Medical justification for cannabis prescription in cancer treatment

Medical Marijuana

The question of whether and when to prescribe medical marijuana to patients suffering from debilitating and potentially terminal diseases like cancer is so complicated because it locates the potential conflict between medical ethics and the law in the patient-physician relationship. This relationship presents the core upon which any medical treatment program is built, and understanding what makes it acceptable to prescribe marijuana to cancer patients requires understanding the physician's responsibilities to the patient. Physicians are ethically required to do no harm to their patients, and as a potential treatment of the symptoms of cancer, marijuana presents an option where the potential harm seems minimal, even if the legal classification of marijuana presents it as a dangerous drug. Examining the potential benefits of prescribing marijuana to cancer patients demonstrates that its potential to ease pain, increase appetite, and improve the patient's psychological well-being outweighs any potential harm, and thus a physician would be ethically justified in prescribing marijuana.

Before examining the key reasons why it would be acceptable to prescribe marijuana to cancer patients, it will be useful to first consider the arguments against this practice in order to have a better idea as to the controversy. The most obvious argument against prescribing medical marijuana to a patient is the simple fact that in many areas, marijuana remains illegal. In the United States this situation is compounded by the fact that certain states have legalized marijuana for medicinal and in some cases recreational use even as the federal government continues to classify marijuana as a Schedule I drug, meaning that it is classified in the same way as "heroin, ecstasy, LSD, GHB, and peyote," and is even more restricted than "drugs like cocaine, codeine, Oxycontin, and methamphetamine," which are classified as Schedule II (Thomas, 2010, p. 2). As a result, a situation exists wherein states are saying that marijuana is an acceptable drug for both recreational and medicinal use while the federal government is claiming that it has no legitimate use, medicinal or otherwise.

Arguing against the federal prohibition on marijuana is not the direct goal of this study, but it is a kind of side-effect of arguing that it is acceptable for physicians to prescribe marijuana to cancer patients. However, going into the history of the legal regime regulating marijuana is well beyond the scope of this study, so it will have to suffice to say that the legal classification of marijuana as a Schedule I drug has more to do with politics than with science, a fact made clear by the observation that government panels since at least the 1970s have recommended that marijuana be legalized, only to be shot down by presidents and Congress members intent on making a name for themselves as tough on crime (Thomas, 2010, p. 2). Understanding that the current legal classification of marijuana is not based on research or science allows one to more comfortably propose that this is ultimately a case where ethics demands the breaking of law in the name of health and quality of life.

Because federal law ultimately supersedes state law in this area, there is an obvious legal reason not to prescribe medical marijuana, because there is always the looming possibility that the federal government will decide to crack down on medical marijuana patients and providers. While the federal government has not maintained a coherent or consistent approach to drug law enforcement as it relates to medical marijuana, there have been enough instances of federal agents raiding marijuana dispensaries for this to be a genuine concern (Thomas, 2010, p. 4). This could present a real problem for cancer patients, who are already suffering undue stress and anxiety and who likely do not need the added worry of their medicine suddenly being seized by the federal government.

While the legal opposition to medical marijuana presents a practical argument against prescribing marijuana to a cancer patient, this argument says nothing about ethics or the efficacy of the treatment, because in this instance the law is clearly not in line with the available evidence concerning marijuana, as indicated by the fact that marijuana is considered more dangerous and addictive than cocaine. Thus, while there may be a straightforward legal argument against prescribing marijuana to cancer patients, this legal argument should not be enough to dissuade physicians from prescribing marijuana in cases where it might do real good, because when the law and a patient's well-being come into conflict, the physicians responsibility should lie with the patient rather than the law. However, there is also a medical argument against prescribing marijuana that needs to be discussed, but as will be seen, this argument is no more convincing than the legal one.

Partially because of the legal classification of marijuana, in-depth studies as to its effectiveness have not been conducted (Martin, 2002, p. 5; Cohen, 2006, p. 20). Instead, most studies that have been allowed to proceed focus on the potential negative effects of marijuana use, and particularly the smoking of marijuana. In this regard, smoking marijuana has been found to be associated with increased risks of cancer, lung damage, and pregnancy problems, but this research is itself a kind of smokescreen, because pointing out the dangers of smoking marijuana has little bearing as to the efficacy of marijuana in general (Pies, 2010, p. 8). Smoking will of course lead to the issues discussed above, because aside from whatever positive benefits one gets from marijuana consumption, burning and inhaling organic material will always damage the human respiratory system.

