The Ethics of Prescribing
Cannabis: freedom, autonomy, and values
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ABSTRACT
In many Western jurisdictions cannabis, unlike most other psychoactive
drugs, cannot be prescribed to patients even in cases where
medical professionals believe that it would ease the patient’s
pain or anxiety. The reasons for this prohibition are mostly
ideological, although medical and moral arguments have been
formulated to support it. In this paper, it is argued that freedom,
properly understood, provides a sound ethical reason to allow
the use of cannabis in medicine. Scientific facts, appeals to
harm and autonomy, and considerations of symbolic value cannot
consistently justify prohibitions.
WHAT ARE THE QUESTIONS?
A hypothetical case
Suppose that I suffer considerably. My suffering can manifest
itself as localised physical pain, general queasiness, or involuntary
convulsions. Suppose, further, that I have, by consulting medical
literature, become convinced that cannabis is the solution to
my problems—that smoking marijuana or ingesting pills
containing cannabinoids would alleviate my suffering without
causing disproportionate side effects. Should I, in this case,
be free to use cannabis to make myself feel better? And, above
all, what would be the implications of this freedom to medical
professionals?
Four steps to freedom
I will answer these questions by proceeding in four stages.
I will first consider briefly the scientific facts of the case,
and reject the view that the prohibition of cannabis can be
based on medical expertise. My second step is to define freedom
and its normative foundation, and to sketch the practical guidelines
that respect for freedom would entail for healthcare professionals.
The third task is to clarify the distinction between freedom
and autonomy, which is often blurred in ethical and legal discussions.
The fourth and final step is to assess, and to reject, the main
moral and political arguments against the use of cannabis in
medicine.
MEDICAL EXPERTISE AGAINST PRESCRIBING CANNABIS
Scientific facts and professional opinion do not support a ban
on cannabis prescriptions. The scientific facts of the case
are unclear, and the professional views are divided.
Contested scientific facts
There is evidence that human beings have receptors for cannabinoids
in the central and peripheral nervous systems, and that cannabinoids
are analgesic and reduce signs of neuropathic pain in animals.1–7
There is also some evidence that they can reduce pain, nausea,
and spasms in humans.6–9 Against these findings, it has
been argued that the medical benefits of cannabis are overshadowed
by its harmful side effects, and that due to other developments
in pain management, there is no real need for its use as an
analgesic.6,7 As it is illegal and unpopular to conduct studies
on the effects of marijuana and related products in most Western
countries, it is unlikely that decisive scientific clarity will
be reached in the near future.
Professional disagreement
Professional opinion, however, seems to favour a liberal approach.
In a survey conducted in 1997, the majority of British doctors
wanted cannabis prescriptions to be allowed.10 An earlier study
showed that in the late 1980s the majority of the members of
the Washington Medical Association would have preferred, against
the current state law, the controlled medical availability of
marijuana.11 In the early 1990s, 44% of oncologists surveyed
had already recommended the illegal use of marijuana to at least
one patient.12 And in 1997, the editor of the influential New
England Journal of Medicine argued against the prohibition in
an editorial.13
No consistent medical argument
Arguments against the use of cannabis cannot be supported by
scientific facts. The use of marijuana can have drastic side
effects, but nobody seems to deny that it can also benefit some
individuals considerably. If I am one of those individuals,
and willing to risk the side effects, then what could reasonably
be said against selling or prescribing cannabis to me? As the
divided professional opinion indicates, there is no satisfactory
scientific or medical answer to this question.
FREEDOM AND ITS IMPLICATIONS
The main arguments for allowing cannabis use, sale, and prescriptions
stem from the ideas of freedom and autonomy. It is widely assumed
in healthcare ethics that the freedom of individuals is best
protected by paying heed to the principle of self determination,
or autonomy.14 The two concepts have also been more or less
equated in the context of drug prohibitions.15,16 But this is
not necessarily a valid connection. Depending on the interpretations
chosen, respect for autonomy can lead to restrictions of freedom.
The best way to defend my entitlement and access to the medication
I want is to forget autonomy and to proceed from an early liberal
"thin" concept of freedom, or liberty.17,18
What is freedom?
In what follows, I will take freedom to mean the non-restriction
of options. In other words, an individual is free to the degree
that her options remain open to her. And, conversely, an individual
is unfree to the extent that her options are ruled out by clearly
definable constraints, which can be external or internal, positive
or negative.19,20
Within this definition, nobody is perfectly free:
because of physical limitations, human beings cannot fly like
eagles, swim like sharks, or jump like tigers; because of economic
constraints, most people cannot afford to buy a new car every
month, and some people cannot even afford to buy food every
day; because of gaps in education, many people cannot make informed
decisions regarding their own lives, and because of social and
cultural restrictions, many people cannot express their true
opinions without fear of untoward consequences.
