The physician’s code of ethics states, “First, do no harm,” placing patient safety and public health as the central goals.
Thus, one must balance the benefits and the harms of a policy such as cannabis legalization and assure that the potential benefit/harm ratio is greater in a regulated, legal cannabis marketplace than in environment where the cultivation, distribution, sale, possession, and use of cannabis is criminalized.
Foremost, cannabis regulation must optimize public health and promote social justice, with two key priorities:
These two priorities lie in tension. Eliminating the illegal cannabis market is straightforward. Removing all penalties and restrictions regarding the production, distribution, and possession of cannabis would eliminate the illicit market because, by definition, all such activity would be legal. However, that approach does not address the harms associated with cannabis misuse. Conversely, a prohibitive or highly restrictive regulatory environment may slightly reduce problematic use, but it increases the viability and profitability of the illegal market. So, the optimal approach to cannabis regulation is a moderate one, balancing the needs of social justice and public health.
Thus, the issue is not whether cannabis can be harmful. The issue is whether cannabis prohibition is effective in protecting public health (it is not); whether the known harms of cannabis prohibition, particularly upon persons of color who bear the brunt of the drug prohibition, outweigh the potential harms of cannabis regulation (they do not), and whether the public benefits from science-based regulation of cannabis for adult use (it does).
Key points to consider:
Cannabis should never have been criminalized. The rationale for cannabis prohibition was predicated upon racist scare tactics rather than sound medical opinion.
In the U.S., the passage of the 1937 Marihuana Tax Act effectively outlawed the growth, sale and possession of cannabis.
The effort to criminalize cannabis was initiated and pushed by Henry Anslinger, the first commissioner of the U.S. Treasury Department's Federal Bureau of Narcotics (now the Drug Enforcement Agency). He was appointed this position in 1930, at the age of 38, and continued in this position for 32 years. As the end of alcohol prohibition in 1933 left Anslinger with a limited mission, he turned his attention to other substances. Anslinger sought a federal ban on the drug, initiating a high-profile campaign that relied heavily on racism. Anslinger claimed that the majority of pot smokers were minorities, including Blacks, and that marijuana had a negative effect on these “degenerate races,” such as inducing violence or causing insanity. Furthermore, he noted, “Reefer makes darkies think they’re as good as white men.” Perhaps even more worrisome to Anslinger was marijuana’s supposed threat to white women’s virtue. He believed that smoking pot would result in their having sex with black men.
The bill to criminalize cannabis was introduced to Congress without consulting the American Medical Association (AMA), which was against the general practice of the time. The AMA’s legal counsel, William C. Woodward, MD, LLM, LLD, protested the exclusion of his organization from the proceedings, and the hearings were extended to allow his appearance and that of representatives of the hemp industry. Woodward, one of America’s foremost public health experts of his time, lambasted the secrecy of the Congressional hearings, advocated regulation rather than prohibition, and noted that even the name of the Marihuana Tax Act was misleading to the medical community and the general public:
“That there is a certain amount of narcotic addiction of an objectionable character no one will deny. The newspapers have called attention to it so prominently that there must be some grounds for these statements. It has surprised me, however, that the facts on which these statements have been based have not been brought before this committee by competent primary evidence. We are referred to newspaper publications concerning the prevalence of marihuana addiction. We are told that the use of marihuana causes crime.
But yet no one has been produced from the Bureau of Prisons to show the number of prisoners who have been found addicted to the marihuana habit. An informed inquiry shows that the Bureau of Prisons has no evidence on that point.
You have been told that school children are great users of marihuana cigarettes. No one has been summoned from the Children’s Bureau to show the nature and extent of the habit, among children.
Inquiry of the Children’s Bureau shows that they have had no occasion to investigate it and know nothing particularly of it.
Inquiry of the Office of Education— and they certainly should know something of the prevalence of the habit among the school children of the country, if there is a prevalent habit— indicates that they have had no occasion to investigate and know nothing of it.
Moreover, there is in the Treasury Department itself, the Public Health Service, with its Division of Mental Hygiene. The Division of Mental Hygiene was, in the first place, the Division of Narcotics. It was converted into the Division of Mental Hygiene, I think, about 1930. That particular Bureau has control at the present time of the narcotics farms that were created about 1929 or 1930 and came into operation a few years later. No one has been summoned from that Bureau to give evidence on that point.
Informal inquiry by me indicates that they have had no record of any marihuana or Cannabis addicts who have ever been committed to those farms.”
Dr. Woodward’s advice was ignored and the federal government passed legislation criminalizing cannabis.
The Shafer Commission, formally known as the National Commission on Marihuana and Drug Abuse, was appointed by U.S. President Richard Nixon in the early 1970s. Its chairman was former Pennsylvania Governor Raymond P. Shafer. According to oval office tapes declassified in 2002, Nixon told Shafer he wanted a report that would blur the distinction between marijuana and hard drugs.
