Pint-Sized Pot and Hospice Hallucinations: The Role of Illicit Drugs in Medicine

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

Consider a paradox of sorts: there is a variety of illicit drugs that are used legally for the treatment of medical conditions, and there is a variety of legal drugs that are abused illegally to sustain drug addiction. Does anyone else see a problem with this?

Opiate addiction and abuse has had its share of news cycles lately, and for good reason. Access to prescription opiates continues, and addiction has reopened the door for heroin to make a resurgence in a big way. Vermont has recently taken efforts to address this epidemic head on, and other states are working on responses to their own respective crises.  This is a real problem that destroys lives and communities and I applaud the efforts to find solutions.

Alternatively, marijuana has taken a different path into America’s collective consciousness. Marijuana’s contemporary legal status (it was federally legal in the U.S. until 1937) was first introduced in 1996 when California legalized marijuana for medicinal use. Medical marijuana is now legal in 21 states (and Washington, D.C.), and marijuana’s most notable recent headline was when the states of Colorado and Washington legalized marijuana for recreational use in 2013.

Medical marijuana, with it being a federally illegal, Schedule 1 drug, has had a relatively limited amount of research devoted to it, although its claims for relief remain popular and broad. Most studies have revolved around treatment of symptoms associated with cancer and cancer therapies, although preclinical trials (in animals) have indicated the possibility of actual tumor inhibition. This push has been increasing, with stories about children finding relief bolstering pro-pot advocates.

Another illegal drug that has piqued the interest of researchers is LSD. A recent study indicated promising results in reducing anxiety among patients with life-threatening diseases.  Additionally, ecstasy has been studied – again, with promising results – in treating post-traumatic stress.

So we return to our paradox. We have illegal drugs that show promise in the medical field, and we have legal drugs that are being massively abused illegally and causing them to be restricted in significant ways. How ought one reconcile this? Are the researchers acting unethically by studying an illegal drug? Are they acting ethically by studying the most promising drug for their respective conditions or patients, legality be damned?

The line between legality and ethicality can often be a fine one. They are separate entities that do often overlap, but this is one area in which they diverge. From an ethical perspective, it can certainly be beneficial to study a drug with promise. Beneficence dictates that we are to promote actions that can provide a maximum of benefits with minimal harms. By encouraging of these otherwise illegal compounds within the context of a controlled research environment, the otherwise significant harms and risks of harm are minimized, for the patients and researchers.

Our paradox requires a final consideration, that we reconsider how we interact with drugs in America. Illegal ones, legal ones. Prescribed ones, recreational ones. Popular ones like alcohol and tobacco, and taboo ones like LSD or marijuana. They are all in need of social reclassification and put into a single category: drugs. From there, we as a society, as a medical profession and as individuals, can rebuild how we interact with them. Sometimes, as it turns out, the most ethical choice could also the most illegal.

[This blog entry was originally posted in a slightly different form on Mr. Dahlke’s blog on April 19, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Sorry Kid, But Your Mom’s in Jail for Having You

by Patricia Mayer, MD, Bioethics Program Alumna (2009)

Last week the Tennessee legislature voted to approve a bill that criminalizes drug use in pregnancy. Mothers can now be charged with criminal assault if a child is born addicted, harmed or dies as a result of pre-natal use of narcotics. The bill, amended to preclude charges for women who voluntarily enter treatment, now goes to Governor Bill Haslam for signature or veto.

Tennessee eliminated these same criminal penalties just two years ago, deciding treatment made more sense than jail time. The state is now planning to reinstate these sanctions. This would make Tennessee the only state that allows criminal charges against drug-using pregnant women. Seventeen other states consider drug use during pregnancy to be child abuse subject to civil penalties.

Resurrecting criminal penalties for drug-using mothers is a response to pressure to halt the “epidemic of drug dependent newborns” reported by the Tennessee Department of Health. Interestingly, that same Department of Health report reports that the largest percentage of narcotic-addicted newborns was born to mothers taking “substances prescribed to them for legitimate treatment”. That, of course, is another conversation.

While no one is arguing that drug-addicted babies are a good thing, this approach is wrong in every way. First, it creates a new status of criminal. It is not illegal to be a drug addict according to the US Supreme Court (Robinson v. California). It is not illegal to be pregnant. But a person who is drug addicted and pregnant at the same time can be charged with a crime.