Why should freedom be respected?
The basis for respecting freedom as the non-restriction of options
can be found in the seventeenth century liberal doctrine usually
attributed to John Locke.21 According to this doctrine, individuals
have rights. The most important of these are the right to life,
the right to health, the right to liberty, the right to bodily
integrity, the right to private property, and the right to punish
those who violate other people’s rights.
These rights are, essentially, entitlements to
non-interference. Other people should not actively attempt to
end our lives, corrupt our health, steal our property, or curtail
our freedom of choice. If they do, or attempt to do, any of
these things, they partly lose their original entitlements,
and we have the right to punish them, or prevent them by threats
of punishment.
The rights individuals possess were, in Locke’s
original model, based on the idea that people do not in the
end belong to themselves, but to God. We have a strict duty
not to interfere with the lives, health, and liberty of other
individuals, because they should be left free to manage their
God given lives for themselves. They should do this in the best
way they can, in the light of their reason and understanding,
but even if they do not, we cannot legitimately interfere, given
that they do not violate the rights of others.
This defense of freedom as the non-restriction
of options does not necessarily depend upon any particular view
of God, religion, or theology. It can be taken simply to mean
that our individuality, as expressed by our own choices, is
an extremely valuable thing, and that attempts by others to
mess with it cannot add anything to its value. To use a metaphor
popular in bioethical debates, we could say that others are
trying to "play God" if they insist that their claims
and beliefs should override our choices.22,23
How could freedom be professionally respected?
It seems clear to me that respect for freedom is not compatible
with excessive regulations on the sale and use of cannabis in
non-medical contexts. The use of possibly addictive substances
does foreclose some future options, but so do many other practices
and choices which are widely accepted in the name of liberty.
Decisions to have children and to take a mortgage spring to
mind. If competent individuals want to use cannabis, they cannot
be stopped by appeals to their freedom. The question is, does
the medical context change the situation?
Healthcare professionals can respect and promote
the freedom of their patients in two ways. They can try not
to eliminate any options open to the patients before the professional
contact. And they can try to remove physical, economic, educational,
and social constraints by their professional efforts and by
civic participation. But what about prescribing cannabis to
alleviate pain or anxiety, where the patient has expressed a
clear preference in its favour?
Legislation obviously plays an important role
in what health professionals can and cannot do. If the use of
marijuana for medical purposes is legally allowed, then health
professionals would, by denying the request, rule out an existing
option, and thereby explicitly restrict their patient’s
freedom. If, on the other hand, the use of cannabis is prohibited,
the option is not in the same way open to patients before the
consultation.
It can be argued that in the latter case the freedom
of the patient making the request is not actively restricted
by the professionals. But as the option remains closed, the
freedom of the individual is not maximally promoted, either.
It could, namely, be further enhanced by attempts to legalise
marijuana.
This means that, whatever the legal situation,
respect for the freedom of the individual would imply that requests
like this should be granted, either by health professionals
or by society as a whole.
AUTONOMY AS A FREEDOM RESTRICTING PRINCIPLE
Autonomy can be inimical to freedom, although this is not necessarily
the case. According to a liberal interpretation, based on the
work of the nineteenth century thinker John Stuart Mill, individual
liberty and personal self determination cannot be separated.24,25
But many ethicists and lawyers prefer another reading, in which
autonomy is subjected to particular notions of reason and contrasted
with freedom as the non-restriction of options.26–28
What is autonomy?
The definition of autonomy usually employed in healthcare ethics
can be traced back to the eighteenth century, to the philosophy
of Immanuel Kant.29–31 He held the view that autonomy
means personal self determination in the light of universal
reason. People can, according to his doctrine, be "truly
free" only in the realm of rationality: if they yield to
their desires, attitudes, or emotions, they reject their autonomy
and their "true freedom". As desires, attitudes, and
emotions are a constant factor in our lives, Kant believed that
people cannot be perfectly autonomous, but he argued that we
have a moral duty to try to achieve this impossible goal.
Kant’s primary concern was to show that
morality, as the freedom to choose between right and wrong,
is possible in a Newtonian world governed by material causes.
To prove his case, he introduced the distinction between the
empirical world, which is causally determined, and the noumenal
world, which is not. As bodily creatures, we belong to the former
sphere, but as rational agents, we inhabit the latter. Our "morally-practical
reason" is free to make its own laws, and to act in accordance
with them, without paying unnecessary attention to the demands
of the body.