On March 22, 1972, the commission issued a report on its findings in 1972 that called for the decriminalization of cannabis possession in the United States. The Schafer Commission recommended a policy “which prohibits commercial distribution of the drug but does not apply criminal sanctions to private possession or use nor casual, non-profit distribution incidental to use.” This approach was dubbed “decriminalization.” Other major findings included:
“No significant physical, biochemical, or mental abnormalities could be attributed solely to their marihuana smoking… No valid stereotype of a marihuana user or non-user can be drawn… Young people who choose to experiment with marihuana are fundamentally the same people, socially and psychologically, as those who use alcohol and tobacco… No verification is found of a causal relationship between marihuana use and subsequent heroin use…. Most users, young and old, demonstrate an average or above-average degree of social functioning, academic achievement, and job performance…"
“The weight of the evidence is that marihuana does not cause violent or aggressive behavior; if anything marihuana serves to inhibit the expression of such behavior… Marihuana is not generally viewed by participants in the criminal justice community as a major contributing influence in the commission of delinquent or criminal acts… Neither the marihuana user nor the drug itself can be said to constitute a danger to public safety… Research has not yet proven that marihuana use significantly impairs driving ability or performance…"
“No reliable evidence exists indicating that marihuana causes genetic defects in man… Marihuana’s relative potential for harm to the vast majority of individual users and its actual impact on society does not justify a social policy designed to seek out and firmly punish those who use it.”
Rather than accept the recommendations of commission, Nixon declared drug abuse "public enemy number one.” As later explained by John Ehrlichman, Nixon’s domestic policy chief,
“The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people…We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin. And then criminalizing both heavily, we could disrupt those communities,” Ehrlichman said. “We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”
Similar to the Schafer Commission, a special committee was mandated in Canada to assess ;the approach taken by Canada to cannabis, its preparations, derivatives and similar synthetic preparations, in context; the effectiveness of this approach, the means used to implement it and the monitoring of its application; the related official policies adopted by other countries; Canada's international role and obligations under United Nations agreements and conventions on narcotics, in connection with cannabis, the Universal Declaration of Human Rights and other related treaties; and the social and health impacts of cannabis and the possible consequences of different policies.”
The Committee concluded:
“When cannabis was listed as a prohibited substance in 1923, no public debate or discussion was held on the known effects of the drug. In fact, opinions expressed were disproportionate to the dangers of the substance. Half a century later, the Le Dain Royal Commission of Inquiry on the Non-Medical Use of Drugs held a more rational debate on cannabis and took stock of what was known about the drug. Commissioners were divided not so much over the nature and effects of the drug but rather over the role to be played by the State and criminal law in addressing public health-related goals. Thirty years after the Le Dain Commission report, we are able to categorically state that, used in moderation, cannabis in itself poses very little danger to users and to society as a whole, but specific types of use represent risks for users.
In addition to being ineffective and costly, criminalization leads to a series of harmful consequences: users are marginalized and exposed to discrimination by the police and the criminal justice system; society sees the power and wealth of organized crime enhanced as criminals benefit from prohibition; and governments see their ability to prevent at-risk use diminished.
We would add that, even if cannabis were to have serious harmful effects, one would have to question the relevance of using the criminal law to limit these effects. We have demonstrated that criminal law is not an appropriate governance tool for matters relating to personal choice and that prohibition is known to result in harm which often outweighs the desired positive effects. However, current scientific knowledge on cannabis, its effects and consequences are such that this issue is not relevant to our discussion.”
As state by the California Medical Association (CMA) explained in its 2011 white paper endorsing cannabis regulation (2):[BA1]
“Thus far, the criminalization of cannabis has proven to be a failed public health policy for several reasons, including:
a) The diversion of limited economic resources to penal system costs and away from other more socially desirable uses such as funding health care, education, transportation, etc.;
b) The social destruction of family units when cannabis users are incarcerated, rather than offered treatment and other social assistance;
c) The disparate impacts that drug law enforcement practices have on communities of color;
d) The continued demand for cannabis nationally, which supports violent drug cartels from Mexico and other international sources;
e) The failure to decrease national and international supplies of cannabis from criminal and unregulated sources;
f) The failure of the federal government’s limited actions through the ‘War on Drugs’ in mitigating substance abuse and addiction.”
California Medical Association. Cannabis and the Regulatory Void, 2011. https://dfcr.org/wp-content/uploads/2020/01/CA-Medical-Assn_Cannabis_and-the-Regulatory-Void_White_Paper.pdf (accessed Feb 28, 2020).
From a pharmaceutical perspective, botanical cannabis is a very safe drug. In the U.S., tobacco killed almost 500,000 people in 2020, alcohol 95,000. The opioid epidemic was responsible for over 70,000 overdose deaths in 2020, a 30% increase from 2019. By contrast, even though cannabis was first legalized in California 25 years ago and the full plant is now legal (either for medical and/or adult use) in 36 states and the District of Columbia, there has not been a single documented case of death by cannabis overdose.
This is not to dismiss the potential dangers of cannabis use, particularly with cannabis products that contain high concentrations of THC. Approximately 9% of cannabis users exhibit evidence of problematic cannabis use. There is a growing literature suggesting that cannabis may result in persistent psychosis, particularly in individuals at genetic risk for psychotic disorders. Cannabis intoxication, particularly when mixed with alcohol, increases the risk of motor vehicles accidents. Cannabis use during pregnancy is generally ill-advised. Although some studies suggest that cannabis use can be beneficial in the treatment of depression and anxiety, overall the medical literature suggests that the use of cannabis can worsen depression, anxiety, and suicidal thoughts. Adolescents may also be at particularly risk of cannabis-related problems; several studies suggest that heavy cannabis use during adolescence is associated with persisting problems in cognitive functioning, although this finding remains uncertain. Cannabis hyperemesis syndrome, evidenced by severe cycles of nausea, vomiting, and abdominal pain, is now frequently reported in heavy cannabis users, particularly in those using products with high concentrations of THC.