In addition to the physical harm that can come from smoking marijuana, there are also psychoactive effects of the drug that must be taken into account. While there is evidence to suggest that marijuana "can induce acute transient psychotic symptoms or an acute psychosis in some individuals," this effect is extremely rare when considering the sheer number of people who ingest marijuana regularly (Pies, 2010, p. 8; Schwartz et. al., 2003, p. 549; Ogborne, 2000, p. 1685). In fact, while a physician or psychiatrist should be careful when prescribing marijuana, the risk of potential psychotic symptoms is far less than the negative side effects associated with many commonly prescribed drugs. Because the risk of these extreme side effects is so low, it is not enough to justify a complete ban on marijuana.

Aside from legal and medical arguments against the prescription of marijuana as a medicine, there is also a cultural argument concerned with the patient-physician relationship directly. Specifically, as medicinal marijuana becomes more popular, physicians that are willing to prescribe it are increasingly being seen as single-issue providers rather than professionals who should be directly engaged in their patient's health. This tendency has been seen in states like Colorado, where just 15 physicians have been responsible for registering 49% of the total number of medical marijuana patients in the state (Nussbaum et. al., 2011, p. 1364). While this is definitely a problem and physicians should avoid contributing to this dissolution of the patient-physician relationship where possible, it is not enough to warrant prohibiting the prescription of marijuana, because this problem is a result of the current legal regime rather than the drug. The idea of doctors becoming semi-legal drug dealers is a frightening one, but ultimately it is the law that has created this situation and not the drug.

Having examined the arguments against the prescription of marijuana from a legal, medical, and cultural standpoint and found them wanting, it is now possible to discuss the positive reasons why it would acceptable, and even recommendable, to prescribe marijuana to a cancer patient. Although there are a number of benefits marijuana could have for a cancer patient, the three that will be focuses on here are its ability to reduce pain, increase appetite, and elevate mood. While none of these effects actually treat the cancer directly, they are extremely important for maintaining the well-being of the patient and thus increasing their chances of living.

As mentioned above, there has not been substantial research into the effects of marijuana due to the federal governments strict control over the substance. However, there has at least been some research on the active ingredients in marijuana, and this research has indicated that the cannibinoids contained in marijuana are useful for "anxiety reduction, appetite stimulation, nausea reduction, and pain relief" (Pies, 2010, p. 8). On top of this relatively minimal scientific data on the potential positive effects of marijuana are millennia of anecdotal and cultural evidence indicating its utility as a medicine.

In fact, marijuana is one of the oldest known medicines, and "indeed, the world's oldest surviving medical text, the Chinese Shen-nung Pen-tshao Ching, recommends marijuana to reduce the pain of rheumatism and to address digestive disorders" (Thomas, 2010, p. 1). In addition to its use in China, India, and elsewhere, marijuana was actually considered a useful medicine in the United States for decades, up until it was deemed a dangerous drug by the federal government. In fact, "between 1840 and 1900, more than 100 articles extolling its therapeutic virtues appeared in American and European medical journals," and "American physicians routinely prescribed marijuana until the late 1930s" (Thomas, 2010, p. 1). Of course, anyone who recalls the popularity of cocaine and opium during the late nineteenth-century knows that the historical use of a drug is not, in itself, a testament to that drug's safety or efficacy, but this long legacy of marijuana use for medicinal purposes is important due to the relative absence of clinical studies.

The three important treatments that marijuana can offer cancer patients is pain relief, appetite stimulation, and mood elevation. The first treatment is perhaps the most obvious, because cancer and the radiation treatments that frequently accompany it are extremely painful and force patients to live in near-constant pain. Marijuana offers an important response to this pain because it has the ability to relieve pain without the serious side-effects that accompany other pain relievers, and particularly those based in barbiturates. Furthermore, marijuana has a much lower potential for addiction compared to painkillers like codeine or morphine, which is important for someone suffering from the chronic pain that accompanies cancer (Martin, 2002, p. 5). The treatment for catastrophic diseases like cancer often has to be as dramatic and extreme as the disease itself, so there is an urgent need for pain medications that do not carry dangerous side-effects, and in the case of cancer, marijuana can be one such medication.

