Medical Cannabis, Medical Ethics
By Diana Hahn and Stacey Marie Kerr MD
First do no harm
Physicians take the Hippocratic Oath to heart: "First do no harm." Honoring this with medical cannabis can be difficult, especially considering the many gray areas regarding the law as well as the risks, benefits, and unknowns of the medicine itself.
Physicians must rely on their own knowledge of cannabis and their patients' histories to determine how or whether to proceed with certifying and/or monitoring medical cannabis usage.
The following topics touch upon ethical issues that may commonly arise in regards to medical cannabis. The ideas laid out below are not intended to dictate or recommend a course of action in regard to the treatment or certification of any specific patient.
Legitimate Need and Certification
If a patient approaches a physician for certification, that physician has an ethical and legal responsibility to provide an honest professional opinion. In order to provide quality care to the patient, and to be in compliance with the law, a physician should seriously consider a patient's condition without refusing or agreeing to write a certification based on personal opinions or assumptions. There should be a bona fide physician-patient relationship that includes follow-up on an ongoing basis.
Risk, Benefit, and Experience
Some physicians are hesitant to support medical cannabis usage due to a lack of information and experience regarding the potential risks and benefits. Medical cannabis may get a lot of press, but the number of qualified patients who actually register and use medical cannabis still remains a minority of the population of qualified patients.
Similarly, the number of doctors who write certifications remains a minority of those practicing in the state. Combined with a general ban of medical cannabis in hospitals and sanctioned health care facilities, many physicians have yet to witness and/or monitor the risks and benefits of medical cannabis first hand.
There are opportunities for physicians to learn about cannabis as medicine. Although medical cannabis research is in its infancy, it would be untrue to say that evidence-based research does not exist.
Throughout the country and internationally, legitimate peer-reviewed, evidence-based studies are being published regularly. Considering the complexity, relative recent discovery of, and legal issues that make research on cannabis and the endocannabinoid system difficult, these initial studies (as well as anecdotal evidence) deserve consideration, especially if they could point a physician in the right direction to help a patient in critical need.
Chronic pain affects a significant portion of the population. Harm reduction refers to reducing or minimizing the risk of harm, and often arises in the context of introducing cannabis as an alternative or supplementary therapy for opioids.
Opioid use, dependency, and abuse is on the rise, with sometimes fatal outcomes. Medical cannabis may be an alternative or synergistic analgesic that is equally, if not more, effective than opioids. The side effects of cannabis are less serious than opioids, and do not include death.
While the idea of substituting a safer drug for a more dangerous drug may seem simple, there are many subtleties in regards to what is considered dangerous. Are known serious side effects less dangerous than unknown ones, simply because they are known?
Not if the known effects include death. Is the risk of dependency or abuse of a safer drug worth lowering the dosage or taking a patient off a more dangerous drug? How can chronic pain best be addressed, while limiting side effects and risk of drug dependency? These questions must be seriously considered in order to determine whether medical cannabis is an appropriate treatment for a particular patient.
Many of the qualifying conditions for medical cannabis under Hawaiʻi state law are related to the palliative care associated with chronic or debilitating conditions. While there are prescription medications that address these conditions, they may be inadequate, inappropriate, or cause intolerable side effects for certain patients.
In these situations, it may be a physician’s ethical responsibility to research medical cannabis as an alternative treatment for a particular condition and discuss with a patient. This may be especially true for patients who are fragile, have exhausted pharmaceutical options, and have yet to find relief or effective treatment.