Dr Michael Fitzpatrick
The ethics of cannabis
Many years ago, before I became a medical student, I visited a friend who had been admitted to hospital with glandular fever. He directed me discreetly to his bedside cupboard where he had hidden a little stash of his favourite Lebanese Red cannabis resin. Feeling rather feeble, and fearing the surveillance of the ward staff, he insisted that I roll him a couple of joints for his customary nocturnal recreation. Impressed at this triumph of the spirit of hedonism over both physical debility and medical authority, I duly complied.
I recalled this long-forgotten episode last month when I came across a major feature in the British Medical Journal, subtitled 'ethical debate', which focused on the case of a man suffering from multiple sclerosis, who had been forbidden to smoke his customary spliff while in hospital (21 March). Vigilant nursing staff suspected that the cake his mother brought in every day, which he 'ate with relish', 'might contain cannabis'. The ethical problem, which was thrashed out by a psychiatrist, a neurologist, a clinical ethicist, a professor of health law, nurses and other authorities over several pages, was, given the staff's suspicions of crim-inal activity in the ward, 'should they investigate further?'.
Perhaps the most useful response would be for these experts to eat a slice of dope-cake each, sit in a circle and listen to some old Grateful Dead albums. Though it should be said that the ethical consensus was in favour of allowing the patient his illegal indulgence, this inflation of a commonsensical judgement reveals both the emptiness of much of what currently passes for ethical debate in medicine and the trend for pleading exemption for cannabis from the intensify- ing war on drugs - on medical grounds.
Last year the British Medical Association published an authoritative report on 'The therapeutic uses of cannabis' and the recent national demonstration in London calling for the legalisation of cannabis was led off by sufferers from multiple sclerosis, some in wheelchairs, who have been prominent in proclaiming the benefits of the Weed. People with Aids and others with terminal illnesses have found cannabis helpful and there are claims of its potential value in con-ditions from asthma to glaucoma.
The underlying problem here results from the indiscriminate character of the national - indeed international - moral panic about drugs and the increasingly repressive measures, well symbolised by the appointment of a 'drugs tsar' in Britain, proposed to deal with the problem. An anti-drugs crusade which began in response to a perceived increase in the (largely self-destructive) use of heroin by marginalised youth has widened to include the (largely recreational) use of cannabis among much wider layers of society. In response, a number of respectable professionals who have been smoking the occasional joint since their student days - and now discover that their children are doing the same - have resorted to claiming the medical benefits of cannabis to justify an end to the criminalisation of its use.
One defect of this campaign is, as the BMA report makes clear, the limited evidence of the therapeutic value of cannabis. Only a few of the 60-plus 'cannabinoids' derived from cannabis have been studied. Some appear to be of some benefit in relieving the nausea and vomiting associated with chemotherapy for cancer, whereas others are not: the report indicates useful directions for further research in this area and in the treatment of people with Aids. Despite individual claims of dramatic benefit in multiple sclerosis, objective studies suggest only moderate improvement.
While such research is no doubt worth pursuing, it is quite irrelevant to the wider debate about legalisation, for two reasons. Firstly, it is conducted using some extracted active ingredient of cannabis, administered in pure form, generally by mouth. It does not consider smoking, the standard mode of recreational consumption. As a recent BMJ editorial points out, 'cannabis smoke is as rich in toxic gases and particulates as tobacco smoke, so regular heavy smokers probably face an increased risk of cardiovascular and respiratory diseases' (4 April). Secondly, it is concerned with relieving the symptoms of the sick, not with enhancing the mental state of the healthy dope-smoker.
The drive to medicalise cannabis as a way of avoiding the current trend to proscribe its use and criminalise its users is the latest manifestation of a long-standing tension between doctors and the state over the issue of drugs. Defining drug addiction and abuse in physiological and psychological terms, doctors have sought to extend medical influence over the prevention and treatment of problems of drug abuse and over the rehabilitation of casualties. The courts and the police have enforced legislation defining the legitimate and illegitimate use of various drugs, generally in the context of concerns about individual morality and social order.
The curious feature of the past decade is that measures of increasing state repression have evolved in tandem with measures of increasing medicalisation. Thus New Labour home secretary Jack Straw proposes, on the one hand, harsher sentencing and confiscation of drug dealers' assets, and on the other, more resources for drug education in schools, and for treatment and rehabilitation programmes. The attempt to medicalise cannabis simply offers an alternative 'medical' means of regulating illicit drug use. Making various active ingredients of cannabis available on prescription might enhance medical authority, but it would do nothing to enable people to smoke it free from state interference. The government may, or more likely, may not, take up the offer. But the fact that the main body of resistance to the prohibitionist and repressive drive of government policy merely suggests another way of containing drug use can only strengthen its hand.
For my old friend, in those simpler times, there was only one reason for smoking cannabis: to get stoned. I certainly never heard him argue that it was good for his glandular fever.
Reproduced from LM issue 110, May 1998