with histories of mental illness, children, and adolescents should be highly discouraged.
In the full paper, we go into greater detail about specific ethical and practical considerations to consider for medical marijuana patients. These include understanding the local context of medical cannabis, conservative management, different modalities of cannabis consumption (which are especially relevant given the potency of some cannabis products), shared decisionmaking, pathways for physician education given the peculiar status of medical marijuana in the U.S., and how to navigate the tension between what is ethically defensible and legally acceptable.
With two-thirds of the U.S. public supporting broader legalization, medical cannabis is here to stay. It is likely that many of the challenges and recommendations we make will evolve over time, especially if federal restrictions on medical cannabis research and use change. Ignoring cannabis is no longer an ethically defensible option for physicians. Patients will come to them with questions about medical cannabis. Physicians now have a duty to provide unbiased, informed advice and competent medication management.
Dominic Sisti, PhD is an Assistant Professor of Medical Ethics and Health Policy and an LDI Senior Fellow.