For health care providers in the use of medical marijuana

By Joan Cody, RN Administrator

There are many reasons why health care providers should look at ethics in policy development and in providing clinical direction. Simply following legislation, meeting the wants of patients or avoiding the risk of liability is not enough to address the complex issues that arise in many situations. A more aware and demanding public, regulatory issues, new technologies, changes in law and advanced health research all have far-reaching ramifications that will require us to look at much more.

Dennis Robbins, in his book Ethical and Legal Issues in Home Health and Long-Term Care—Challenges and Solutions (1996), states “Policy should be dealt with proactively, it must be justifiable, and we need to ask what is right rather than who is right.”So when health care providers are asked if they support the use of marijuana by patients in their hospitals, clinics and long-term care homes, there is a lot to think about. There is no shortage of anecdotal stories on the benefits of marijuana: Its use in the treatment of chronic pain, muscle spasms, fibromyalgia, arthritis, neuropathy, glaucoma, depression, anxiety, nausea and vomiting, and cancer is supported by many testimonies, with patients saying it is an effective treatment alternative. And while patient opinion has a clear place in policy development and clinical practice decision-making, it must be examined, tested and held up for re-examination.

Although some US states have legalized medical marijuana, federal law still maintains that it is a schedule 1 narcotic that it is illegal to grow, distribute, prescribe or use. In Canada, Health Canada administers legislation only related to the possession of medical marijuana, including a possession cap. But it neither regulates nor advises on how to grow marijuana, nor does it place any restrictions on doses or recommend medicinal amounts of consumption.

This has left many in the medical community confused about the ambiguity of their role and any associated risks they may be taking in supporting patients who wish to use marijuana as a medical treatment. In February 2013, the Canadian Medical Association stated: “We remain deeply concerned that, though the [Medical Marihuana Access Program] has made a physician’s authorization the key to a patient’s access to medical marijuana, physicians and other health professionals have little to no evidence-based information about its use as medical therapy.”

Health care duties
With the first Canadian clinical trials of medical marijuana only having been registered to begin in March 2014 (by Prairie Plant Systems), the void of comprehensive scientific research remains an issue in Canada and for Canadian health care providers. Entrusted to do no harm and equally to protect from harm, health care providers have a fiduciary duty to their patients and must consider how they will assess the balance of benefits and harms related to the use of a drug with such a significant lack of clinical facts. For example, some research shows that tetrahydrocannabinol (THC), which is responsible for the effects of medical marijuana, varies greatly depending on the seed, strain and growing conditions, with sample variations of THC between 4% and 30%. In addition, the method of THC intake—smoking or oral ingestion in food or by tablet—presents another variable.

It is hoped that the ongoing trials will help to provide prescribing doctors and other health care providers with the clinical data they are looking for.

Many may argue that the use of medical marijuana is simply an issue of autonomy and that the right of patients to choose is a fundamental tenet of health care. But respect for self-determination is both an ethical and a legal issue, and in this case our society also has concerns related to addiction and the resulting complications associated with taking substances that might hinder rational, self-determined decision-making, as are known to occur with the use of psychoactive substances such as marijuana.

If mental competency is the cornerstone of self-determination, consideration must be given to how to manage patients who have taken medical marijuana and might then lack the capacity to make other health care decisions. The current literature indicates that medical marijuana can have short-term effects such as coordination disorders, impaired memory and judgment, and psychotic episodes, while long-term use has been associated with cardiovascular events, addiction, mental health disorders and respiratory disorders.

It is equally important to recognize that health care providers have a responsibility not to submit to their own prejudices or biases when evaluating patient choice and quality of life. Historically, health care has had a difficult time managing what it can view as alternative medicines and social vices such as alcohol consumption. How will we manage the care provider who sees medical marijuana as a socially immoral enterprise? What will our role be in protecting patients who use medical marijuana from possible social isolation, or from being labelled “users” within our treatment facilities?

There is little doubt that medical marijuana will become more widely used in Canada in the coming years, and that health care providers will need to learn more about the complex medical and social implications related to its use. They will also need to examine their personal views for potential biases as they fulfill their professional and moral obligations to the patients in their care.

Talking Points
1) Do you support the use of medical marijuana for the patients in your care? Why/why not?
2) Under what circumstances, if any, would you recommend medical marijuana as a treatment option?
3) What is your role in the decision to use medical marijuana for your patients?

Joan Cody, RN, is ethics practice leader at Extendicare (Canada) Inc.