Medical Establishment Abandons Patients and Ethics Is There a Doctor (or Nurse) in the House? By Ed Glick
Nursing is caring Twenty years ago I began to learn what real suffering looks and feels like. I watched helplessly while beautiful young men would, in three months time, age 50 years, dying from a disease no one knew anything about at the time.
I have watched tobacco-cancer eat the lungs, livers and hearts out of people. They had no idea, when they began using this legal herb, the consequences in store for them.
I’ve cared for all of these people because they were suffering, and because I am a nurse.
Today I sadly witness another widespread—and preventable—tragedy of human suffering. It is the pain of ill and dying people, legally persecuted for using an illegal herb, and simultaneously denied their appropriate medicine by the medical establishment. This is the everyday experience of cannabis patients, the “untouchables” of American medicine.
I’ve listened countless times as patients beg me to give them something I can’t—permission to use, grow, smoke, eat, and possess one simple herb. They ask me to tell a narcotics “task-force” that they couldn’t find their registry card, or explain to a doctor that the drug keeps them from vomiting up their protease inhibitors.
I’ve been watching this nightmare unfold in slow motion, while the medical system that I thought supported patients consigns them to unnecessary suffering and death.
My nursing education, which taught me all about mitering the corners of bed sheets and the anatomy of disease, never prepared me for this.
Nursing school taught that the essence of nursing is compassion. Yet today, I watch as Oregon’s nursing and physician leaders cause pain and suffering to the very people they are ethically committed to care for. Who forbids a dying cancer patient a safe and natural herb that mitigates some of the worst symptoms of their disease? What kind of society allows legalisms to envelop and destroy an entire class of people, namely cannabis patients? What can I say to these patients, other than “I’m sorry”.
Oregonians to Medical Establishment: “Take Care of ’em” Scientific, historical, and experiential research has described numerous clinical indications for cannabis. The biochemical mechanisms underlying its efficacy are only now being uncovered. Although its primary medical indication is for pain, it is also indicated as an anti-emetic (anti-nausea), anti-spasmotic, intraocular (eye) pressure reducer, anti-anxiety agent, and appetite stimulant—among others. For many sick and suffering people, Cannabis is a good medicine.
On November 3rd 1998, voters approved Ballot Measure 67, The Oregon Medical Marijuana Act, 54% to 45%. Voters’ intention was clear: cannabis patients belong in the medical, not the criminal justice system.
The Oregon Medical Marijuana Act represented a watershed event in Oregon, and nationally, by exempting patients from state criminal sanctions for using cannabis, and by mandating the Department of Human Services (DHS), Health Services (formerly the Oregon Health Division) to establish a registration system on their behalf.
Upon passage, and with such unequivocal voter mandate, the legal protection envisioned by OMMA’S framer’s was finally realized. We thought.
First results were encouraging. Through 1999 and 2000 the Medical Marijuana Program grew rapidly under the leadership of Ms. Kelly Paige, an employee of the Department. By May of 2001 it had grown to include 2800 registrants, with some 550 physicians having registered one or more patients in the Program. This remarkable number represents the highest physician compliance rate in the US. It also reflects the large number of patients in Oregon who use cannabis. And, in the three years that the Medical Marijuana Program has existed, it has afforded some substantial protection to thousands of Oregonians from unwanted contact with police.
But all is not well in this system. Structural flaws and interpretations have left thousands more vulnerable to legal harassment. And, unfortunately, even registrants in the Medical Marijuana Program face frequent police searches because of inadequate possession limits and confusion in the law. At the end of the day, thousands of ill Oregonians still suffer from double exclusion (from both the Medical Marijuana Program, and the medical system), and double inclusion (into the legal and criminal system). This is not what Oregonian voters voted for.
The passage of the OMMA should have ended forever the abuse of cannabis patients at the hands of police and District Attorneys. Unfortunately, it didn’t. In the intervening years, multiple unforseen problems have developed. These include 1. Patient inability to pay the application fee; 2. Inadequate cannabis possession limits; 3. Uncooperative physicians, 4. Obstruction of physicians by the Board of Medical Examiners, and 5. The Oregon DHS’s prohibitive new Administrative Rules. Each of these hurdles effectively pushes patients back into the waiting arms of police and the criminal justice system.
Prohibitive program registration fees have prevented many patients from accessing the program. Chronically ill patients, bankrupted by America’s for-profit medical system, are forced to choose between sending $150 to the Medical Marijuana Program, or paying rent. Some patients resort to selling pharmaceuticals on the black market to raise the funds. As one patient stated at recent Administrative Rules hearings: [The] “Oregon Health Divisions Medical Marijuana Program is a Mafia Protection Racket.”
