Neuroethics Canada goes green: A year-in-review of medical cannabis research

In collaboration with Canadian Childhood Cannabinoid Clinical TrialsNeuroethics Canada conducted a series of research projects to investigate ethical, legal and social issues surrounding medical cannabis. We studied news media representations of medical cannabis, conducted interviews with clinicians, and held virtual workshops to garner a greater understanding of the perspectives of key stakeholders, and to make recommendations for future medical cannabis research, regulation and use.

Ethical issues at the forefront of news reporting on medical cannabis: Capturing the focus of multiple formats of news media coverage on medical cannabis is essential to understanding how public opinions and public policy are shaped. We studied traditional and alternative news media messaging surrounding medical cannabis and health. Analysis revealed that key ethical, legal and social (ELS) issues were the main focus of both traditional and alternative news articles. Alternative news articles covered ELS issues more in fewer articles, and reported on fewer themes per article. Overall, access was found to be the dominate ELS issue. Multiple factors impacting patient access, such as institutional regulations and supply of products, were reported on in both traditional and alternative sources (Figure 1). In traditional news coverage, institutional gatekeeping of patient access declined significantly post-legalization of adult possession and use of medical cannabis; by comparison, there was no change in alternative news pre- and post-legalization with regard to gatekeeping, although coverage of the access factor of product supply increased post-legalization (Cannabis Act, 17 October 2018). There was limited coverage of issues specific to exceptional populations, including children with neurological and medical disorders and Indigenous peoples. See Gunning and Illes, Coverage of medical cannabis by Canadian news media: Ethics, access and policy, International Journal of Drug Policy, 97, 103361 (2021); and response to publication, International Journal of Drug Policy, under review.

Figure 1: Major access factors by percentage of coverage of the ELS subtheme of access. Minor access factors accounting for less than 5% of total coded references are not shown.

Harm reduction approach for medical cannabis in the care of youth and children: The use of cannabis for medical purposes by youth and children is expanding. However, supporting evidence and federal and local regulations are lacking. Understanding clinician perspectives of this landscape is key for addressing access barriers, and for supporting safe, appropriate use. We interviewed Canadian clinicians practicing in areas related to paediatric medicine including neurology, oncology and palliative care. Clinicians discussed barriers to patient access, chiefly obstacles in the authorization process such as considerations around supply, quality and cost of products. The need for facilitating open, honest clinical communication between patients, caregivers and clinicians was described as essential for ensuring informed consent. As with all other treatment decisions, clinicians described considerations that could mitigate risks, such as life-limiting prognosis and number of tried and failed conventional therapeutic options. Further, they expressed that more methodologically-sound research is essential for expanding medical applications of cannabis. Overall, the discourse aligned with the principles of harm reduction: pragmatism, humanism, harms, and prioritization of immediate goals (Figure 2). Gunning et al., Canadian Medical Association Journal, under review.

Figure 2: Harm reduction approaches employed by clinicians to ensure ethical, safe use of medical cannabis for children and youth.

Building trust in the tense world of medical cannabis: We convened a two-day virtual workshop to discuss ethics and medical cannabis for children and youth in healthcare. Three main topics were covered in each session: (1) the current scientific and regulatory landscape of medical cannabis; (2) surrogate decision-making and assent; and (3) social and political culture of medical cannabis. In attendance were members of the public, ethicists, clinicians, researchers, policy makers, patient representatives, and industry representatives. Despite having a medical cannabis access program in Canada for two decades, participants expressed disappointment that there is still a large amount of uncertainty around medical cannabis due to a lack of data and poor data translation. Also highlighted by participants was the importance of clinicians building trust with patients by demonstrating their trustworthiness in clinical consultation. Respecting patient informed choice, assent and dissent, and understanding and addressing the root cause of clinician hesitancy to authorize were described as ways clinicians can facilitate trust with patients and their caregivers. Participants discussed historical and ongoing stigmatization of medical cannabis and medical cannabis users, particularly of people who are already marginalized within the healthcare system. There were calls for more strength-based research with Indigenous youths’ and communities’ to understand their perspectives on medical cannabis and health. Gunning et al., in preparation.

Our work, including media analyses, interviews, and workshops, highlighted three key areas that will be critical to addressing ongoing issues in the study, regulation, authorization and use of medical cannabis: (1) continued examination of ethics issues surrounding medical cannabis; (2) acquisition of evidence using innovative, adaptive study designs and diverse knowledge systems; and (3) public consultation and engagement with key stakeholders.

Acknowledgments to Dr. Judy Illes, research members Ari Rotenberg and Alissa Wong, project collaborators at Canadian Childhood Cannabinoid Clinical Trials, and members of Neuroethics Canada for their leadership, contributions and continued support.