Second, this law flies in the face of all medical recommendations, including those by the American Medical Association, the American Pediatrics Association, and the American College of Obstetricians and Gynecologists (ACOG). The latter group issued a formal opinion in November 2005 that specifically condemned “punitive and coercive” approaches to addicted pregnant women. That opinion summarizes legal cases up to that point, reviews pertinent ethical principles, and reports six main objections to the punitive approach Tennessee is considering. In particular, medical societies, professional organizations and substance-abuse experts are convinced this law will discourage pre-natal care. What woman will admit to use of narcotics (legal or otherwise) if she thinks she might go to jail or have her baby taken away? Pro-choice advocates also oppose the bill, fearing that it will cause more women to get abortions in order to avoid criminal sanctions.

Third, the law makes no medical sense as written. The law refers to children addicted, harmed or who die as a result of a mother’s narcotic use. But far too many pregnancies have poor outcomes. Often, the exact causes of a poor outcome are unclear. The ACOG report particularly highlights the limitations of medical knowledge and predictions of birth outcomes. Will prosecutors now investigate every woman who has the misfortune of delivering a child with birth defects? Are we then going to prosecute women for stillbirths? In 1999, South Carolina did this with a cocaine-addicted mother whose child was stillborn. In that case, the grieving mother was convicted of homicide by child abuse, and sentenced to 12 years in jail. That case, upheld by the South Carolina Supreme Court, was refused a hearing by the US Supreme Court.

Fourth, these types of prosecutions disproportionally are directed at women of color. Despite similar rates of addiction in Caucasian and non-Caucasian women, multiple studies have found that women of color are uncommonly subject to criminalization of pregnancy related behaviors.

Finally, it is unclear who will benefit under this scheme. It certainly won’t benefit the addicted mothers, who will be in jail instead of in treatment. It won’t benefit the affected babies, who will have no chance to be with their families; mom will likely be in jail and unavailable to her baby. This is despite the fact that there is no proof drug addicted mothers do not care about their children. In fact, the opposite is true, and there is compelling evidence that women who have custody are more likely to complete treatment for addiction. Society is also unlikely to benefit. Taxpayers in Tennessee will end up paying for more inmates in prison and more children in foster care. Abortion rates and infant mortality rates could rise, as drug-using mothers selectively terminate their pregnancy or avoid pre-natal care out of fear that they will be arrested. None of these outcomes benefits society.

There are fatal flaws in this bill, and the Governor should not sign it. Tennessee (and all states) can do better than this.

[The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

16 and Pregnant: The Tragic Case of Rennie Gibbs

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

Rennie Gibbs was 15 years old when she found out she was pregnant. In late 2006, then 16 and pregnant 36 weeks, she was admitted to a hospital in Lowndes County, MS, diagnosed with fetal demise and induced to gave birth to a stillborn baby named Samiya. A urine test detected marijuana and cocaine in Ms. Gibbs’ system upon admission. An autopsy revealed that Samiya’s death was most likely due to the umbilical cord wrapping around Samiya’s neck, causing blood supply to be cut off. But that interpretation of the autopsy report is not what was given days after Samiya’s death, when Samiya’s death was ruled a homicide and Ms. Gibbs was subsequently indicted for murder. The claim was that, because Rennie had smoked crack during her pregnancy, she had caused the death of her baby. Under Mississippi statute, that constitutes murder if one’s acts are “eminently dangerous to others and evincing a depraved heart, regardless of human life, although without any premeditated design to effect the death of any particular individual”. A judge is expected to rule later this week as to whether the case will continue or be dismissed.

On its face, the legal perspective would seem laughable were it not real. The case highlights the problems of Mississippi’s medical examinations and the ‘medical examiner’, Steven Hayne.  I use quotations because of Hayne’s reputation for being, well, spectacularly corrupt. For example,

       “Here’s how it works: Each county in Mississippi elects a coroner to take the lead in conducting
       death investigations. The job requires no prior training, medical or otherwise – only a high
       school degree. If a death appears to have been caused by criminal activity, the coroner will
       consult with the local district attorney. Between the two of them, they’ll then refer the body to a
       private medical examiner for an autopsy. If a crime did occur, that medical examiner will likely
       then be asked to testify at trial. The system … encourages prosecutors and coroners to send
       bodies and the fees that come with them to medical examiners they trust … it undermines the
       notion of an adversarial criminal justice system. Medical examiners who have a financial 
       incentive to keep prosecutors and coroners happy end up testifying against indigent 
       defendants who can’t afford to hire their own experts to review the state expert’s work. At the
       center of all of this is a Rankin medical examiner Dr. Steven Hayne, the man who over the last
       20 years has come to dominate Mississippi’s autopsy business.” (emphasis mine)

(Much more on Hayne has been excellently written by Radley Balko; it is interestingly infuriating, but you may wish to shower after. Mississippi seems to have improved since severing ties with Hayne in 2008 and contracting services out to a company from Tennessee).