Yet the Department is currently taking in excess of $350,000 per year in patient money. This income should have allowed for a reduction in the registry fee. It didn’t.
Instead of a reduction in the registry fee, vast sums of patient moneys are being spent by the bureaucrats of the Medical Marijuana Program on Attorney General consultations, and Administrative Rules revisions. These activities have prevented timely processing of applications. Legally, the OMMA requires processing of applications within 30 days. The Department is chronically out of compliance. This great waste of energy has come at the expense—physically, and financially—of the patients whose wellbeing the program is supposed to support.
Impossible plant and medicine possession limits also obstruct patients. The OMMA allows only seven plants, up to three of which can be mature at any time. “Usable” cannabis amounts are tied to the number of flowering plants. Patients are often unable to maintain compliance with these small allowances. If they harvest one plant then the allowable possession limit of cannabis is reduced by one ounce! If they harvest all plants together, or make cuttings, they exceed the limit again. If they grow their seven plants outside, a sensible approach, they end up with seven large flowering plants, and a pound or more of medicine. Most often the problem is simply an inability to grow a quantity of medicine sufficient to meet the patient’s medical needs.
Unfortunately, Administrative Rules don’t address these issues.
Doctors to Patients: “Don’t bug me” An even greater obstacle to patients became apparent in 1999, as large numbers of physicians quietly decided not to participate in the Registry Program. This left chronically ill people all over Oregon searching for a physician who’d sign their form, allowing entry into the Medical Marijuana Program.
Often, the doctor will privately admit to the patient that cannabis appears to be an effective treatment. Still, many physicians refuse to sign the form, citing fear of Drug Enforcement Administration (DEA), or disagreement with cannabis therapy on ideological or medical grounds.
DEA fear is not entirely unjustified. US Attorney General John Ashcroft has shown his disregard for patient suffering by actively arresting physicians and patients, and closing Cannabis Resource Centers in California. There is a possibility that the Attorney General may attack physicians in Oregon, though this has yet to happen. (Amazingly, the Attorney General is fighting Oregon patients on two opposing fronts. He simultaneously opposes terminally ill patients who wish to use drugs to die, and severely ill patients who wish to use drugs to live.)
Unfortunately physician non-participation inevitably pushes the problem back on the patient. This constitutes gross patient abandonment. By protecting themselves from the slight possibility of legal involvement, physicians place their patients directly in the crosshairs of the criminal justice system. Patients are easy prey to well-financed and trained narcotics task-force paramilitaries. In 2001, cannabis patients in Oregon endured numerous knock-and-talk searches and full-blown raids, including the indignity of forced urine collections while handcuffed. In 2002, cannabis patients are arrested and prosecuted because they lack legal and medical protection.
Oregon’s medical establishment has either ignored or exacerbated the problem. The Board of Medical Examiners has initiated a witch-hunt against one physician with the aim of removing his license to practice medicine in Oregon. The Department of Human Services has introduced new rules resulting in a decrease of the numbers of patients who can apply to the medical marijuana program.
Nursing organizations in Oregon have followed in the doctors’ wake, much as women (once) followed men: with silence and acquiescence. Neither the Oregon Nurses Association nor the Oregon State Board of Nursing has addressed the many problems cannabis patients and their nurses face in Oregon. Through simple non-participation, nurses have mostly removed themselves from an issue of great importance to thousands of Oregonians.
Government and Medical Board to Doctor Leveque: “Oh no you don’t!” Into this vacuum of medical conscience stepped one physician: Doctor Philip Leveque, a retired Osteopath from OHSU. Through 2000 and 2001, doctor Leveque signed 800 Medical Marijuana Program applications. His effort allowed virtually any patient suffering from a legally qualifying “Debilitating Medical Condition” to access the safety net of the Medical Marijuana Program. Through these actions, Doctor Leveque prevented a public health emergency by simultaneously integrating large numbers of patients into the medical system, and removing them from the illegal drug underground.
Doctor Leveque was so successful, in fact, that in 2001 both the Oregon DHS and the Board of Medical Examiners undertook investigations of him which continue to this day. Citing concerns about documentation, the validity of the “attending physician relationship”, his “failing to uphold minimum standards of practice”, and now his psychological stability, they are attempting to undo his good work and remove his license to practice. This sends a signal to other physicians to not get involved in OMMA.
These actions are a clear example of a medical system that has distanced itself from the needs of patients, even as it proclaims support for them.
