The legalization of medical marijuana in the U.S. is an object of continued public debates. A number of states have already enacted laws, legalizing therapeutic marijuana use, whereas other states have pending legalization laws. This paper uses a medical marijuana bill, recently introduced by Kentucky’s Senator Perry Clark to the Senate. The background, significance, and scope of the legalization problem are discussed. The social, economic, and ethical considerations of medical marijuana legalization are described. Proponent and opponent arguments are included. The paper recommends defining the scope and boundaries of the term “legalization” and methods to control the use and prevent abuse of marijuana for medicinal purposes.
Keywords: medical marijuana, legalization, abuse, nursing.
Legalizing Medical Marijuana
Introduction of Problem and Related Bill
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To legalize or not to legalize? - paraphrasing William Shakespeare, this question remains one of the major subjects of public debate in the developed world. Over the past 40 years, the legal status of marijuana, in general, and medical marijuana in particular, has been vigorously debated (Joffe & Yancy, 2004). Proponents of medical marijuana claim than marijuana can alleviate painful symptoms and reduce the scope of physiological and neurological problems in patients with various health conditions, including cancer. Opponents feel that legalization will send the wrong message to the public and subject children and youth to unreasonable risks of drug abuse. Despite the lack of public agreement, a number of states have already enacted legalization laws. Other states, including Kentucky, have pending medical marijuana legalization bills. On January 31, 2012, Kentucky’s Senator Perry B. Clark introduced Senate Bill 129, titled “Gatewood Galbraith Memorial Medical Marijuana Act” (Bachara, 2012). The Act will limit patients, prescribed therapeutic marijuana, from possessing more than five ounces of marijuana per month (Bachara, 2012). Patients will not be allowed to grow more than five plants at a time (Bachara, 2012). According to Marijuana Policy Project (2012), SB 129 is a symbolic bill recognizing marijuana’s medical value; it has been assigned to the Senate Judiciary Committee but has not advanced before the legislative deadline (MPP, 2012).
Background/ Significance/ Scope of the Problem
Information. SB 129 is, probably, one of the most controversial and challenging pieces of legislation pending in the Senate. The purpose of the discussed Bill is to re-schedule cannabis from being a Schedule I to become a Schedule II drug (Bachara, 2012). This will also make marijuana legal for doctors to prescribe (Bachara, 2012). The Bill is sponsored by Senator Perry B. Clark (Bachara, 2012). The history of the Bill can be traced to the life and death of a prominent Kentucky lawyer, Gatewood Galbraith, who used to be an active supporter of medical marijuana legalization (Bachara, 2012). Galbraith devoted more than 40 years of his life to legalizing the status of cannabis plants in his state (Bachara, 2012). He died early in 2012 from pneumonia complications (Bachara, 2012). It is no coincidence that SB 129 is named after Galbraith: it is both a unique and effective way to recognize his professional and legal achievements.
Gatewood Galbraith’s daughter watched how her father was fighting to legalize marijuana and hemp in Kentucky: she believes that legal marijuana could boost the state’s economy, protect civil liberties, and ease the pain of the sick and dying (Bachara, 2012). In a long-term perspective, medical marijuana has the potential to alleviate the burden of health care costs. If passed by the Senate, the Bill will not simply allow patients to use marijuana for treatment purposes but will limit the amount of the substance they can use for medical purposes and the number of plants they can grow at home. For example, patients using marijuana for medical purposes will not be allowed to hold more than five ounces per month (Bachara, 2012). They will not be allowed to cultivate more than five plants at a time (Bachara, 2012). As a result, the discussed Bill is actually a double-edged sword: it legalizes medical marijuana and, simultaneously, sets severe limits on the amount of marijuana patients can possess and consume on a monthly basis.
Review of literature. The current state of literature provides abundant information, regarding the uses and abuses of marijuana, including its medical forms. The problem of using marijuana for medical purposes is not new. The history of medical marijuana can be traced back almost 5,000 years, when Chinese physicians used marijuana to treat constipation and malaria and ease childbirth pains (Doweiko, 2011). A mixture of marijuana and wine served as a good surgical anesthetic (Doweiko, 2011). Since 1611, Jamestown settlers started to cultivate cannabis for hemp fibers (Doweiko, 2011). The latter were used to produce quality rope (Doweiko, 2011). At that time, physicians in both the New and Old Worlds used marijuana to treat a wide range of health disorders. In the United States, cannabis was used by medical professionals to treat migraine headaches (Doweiko, 2011). It was also regarded as a good sedative and anticonvulsant substance (Doweiko, 2011). At the beginning of the 20th century, marijuana was commonly used to treat morphine addictions (Doweiko, 2011). It was not before the 1930’s that the use of marijuana became an object of law enforcement scrutiny.