In addition to chronic pain, the treatments that frequently accompany cancer often result in nausea and a loss of appetite, a problem that can exacerbate cancer's ill effects by preventing the patient from receiving important nutrients. Once again, marijuana can counter these symptoms by simultaneously reducing nausea while increasing the appetite, thus reducing the unpleasant side-effects of cancer treatments while helping the patient maintain a relatively normal nutritional schedule (Martin, 2002, p. 5). This use of marijuana is important because it directly counters the side effects that arise from cancer treatments, meaning that the patient can reap the benefit of preexisting treatments like radiation while being able to maintain a much higher quality of life than has been previously possible.

Lastly, marijuana has the potential to decrease anxiety and elevate a patient's mood, something that is extremely important when dealing with something like cancer. It is important to point out that this is not the same as saying that positive thinking and a "fighting spirit" will help someone survive cancer, because these ideas have not been substantiated by the data (Coyne & Tennen, 2010, p. 17; Harris et. al., 2007, p. 4). To say that marijuana has the potential to elevate a patient's mood cuts to something far more fundamental than the silly idea of a "triumph of character and attitude over biology" (Coyne & Tennen, 2010, p. 17). Instead, marijuana's mood-altering effects can be seen as part of a larger program of healthy coping, because the psychological effects of cancer can be as debilitating as the physical effects.

Marijuana's mood altering effects can help patients cope with their cancer psychologically, because it encourages modes of thinking that step outside the usual "repression/blunting vs. sensitization/monitoring" dichotomy that can emerge (Livneh, 2000, p. 41). Specifically, when faced with something like cancer, many people either attempt to avoid the issue or else focus on it excessively, and in both cases the patient's psychological state deteriorates as a result. Marijuana can intervene in this process because the lateral thinking and changes in mood brought on by marijuana can encourage patients to consider their disease in new or different ways outside of their regular patterns of thinking (Cohen, 2006, p. 20). In this case, the point of prescribing marijuana is not based on the assumption that a positive attitude will increase a patient's chance of survival, but rather is based on a desire to simply improve the patient's quality of life.

This last point is crucial to reiterate, because it helps explain why a physician would be ethically justified in prescribing marijuana even in the face of legal, and in some cases medical, opposition. In the case of cancer, marijuana's potential to increase the efficacy of cancer treatments, or even to serve as a cancer treatment itself, is not the reason for its prescription. Even though reduced pain, anxiety, nausea, and an increased appetite may have demonstrable effects on the outcome of a cancer treatment program, this is not the primary ethical justification for prescribing marijuana. Instead, the justification for prescribing marijuana stems directly from the physician's responsibility to the well-being and quality of life of his or her patient.

That is to say, if marijuana has the potential to make a cancer patient's life even slightly more enjoyable, then that patient's physician has an ethical obligation to make marijuana available to the patient. Of course, one can only make this case confidently after appreciating the relative low risks associated with marijuana use, because the ethical obligation only exists wherever the treatment is not worse than the symptom it treats. Because marijuana does not have substantial negative side-effects, however, one can confidently say that if it has the potential to improve the life of a patient and there are not better options, the physician has a responsibility to prescribe it.

In fact, in the case of terminal patients, a physician could be comfortable proscribing marijuana for smoking, because if the goal is an improved quality of life rather than cancer treatment, smoking might be more enjoyable for the patient. Recognizing this cuts to the core of the patient-physician relationship, because it suggests a situation where the quality of life is deemed more important than the length of that life. Deciding whether to value quality over longevity is a decision that can only be made by a patient in consultation with his or her physician, but the current legal regime surrounding marijuana essentially inserts the federal government into this equation in a way that most people likely never imagined or intended. The idea of government intervention in end-of-life decisions is already anathema to many people, but the fact is that the government currently circumscribes end-of-life decisions within a fairly strict set of rules, to the point that it is still illegal for people in the United States to willingly take their own lives or have a physician assist them in doing so.