Early Success The Medical Marijuana Program wasn’t always this dysfunc-tional. When Kelly Paige managed it there were big problems, including chronic understaffing, but patient dissatisfaction was not one of them. Ms. Paige was, from the beginning, a serious patient advocate who designed, organized, implemented and operated the program almost single-handedly. She worked hard to educate physicians and register patients. Ms. Paige was so successful that Oregon’s Medical Marijuana Program became the model program for other States with similar laws. She helped implement programs in Hawaii, Maine and Colorado. Unfortunately, Oregon’s registry program was slowly swamped by lack of administrative support and continual rapid growth.
In May of 2001, Willamette Week prepared a story describing a few cases in which patients forged Dr. Leveque’s signature on application forms. In a colossal overreaction to the story, Department of Human Services Director Bob Mink abruptly ordered Ms. Paige’s reassignment. By stating: “I expect more of my programs and managers”, he in effect killed the messenger and ignored the message. The one person who knew the program inside and out was made responsible for problems she had identified, repeatedly communicated and in some cases solved. Citing serious abuses of the program and poor managerial oversight, new program staff were hired and asked to simultaneously learn the program, operate it and rewrite the Administrative Rules. From May, 2002 onwards, the Medical Marijuana Program floundered with inexperienced staff, large backlogs of unprocessed applications and spiraling patient dissatisfaction that continues to this day.
New, “Improved” & User-Unfriendly The culmination of the new staff’s efforts was a set of provisional rules released in November, allowing the Department of Human Services to obtain and review any patient’s medical records to establish a “bona-fide” physician/patient relationship. They also “clarified” the definition of “attending physician” to exclude Dr. Leveque, (or any other physician) from “rubberstamping” patient applications. Additionally, the Department applied the rules retroactively, requiring all of Dr. Leveque’s patients to submit all their medical records for review and/or resubmit another application. Failure to do so would disqualify them from the program. This action in particular caused a collective anxiety attack amongst hundreds of patients who had already gone to great personal effort to comply with the law. Many subsequently gave up.
The Department of Human Services has continued to narrowly interpret the OMMA, to the detriment of patients. In February 2002, Program Managers announced that “designated primary caregivers” may only deliver cannabis to a patient registered to that caregiver. This has the potential to destroy the many advocacy and support organizations that assist patients by sharing medicine with those who have no access.
Legal challenges to this “interpretation” are likely. Unfortunately, police agencies will use this as an opportunity to intensify searches and arrest patients and caregivers. The Department of Human Services bears direct responsibility for the unnecessary suffering of patients and caregivers caught in this legal crossfire.
Cannabis Patients to Medical Establishment: “Get used to us.” Today, there are many thousands of ill Oregonians using cannabis to relieve their symptoms. They use it because cannabis affects “root” physiology of pain, suffering and anxiety. Doctors and nurses know this to be true.
But most cannabis patients in Oregon use cannabis outside of the Medical Marijuana Program, and will continue to do so. Why? For starters, the misfortunes of many of the program’s registrants are not lost on the many disabled, but unregistered, people in this state. These folks have a legitimate interest in registering for the program but, given current conditions, would rather take their chances with the local cops.
Sadly, the current situation pulls patients in two opposite directions: one of promised (but unobtainable) legal protection under the OMMA law; the other of quiet disobedience. Either way, people will continue to use cannabis as a proven effective medicine—and be arrested for it.
The Future Patients in Oregon will receive the medicine they need and cease being the targets of police harassment only when they are fully integrated into the medical system. Until then, cannabis patients will continue to be uniquely vulnerable. Their suffering is needlessly prolonged and exacerbated by the Federal Government’s War on Drugs (WOD) combined with physician and medical system abandonment. We may not be able to do much about the WOD, but we can influence physicians and the medical establishment of Oregon by holding them to the highest medical ethics.
The Health Services’s Mission Statement says it exists “To protect, preserve and promote the health of all the people of Oregon. To prevent unnecessary death and disability, improve the health status, and reduce the per-capita cost of illness care for all Oregonians.” The ethics of medicine and nursing describe a philosophy of compassion that is at the “root” of medical practice. Caring for others is a fundamental quality of civilized society.
Oregon voters clearly expressed themselves in November 1998. Their wishes have only partly materialized.
Edward Glick, RN has been practicing nursing since 1983 in a variety of clinical settings including AIDS, medical, cardiac, ayurvedic, and currently, psychiatric at Good Samaritan Hospital in Corvallis, Oregon. He participated in writing and campaigning for The Oregon Medical Marijuana Act, (1998) and is a member of the DHS’s Debilitating Medical Conditions Advisory Panel (2000).
Ed is founder of “Contigo-Conmigo”, an Oregon educational non-profit corporation (1999), and a co-Chief Petitioner on OMMA-2.
Ed Glick is author of The Oregon Medical Marijuana Guide- A Resource for Patients and Health Care Providers, (2001). Ed can be reached at [email protected]