The scope of the legalization debate can hardly be overstated. At present, marijuana is the most commonly used and abused illicit drug (Doweiko, 2011). Approximately 166 million of people all over the world use marijuana regularly (Doweiko, 2011). 24% of all worlds’ abusers live in the North America (nearly 38 million) (Doweiko, 2011). In the United States, marijuana is the most commonly abused drug and the biggest cash crop (Doweiko, 2011). Every day, approximately 6,000 people in the United States use marijuana for the first time (Doweiko, 2011). More often than not, the patterns of marijuana abuse resemble those of alcohol abuse: 14% of marijuana users do it on a daily basis and consume approximately 95% of the marijuana offered in the illicit markets (Doweiko, 2011). In light of these data, legalization of medical marijuana can increase the risks of drug use and abuse among Kentucky citizens.
The significance of the problem is two-fold. On the one hand, thousands of patients with serious health disorders hope that marijuana will ease their physical and moral sufferings. Contemporary researchers provide a number of evidence-based arguments in favor of legalizing medical marijuana. According to Denson and Earleywine (2006), medical marijuana reduces symptoms of depression, leading to the development of positive affect and decreasing the scope of somatic complaints. HIV patients, using marijuana, report relief of anxiety, reduced depression, improved appetite, increased pleasure and pain relief (Prentiss, Power, Balmas, Tzuang & Israelski, 2004). Therapeutic uses of marijuana expand to cover the following health states: (a) severe nausea and vomiting after chemotherapy; (b) weight loss in cancer and HIV; (c) multiple sclerosis and similar neurological complications; (d) pain syndromes; and (e) glaucoma (Seamon, Fass, Maniscalco-Feichtl & Abu-Shraie, 2007). Marijuana has been used to treat spinal cord injuries and alleviate the symptoms of multiple sclerosis (Seamon et al., 2007). In patients with amyotrophic lateral sclerosis, marijuana increases appetite, relaxed muscles and reduced physical pain (Seamon et al., 2007). Marijuana can be used to prevent seizures in patients with epilepsy (Seamon et al., 2007). However, many of these effects and uses require further empirical validation: because the use of cannabis is strictly regulated, clinical trials conducted to test its efficacy have been but few. Moreover, “much of the research on marijuana and its potential uses, abuses, and dangers was carried out 25 years ago, when less-potent strains were commonly abused, and thus, there are questions as to its current applicability” (Doweiko, 2011, p.124).
On the other hand, the risks of cannabis use should not be disregarded. Prevalence of marijuana use disorders in the United States steadily increases (Compton, Grant, Colliver, Glantz & Stinson, 2004). Marijuana use can be responsible for the development of numerous adverse health effects, ranging from visual disturbances to psychological, neurological and respiratory dysfunction (Seamon et al., 2007). Cardiac effects of marijuana may include but are not limited to tachycardia, palpitations, stroke and hypotension, and even paroxysmal atrial fibrillation (Seamin et al., 2007). To a large extent, the question of legalizing medical marijuana is that of choosing the most appropriate balance of the greatest positive and minimal negative effects on health. Even if medical marijuana does have the potential to alleviate the burden of various health disorders, how to reduce the risks of abuse remains an open question. The fear of the federal authorities and the public is that legalization of medical marijuana will open the gateway to the subsequent legalization of other drug products, sending the wrong message about the availability and usefulness of drugs (Clark, 2000). Yet, the slippery slope of marijuana legalization, even for medical purposes, does not stop senators and organized groups. The introduction of SB 129 and the ongoing debate over legalization of medical marijuana suggest that the issue has far-reaching political, economic, social, and ethical implications.
Political, economic, social, and ethical aspects of the problem. The problem of legalizing medical marijuana is equally political and scientific. Unfortunately, political ideology often overrides the body of scientific evidence, regarding the utility and safety of marijuana use. Whether or not marijuana should be legalized every state answers for itself, but politics greatly influence the quality of the final answer (Cohen, 2009). There is a serious conflict between the evidence obtained from scientific studies and experimental research and policies founded on purely political and ideological considerations (Cohen, 2009). Legalization of medical marijuana is an extremely convenient subject of political speculations, and decisions, made by states, do not always reflect the real state of things in medicine and science. Given the potential uses and abuses of medicinal marijuana, popular ideology and political considerations should not reduce the validity of scientific evidence, regarding its use. Cohen (2009) is right: only dispassionate scientific analysis can justify the use of medical marijuana as an important pharmaceutical agent.