As morality requires freedom, and freedom can
be attributed only to our practical reason, or will, it follows
that the only way to act morally is to obey the commands of
the will. This is what Kant called autonomy: "Autonomy
of the will is the property that the will has of being a law
to itself. [Morality] is the relation of actions to the autonomy
of the will [...]. That action which is compatible with the
autonomy of the will is permitted; that which is not compatible
is forbidden."30
Kant believed that the demands of practical reason
are the same on all rational beings. This provides us with a
test for our moral principles. In order to act autonomously,
we must act according to rules which could be autonomously chosen
by any rational agent. The requirements of the moral law are,
in other words, universal.
Why should autonomy be respected?
Kant thought that we should celebrate our autonomy, because
it is the only thing that can distinguish us from the rest of
the world, and make us moral. Desires, attitudes, and emotions
belong to the empirical realm, which can be encountered only
as a determined sequence of causes and effects. In this prearranged
world of phenomena, there is no freedom of choice, hence no
responsibility for one’s actions, and hence no morality.
Autonomy of the will also makes human beings "equal
to God" in the sense that, as rational beings, we, like
God, can make our own laws. This is where Kant introduced the
concept of dignity. In the empirical world, human beings are
entities of little significance, and human feelings, desires,
aspirations, and inclinations do not amount to much. In Kant’s
words, however: "man as a person, i.e., as the subject
of a morally-practical reason, is exalted above all price. For
as such a one (homo noumenon) he is not to be valued merely
as a means to the ends of other people, or even to his own ends,
but is to be prized as an end in himself. This is to say, he
possesses a dignity (an absolute inner worth) whereby he exacts
the respect of all other rational beings in the world, can measure
himself against each member of his species and can esteem himself
on a footing of equality with them."29
Autonomy, then, means rational self determination
in accordance with universal moral laws. It should be respected,
in oneself and in others, because it is the basis of our morality
and dignity, and enables us to belong to the same moral community
with God.
How should autonomy be respected?
Respect for freedom in the Lockean sense and respect for autonomy
in the Kantian sense can, in theory, produce similar normative
conclusions in our present context. It could be argued that
universal reason, if interpreted correctly, would not oppose
the use of cannabis, especially if there are good medical grounds
for this. Then autonomy as conformity to the moral law would
not require restrictions of freedom as the non-restriction of
options.
But it can also be argued that the use of cannabis
would not, in fact, be consistent with the demands of humanity
and universal reason, as defined by Kant. The use of psychoactive
substances confuses the mind and leads to addiction, and these
are serious matters within the Kantian model, since both bafflement
and chemical dependency are prone to hinder rational, self determined
decision making. Reduction of suffering is, of course, a worthwhile
goal, but it should not, according to Kant, be pursued at any
cost. We should not, he argued, take our own lives in the face
of suffering or sell our integral body parts to defeat poverty,
because these actions would diminish our dignity as human beings.31
How, then, could we legitimately give away our presence of mind—the
basis of our rationality—in order to avoid pain and anguish?
These are, after all, only phenomena of the empirical world,
while clarity of mind connects us with the rational realm.
Medical professionals who embrace the Kantian
notion of autonomy should probably not prescribe cannabis to
their patients. If rational decision making ought not to be
hindered, and if the confusion and addiction related to the
use of cannabinoids would have this effect, then it would be
wrong to do so. Respect for autonomy in this sense seems to
preclude the option of alleviating pain with psychoactive drugs.
MORAL AND POLITICAL ARGUMENTS AGAINST PRESCRIBING CANNABIS
There are three main moral and political lines of argument against
allowing cannabis use and prescriptions. The first is an appeal
to concrete harm, and can be formulated in terms of freedom
and its legitimate restrictions. The second states that autonomy
should be preferred to freedom, when these clash. The third
is an appeal to values which cannot be expressed in terms of
harm and individual autonomy. None of these arguments is conclusive
in our present context.
Medical cannabis does not inflict harm
on others
Within the liberal model, freedom can be legitimately restricted,
if respect for it would inflict harm on innocent third parties.32
For those who want to allow the medical use of cannabis, but
who remain sceptical regarding its recreational applications,
this could provide a basis for making the required distinction.
They can argue that even if the full legalisation of marijuana
could have adverse effects on family relationships, workplace
security, or traffic safety, these effects can be contained
in the medical setting. This has, after all, been the case with
opiates and other psychoactive drugs, which have been medically
available in most countries for decades.