Perhaps more interestingly, Ms. Gibbs’ attorneys appear poised to challenge the medical evidence associating prenatal cocaine use with fetal harm, which may further bolster their case. Researcher Deborah A. Frank’s affadavit indicates there is “no consistent association between cocaine use during pregnancy and serious fetal harms; … no convincing evidence that prenatal cocaine exposure is more strongly associated … than exposure to… tobacco and alcohol”. Their argument: there simply is no causal connection between the drugs in in Ms. Gibbs’ system and the Sayima’s death. Besides that, there were only trace amounts of a derivative of cocaine, which is a significant departure from the “cocaine toxicity” indicated by Hayne in the autopsy report.

But I am less interested in the legal perspective of the case than I am about the ethical ones. For example, what if anything does this case say about reproductive rights in Mississippi?

It may be relevant to consider Ms. Gibbs’ actions from one of two perspectives. First, what if Ms. Gibbs did not want to have a baby? Second, what if she did want to have the baby? This puts her case into a sort of discussion about abortion rights, and focuses on her actions as a function of her intent. While intent does not seem to matter in terms of Mississippi law, it can matter ethically.

Let’s consider first if Ms. Gibbs did not want to continue her pregnancy. As a teen, consideration is often given to parents’ wishes for their children. Children do not yet have the capacity to make decisions for themselves and we thus seek the decision from parents. This autonomy is something that emerges over time, congruous with a person’s development to adulthood when decisions can be made independently and autonomously. As children begin to demonstrate this ability to consider their own decisions and their impact, the decision-making process moves from assent (parents consenting, and the child agreeing) to consent (child consenting). Ms. Gibbs was at that threshold when this transition typically occurs, meaning she would likely have had the ability to make the decision about her pregnancy autonomously.

If we are to assume that Ms. Gibbs did not want to continue the pregnancy, but could not get an abortion, then her options may have been further limited. Could Ms. Gibbs’ drug use constitute actions taken to terminate the pregnancy on her own? It would be difficult for anyone to legally prove her intent, but from an ethical perspective it matters. If she were trying to terminate the pregnancy on her own by using or abusing drugs, then her situation could be considered similar to an abortion. This is at least plausible, since abortion would have been rather difficult for Ms. Gibbs at the time. Lowndes County sits on the eastern border with Alabama, about 120 miles west of Birmingham. The closest clinic is in Tuscaloosa, AL, 60 miles away. While they appear to address the needs of MS women, the mere fact of having to cross state lines to get an abortion may be a barrier. There is exactly one clinic that provides abortion in Mississippi, 150 miles away in Jackson. It seems to face consistent pressure and scrutiny to even keep its doors open. Her age would have been a barrier, though; in Mississippi consent is required by both parents, with exceptions for judicial permission or medical emergency (threatening the life of the mother). If she were attempting to abort the fetus in the absence of professional assistance, it would likely be ethically justified, although not recommended. The risk of harms would be much greater than a clinically assisted abortion – both to Ms. Gibbs and to a potential baby that essentially survives an abortion attempt with likely significant health problems. But justified still, since Ms. Gibbs could evaluate the benefits and harms of continuing the pregnancy versus ending it in this way. Autonomy allows a person to make choices that appear unwise and even sometimes unsafe based on this evaluation of benefits and harms.

Perhaps it is wrong to construct a narrative around Ms. Gibbs’ actions that indicates her desire to end the pregnancy. Perhaps she did indeed wish to have the baby, meaning that her actions tell a different story. For an autonomous individual (if we presume she is) to make decisions that definitively add risk to a situation, there are a couple of likely reasons. The first and most likely is a lack of understanding that the specified action (drug use during pregnancy) can cause harms. In this regard, there could be a entire volume of reasons for why Ms. Gibbs was not educated on these matters, none of which matter except for noting that they exist. The second reason that may have compelled Ms. Gibbs to her actions is also likely, in my opinion: She was a teenager, and teenagers (in addition to gaining autonomous capabilities) tend to test the limits imposed on them, and this can often be expressed in using various drugs. Even if there was some correlation between her drug use and her stillborn baby (remember, there is not), it is difficult to see how charging a teenager with murder would improve anything, except as perhaps some ‘cautionary tale’ to warn other teens not to do drugs or get pregnant. Except that doesn’t work.

I cannot say that a better health care system, or better schools that teach responsible sexuality, or better access to abortion, or any other broad factor could have avoided this scenario. But I do envision a situation in which we do have all of those things, and I imagine if this would then be a ‘cautionary tale’ for others. Instead, in reality, I fear that it represents ‘more of the same’.