The economic aspects of the issue are even more challenging. Proponents of legalization argue that legalizing marijuana will result in considerable savings and reduce the amount of money spent on drug prohibition. Marijuana legalization will enable state and local governments to save up to $5.3 billion (Miron, 2005). Additionally, legalization of marijuana will yield billions in tax dollars (Miron, 2005). However, the economic features of legalized medical marijuana should be weighed against its medical benefits and potential risks. On the benefits side, medical marijuana can save considerable health care costs. In chemotherapy alone, legalized medical marijuana can save up to $18,000 per person per year: these are the costs of chemotherapy-related adverse effects and ambulatory encounters (Hassett, O’Malley, Pakes & Newhouse, 2006). The costs of moral and emotional sufferings among patients with serious health complications are even more difficult to estimate, but legalizing medical marijuana can certainly address these issues. On the other side of the legalization debate are the risks and costs of potential drug addictions and abuse. More significant are the costs of drug abuse treatments as well as the effects of marijuana on individual health outcomes. Specialists at the National Bureau of Economic Research recognize that only a small proportion of adults use marijuana in ways that pose direct health risks (Pacula, 2005). Nevertheless, health problems, associated with marijuana use, are on the rise (Pacula, 2005). In 2001 alone, there were more than 5,000 hospital discharges, where marijuana abuse had been the primary cause of hospitalization (Pacula, 2005). The mean length of stay for those using and abusing marijuana was 16.4 days, compared to only 5.4 days for individuals with alcohol dependence (Pacula, 2005). Mean hospitalization charges for marijuana abusers reached $12,447, compared to $5,734 for heroin users and $6,706 for alcohol abusers (Pacula, 2005). Apparently, the economic costs of legalizing marijuana can be far-reaching.
The social implications of legalized medical marijuana should be considered. The effects of legalization on society can be tremendous, mainly through the change in public attitudes to marijuana use. Until present, there has been little evidence showing that legalization of marijuana results in increased marijuana use (Khatapoush & Hallfors, 2004). Khatapoush and Hallfors (2004) write that medical marijuana legalization in California did not change marijuana-related attitudes among non-users. However, by legalizing marijuana, the Senate may send the message to the community that legalizing other drugs and drug-related substances is possible. Most probably, if medical marijuana in Kentucky is legalized, the state government will need to organize a public campaign, explaining the importance and potential implications of legalization for the society.
From the ethical viewpoint, legalization of medical marijuana is intended to achieve the greatest good for the greatest number of people. Simultaneously, the unintended evil effects of legalization cause a lot of public controversy. This is the ethical principle of double effect, when a decision or action is intended to benefit the society but is not free of unintended negative consequences. Here, an action should meet four essential conditions, for it to be good and for its evil effects to be justified (Clark, 2000). First, the action, when considered independently of its effects, should not be morally evil (Clark, 2000). It should be neutral or good (Clark, 2000). Second, the evil effect of the action should not serve the means of producing the positive effect (Clark, 2000). Third, the evil effect should not be intended (Clark, 2000). Fourth, there should be a solid reason for initiating the action, despite its unintended evil consequences (Clark, 2000). Looking at the potential benefits of marijuana use in medical settings, it is clear that the reason for legalizing medical marijuana is solid and proportional. Moreover, it is clear that the evil effects of legalization are unintended and, actually, anticipated. This means that medical professionals and political activists can prevent the development of adverse outcomes, following the legalization of medical marijuana. Meanwhile, thousands of patients with severe health conditions will get a chance to alleviate their pains and sufferings.
Proponents and Opponents of the Bill
Unfortunately, no information, regarding the proponents and opponents of the Bill, has been provided. Nevertheless, it is possible to analyze the most common arguments in favor and against legalizing medical marijuana. Generally, these arguments can be divided into right-based and consequentialist: the former consider the rights of individuals to use or not to use marijuana, whereas the latter review possible consequences of legalization for the society.