The liberal model may also work for those who
want to grant competent adults the right to use cannabis, but
who do not like to see children subjected to it. They can claim
that children are not capable of making free choices, and cannot
therefore adequately consent to the risks involved. Letting
them use potentially harmful substances would equal inflicting
harm on them. Claims like this would, within the liberal model,
have to be validated by empirical evidence. In the case of cannabis
prescriptions, the evidence for freedom already exists in the
form of the relative harmlessness and subsequent acceptability
of opiates and other psychoactive drugs. In the recreational
context, those defending the current restrictions ought to be
able to show what harm would be inflicted on innocent third
parties by the legalisation of marijuana.
A preference for autonomy does not support
prohibitions
Some theorists prefer the Kantian concept of autonomy to the
Lockean notion of freedom, because respect for autonomy does
not necessarily demand respect for choices we see as irrational,
or immoral. Freedom as the non-restriction of options may require
us to allow the use of cannabis, but a more prohibitive attitude
can be justified by the prudential and moral good of the users
themselves. They must be rescued from confusion and addiction,
which can only undermine their rational autonomy and dignity
as persons.
This paternalistic line of argument has its defenders,
but it also has its theoretical weaknesses.33 If other people
tell me what I should choose for my own good, then in what sense
are we talking about my good, as opposed to other people’s
perceptions and attitudes? Questions like this should at least
be carefully addressed in particular cases before freedom is
restricted in the name of autonomy.
Bearing this in mind, it would not be easy to
extend considerations of autonomy to the medical use of cannabis.
Addiction is not an issue for terminal patients, and if they
are already confused by pain or anxiety, there is no reason
to restrict their freedom. For non-terminal patients who want
to be cured, the case is even stronger. If they and their carers
are convinced of the effectiveness of cannabis, then what could
undermine their autonomy and dignity more than a ban on the
medicine they want to use?
The established and accepted use of other psychoactive
drugs further weakens the autonomy based ban on cannabinoids.
Morphine is commonly prescribed to relieve pain despite its
confusing and addictive effects. How could autonomy in the Kantian
sense provide an argument against the use of cannabis, when
morphine and other similar drugs are, at the same time, a part
of standard medical practice?
Respect for symbolic values cannot support
prohibitions
The liberal assumption is that restrictions are not justified
unless there is evidence of concrete harm on innocent third
parties. Many critics of the model think, however, that this
burden of proof is excessive and misplaced. They have argued
that the harm produced by the use of marijuana is moral rather
than physical, and indirect, inconspicuous and symbolic rather
than direct, visible, and concrete.34 Prudential precaution
and a commitment to the values of the society demand us to prevent
the use of substances which confuse the mind, corrupt the young,
and challenge our perception of what is right and good.
Whatever the merits of arguments like this in
the context of recreational drug use, they cannot be reasonably
applied to the case of prescribing cannabis to alleviate pain
and anxiety. The direct and concrete reduction of suffering
provides, in almost any system of values, an excuse for causing
some offence or creating a mild threat of unspecified future
harm. I am also tempted to say that systems of value which do
not recognise this excuse can be justly ignored in moral and
legal discussions.
WHAT ARE THE ANSWERS?
My first question was, should I be free to use cannabis to alleviate
my pain and anxiety? The answer, based on my individual freedom,
is yes. Medical facts are too vague to overturn my informed
choice, concrete harm is not inflicted on innocent third parties,
and considerations of autonomy and symbolic harm cannot outweigh
the suffering that can probably be removed by the drug.
My second question concerned the implications
of my entitlement for medical professionals. These, too, are
unambiguous. If prescribing cannabis is legally permitted, physicians
should prescribe it to their patients whenever it is, in their
best professional judgement, called for. If, on the other hand,
the medical use of cannabis is prohibited, physicians should
make it known to the political and legal authorities that the
prohibition is unethical, and that it should be removed forthwith.
The case for the free sale and use of cannabis
for recreational purposes, and the case for prescribing it to
suffering patients, are slightly different. As people are allowed
to buy and use many dangerous substances anyway, there are strong
analogical grounds for permitting the sale and use of cannabis
products. This is not, however, a sufficient argument for prescribing
cannabis, as medical professionals are legitimately concerned
about the wellbeing of their patients. On the other hand, the
pain and anxiety experienced by the patients provide an additional
reason for permitting cannabis prescriptions, although this
consideration cannot be extended to non-medical contexts.
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M Hayry
Correspondence to:
M Hayry
Centre for Professional Ethics, University of Central Lancashire,
UK; mhayry@uclan.ac.uk