[This blog entry was originally posted in a slightly different form on Mr. Dahlke’s blog on March 19, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Reefer Madness: Why US Federal Policies on Medical Marijuana Don’t Make Sense

by Sean Philpott, Director of the Center for Bioethics and Clinical Leadership

While I was on the phone with a colleague from Denver last week, our conversation turned inevitably to the topic of marijuana. Colorado legalized recreational use of the drug via popular referendum in 2012, creating the world’s first fully regulated marijuana market. The first commercial sales occurred this past January, with $15 million in sales reported in the first month alone.

Despite this, my friend patiently explained, the “Mile High City” isn’t full of mile-high residents. Tight regulation of the market and increased spending on anti-drug messages, coupled with the drug-testing policies of private employers, makes it unlikely that most Coloradans will be ‘passing the dutchie ‘anytime soon.

While I don’t smoke marijuana I do support the decriminalization of its recreational use. However, I suspect that few states will be following the lead of Colorado and Washington State anytime soon. More likely is the continued legalization of marijuana for medical use. Twenty states and the District of Columbia have laws that allow this. Fifteen other states are considering such legislation, including New York.

The Empire State is the only one in the Northeast without a medical marijuana law, but that may change soon. Governor Cuomo recently proposed reviving a defunct 1980 law — the Controlled Substances Therapeutic Research Act — that would allow marijuana’s limited use. Under the proposed plan, the New York State Department of Health would oversee a program in which 20 hospitals will be allowed to prescribe marijuana as part of a pilot project to look at the drug as a treatment for life-threatening conditions like Dravet syndrome.

I find the Governor’s proposal somewhat stupid. Legal and logistical problems aside, this limited program would add little to existing research on the safety and effectiveness of marijuana as a medical treatment.  But at least it’s a step in the right direction. If only the federal government were so open minded.

Not only has the US federal government not passed a medical marijuana law, it still actively prosecutes those who grow, distribute or smoke marijuana. In 2013, for example, the US Department of Justice spent over $300 million investigating, arresting and prosecuting medical marijuana distributors.

Currently, the federal government regulates marijuana under the Controlled Substances Act of 1970. Drugs that fall under that Act are classified into one of five categories based on their potential for abuse and medicinal value. Marijuana is considered a Schedule 1 drug, the most dangerous and restrictive classification that exists. According to the US Drug Enforcement Agency (DEA), which enforces the Controlled Substances Act, marijuana has a high potential for abuse and no accepted medical use.

By contrast, the DEA considers cocaine to be a Schedule 2 drug. It is highly addictive, but it has been used as a topical anesthetic (particularly in the treatment of certain cancers). The prescription painkiller Oxycontin, which accounts for almost half of all drug overdose deaths in the United States, is also a Schedule 2 drug. Ketamine, an anesthetic that is also a commonly used ‘date rape’ drug, is a Schedule 3 drug. Alcohol and tobacco — two highly addictive and widely abused drugs with no known medicinal benefit — are not included in the DEA’s schedules of controlled substances.

This doesn’t make sense. Marijuana shouldn’t be a Schedule 1 controlled substance. Consider the issue of addiction and abuse. One of the arguments against the legalization of marijuana — either for medical purposes or for recreational use — is that it is a so-called gateway drug. Opponents of legalization argue that people who smoke marijuana are more likely to abuse cocaine, heroin, or other illicit drugs.

That is not true. Decades of research into the addictive properties of marijuana have found scant evidence that the drug is more likely to be abused than a drug like Xanax. We’ve known this fact for years. A 1944 study conducted by the US National Academy of Science found no evidence that marijuana was physiologically addictive. While more recent studies suggest that some users can be psychologically hooked on its use, the risks of mental addiction to marijuana are far lower than for other commonly used prescription drugs.

Questions of addiction aside, more troubling is the DEA’s characterization of marijuana as a drug with no medicinal properties. That is patently false. Prior World War 2, in fact, marijuana was routinely prescribed in the US as a treatment for neuropathic pain. Moreover, hundreds of studies have demonstrated the benefits of the drug for treatment of pain and nausea in cancer and AIDS patients. The drug also helps control epileptic seizures and delays loss of vision in patients with glaucoma.

There are still some concerns about the long-term health effects of using marijuana — particularly since the smoke also contains a variety of carcinogenic compounds — but for people facing life-threatening or debilitating illness those risks are well worth the relief that marijuana provides.

It’s time to change the federal approach to medical marijuana. There’s no reason why marijuana is Schedule 1 controlled substance or why federal agents routinely shut down dispensaries that sell the drug to patients.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 13, 2014. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]