Proponents of legalizing medical marijuana. Inherent in the debate for legalization of medical marijuana is the concept of individual rights. Proponents of legalization are convinced that individuals should be free to decide whether to use marijuana in medical purposes or not (Dennis & White, 1999). The right to use medical marijuana is often justified by the fact that marijuana users (and even abusers) do not cause any harm to the society (Dennis & White, 1999). Moreover, at times, medical marijuana can be useful in treating various health disorders and complications, with little or no harm caused to patients and the rest of community (Dennis & White, 1999). Proponents of the Bill will, most probably, claim that the consequences of using marijuana in medicine are not as serious as the reasons justifying its use, since marijuana is not a hard drug and cannot lead to any negative health and social results. It is possible to assume that patients in the Commonwealth of Kentucky will become the primary group interested in the legalization of medical marijuana: according to Bachara (2012), Senator Perry B. Clark encourages patients to initiate a grassroots movement in defense of the bill.
Opponents of legalizing medical marijuana. More often than not, opponents of legalization argue that the use of marijuana, even for medical purposes, can lead to serious social, health, and political evils. One of the most prominent arguments is that the promotion of medical marijuana is a political attempt to exploit human pain and suffering for the sake of legalizing an illicit drug (Conboy, 2000). The risks of marijuana misuse and abuse should not be totally disregarded. Moreover, there are ample alternatives to cannabis use in medicine, and only prohibition can ensure that the risks of the major social evils, growing from the use of drugs, are minimized (Dennis & White, 1999). Who will object to the proposed Kentucky Bill remains unclear. In this context, the issue of legalization can easily become a convenient object of political manipulations among various interest groups. One thing is clear: the issue of legalization will always have its proponents and opponents, but medical professionals are likely to move to the forefront of legalization defense.
In 2008, the American Nurses Association (ANA) released its position statement on the access and use of therapeutic marijuana. The purpose of the position statement was to reiterate ANA’s support of open patients’ access to therapeutic marijuana (ANA, 2008). The ANA (2008) relies on the premise that medical marijuana has been successfully used for centuries and has proved to be effective in treating numerous symptoms and health conditions (ANA, 2008). This being said, the ANA encourages the education of registered nurses and other medical professionals regarding the use and benefits of therapeutic marijuana (ANA, 2008). The ANA (2008) also votes for the protection of patients using medical marijuana from civil and criminal penalties. The ANA (2008) supports reclassification of marijuana from Schedule I to Schedule II. Finally, the ANA (2008) justifies the need to explore the therapeutic efficacy of medical marijuana.
Nurses’ support of cannabis use in medicine reflects the fundamental principles of nursing care. Nursing is intended to promote well-being of others (Swanson, 1993). Nurses’ focus is on helping clients to regain and maintain an optimal level of living and well-being, depending on the severity of their health condition (Swanson, 1993). As a result, the defense of marijuana legalization is just one of the many instruments, used by nurses, to promote patients’ wellbeing. However, wellbeing is also about providing patients with informed choices, and it is imperative that all patients prescribed medical marijuana are informed about its benefits and potential risks.
In light of everything written about the Bill and the issue of legalizing medical marijuana, it is important that the Senate: (a) defines the meaning and scope of the term “legalization” and (b) defines measures to monitor patients’ compliance with the prescribed doses of cannabis use and the number of plants allowed for household growth and use. First, the Senate must clarify what the term “legalization” means. In the current debate, the term “legalization” can cover a broad range of meanings and proposals (Kleiman & Saiger, 1990). For example, should legalization cover only adult patients? Can patients share their marijuana with other patients with similar health conditions? Should physicians be allowed to recommend marijuana for treatment, or should cannabis remain a measure of last resort? All these questions demand professional answers.
Second, the problem is in how the Senate will control patients’ compliance with the doses and limitations, recommended by the proposed Bill, and whether patients who exceed the recommended dose or violate other provisions of the Bill should be subject to civil and criminal prosecution. These questions are extremely important, since legalization of medical marijuana is associated with potential health and social risks. As previously mentioned, legalization of medical marijuana is a matter of intended goods and unintended evils, and it is within the Senate’s capability to expand the positive effects of medicinal marijuana and minimize its risks. In its current state, the Bill should not be passed, because its provisions do not guarantee the elimination of unintended evils. The Bill should not be passed, until the term “legalization” and measures of monitoring compliance are clarified.
Legalization of medical marijuana demands the development and implementation of new quality indicators. First, in any health condition, cannabis use should be used as part of complex treatment strategies, along with other, non-pharmacological forms of treatment. Second, the first dose of medical marijuana prescribed to patients should be the lowest. Third, patient education should become the foundational measure of reasonable cannabis use in medicine. If the proposed Bill is passed, nurses will face the challenge of developing new quality indicators and guidelines, with the goal of enhancing positive and minimizing negative effects of medical marijuana use.