Ethical Implications of Legalizing Recreational Marijuana

1. Ethical Implications of Legalizing Recreational Marijuana Heidi Keating Master of Public Health, Medical College of WI Faculty Advisor: Dr. Thomas May April 2016

2. Purpose • As of April 2016, recreational marijuana is legal in 4 states plus Washington DC • Colorado, Washington, Oregon, Alaska • Marijuana is classified as a Schedule I drug (great potential for harm and no medicinal value) and remains illegal at the federal level • States allowed to determine how to proceed without interference from federal law enforcement • Use a public health ethics framework to examine the issue of legalizing recreational marijuana

3. Public Health Ethical Framework • Framework influenced by Beauchamp and Childress’ four principles widely used in biomedical ethics • Autonomy: the right of an individual to make his/her own choice • Beneficence: acting with the best interest of the other in mind • Non-maleficence: above all do no harm • Justice: fairness and equality among individuals (Aldcroft, Adrian) • Framework has 3 sections to guide decision-making in order to reach the best possible solution and public health goals • Analysis • Harm related to the issue • Public health goals • Legal scope, stakeholders, and professional code of ethics

4. Public Health Ethical Framework • Framework • Evaluation-Using ethical standards and 4 principles • Utility-balance of benefits over harm • Rights-respect for individual • Justice-benefits and burdens distributed fairly • Common Good-serve the community and not just a few • Virtue/Respect for public institutions-respect of self and civic roles and values • Justification of the decision • Effectiveness—will the public health goals be achieved with this option? • Proportionality-will benefits outweigh infringed morals? • Necessity—is it necessary to override conflicting ethics to achieve goals? • Least infringement-is the action the least intrusive and the least restrictive? (Bernheim)

5. Methods/Research • Research on drug use • National Institute for Drug Abuse • Health and Human Services • Centers for Disease Control and Prevention • Harvard School of Public Health • Research on drug policy • London School of Economics; Expert group on the economics of drug policy • Drug Policy Alliance • Smart Approaches to Marijuana • Ethicists and economists • John Stuart Mill • Milton Friedman • Gerald Dworkin • Joel Feinberg • Doug Bandow

6. Data • Using data to determine the type of harm related to marijuana use • States and voters face complex decisions around marijuana • Is it safe enough to legalize for recreational use? • Will adolescent use increase? • Will adult use increase? • Is the war on drugs effective?

7. Data • Independent scientific committee on drugs used multicriteria decision analysis (MCDA) to score 20 drugs on 16 criteria-9 related to individual harm, 7 related to harm to others

8. Data: Youth • Marijuana use rates for adolescents from Monitoring the Future Study

9. Data: Adults • Colorado use rates: 13.6% according to Behavior Risk Factor Surveillance Survey • From 2010-2014 use rates have remained steady, moving up and down a percentage point between 11% and 13.7% according to the National Survey of Drug Use and Health • Gallup polls report 11% of US adults are current users in 2015, up from 7% in 2013 • 44% of Americans have tried marijuana according to Gallup (2015)

10. Analysis: Public Health Goals • Healthy People 2020 • Reduce substance abuse to protect the health, safety, and quality of life for all, especially children • To achieve health equity, eliminate disparities, and improve the health of all groups • Drug Policy Alliance • Drug policy should cause the least possible harm and the greatest possible benefit • World Health Organization • Prevention and reduction of the negative health and social consequences of psychoactive substance use • Assessment of psychoactive substances so as to advise the United Nations with regard to their regulatory control

11. Analysis: Stakeholders • Pro Legalization • Recreational users • Advocacy groups to reform drug laws to include legalization, taxation, regulation, and education • NORML • Drug Policy Alliance • Law Enforcement Against Prohibition (LEAP) • 58% of the American Public • Support Prohibition • Federal government • Rocky Mountain High Intensity Drug Trafficking Area • Certain states • Community coalitions to prevent youth substance youth

12. Analysis: Professional ethics • In 2002, American Public Health Association adopted “Principles of Ethical Practice of Public Health” • 10 principles that reflect values and purpose of the public health profession including: • PH should address causes of disease, requirements for health, and prevent adverse health outcomes. • Achieve community health in a way that respects the rights of the individual • Work for the empowerment of disenfranchised community members • Implement effective policies and programs that protect and promote health • Provide information • Incorporate a variety of approaches that respect diversity

13. Evaluate: Utility • Utilitarian approach aims to produce the greatest balance of good over harm • “Good” is based on human welfare, pleasure over pain. Expanded to include personal satisfaction and monetary benefits • Utility considers the impact of harm • John Stuart Mill is credited with the harm principle: prevent harm to others

14. Evaluate: Utility (con’t) • Philosopher Joel Feinberg established criteria for harm including: • Magnitude of harm—is the harm a criminal violation or personal interest? • Probability of harm—how dangerous is the activity? • Aggregative harms—notion of banning something that is harmful to some but enjoyable to others. • Marijuana use is a criminal violation for many as current laws stand. One of the greatest harms is not use but criminalization • Use has risk. About 9% of adults who use become addicted, and increase to 17% if use starts during adolescence

15. Evaluate: Utility (con’t) • Teenage use has greatest risk • Negative correlations with grades, college graduation rates, life satisfaction, learning impairment, memory loss, decreased motivation and linkages to schizophrenia • Teenagers have the greatest access to marijuana from the black market • Harm associated with the marketplace • Comparisons to alcohol and tobacco industries • Market to youth • Legalization could make product safer • Regulation • Taxation • Education

16. Evaluate: Rights • A rights approach protects an individual’s ability to determine what to do with one’s life • Many advocacy groups believe legalization is mostly about rights • Rights advocates suggest legalization will not cause widespread harm and there is no proof that it does • Burden of proof should be on those who would make it illegal

17. Evaluate: Rights • Many consider drug use to be dangerous, addictive and harmful • But there are other activities that fit that criteria such as sky diving, gambling, or driving a car • “Adults are entitled to ingest substances even if a majority view that decision foolish.” -John Stuart Mill • “Too much of our policy about illegal drug use is based on generalizations from worst-case scenarios that do not conform to the reality of typical drug use.” –Doug Bandow

18. Evaluate: Rights • Paternalistic government intervention, or using the law to interfere with a person’s liberty for his own good • Paternalism often justified to prevent harm to self, whereby laws are enacted in which individuals give up their autonomy in an effort to keep society safe and ordered • Difference between paternalism and harm to others: Consent • Harm to others principle forbids A from imposing harmful drug to B without B’s consent. If B consents, it is ok for A to give or sell harmful drug • Paternalism: forbids A from delivering dangerous drug to B whether or not B consents

19. Evaluate: Justice • Determines if people are treated equally or proportionately • According to the American Civil Liberties Union, blacks are 3.73 times more likely than whites to be arrested for marijuana possession • A criminal conviction can make it difficult to: • Vote • Obtain educational loans • Get a job • Obtain housing

20. Evaluate: Justice • History of marijuana laws and policy • Fear of Mexican Immigrants during the Great Depression • Reefer Madness, 1936 propaganda film • Suggesting adolescents who smoke marijuana would descend into madness • Marijuana causes violence, insanity, sex crimes • War on Drugs • Strengthen laws and penalties against illegal drugs • Research showed marijuana did not cause people to use harder drugs • Increased incarceration rates

21. Evaluate: Common Good • The best policies that serve the community as a whole, not just some members • Communities are entitled to local control where marijuana is legal • Laws should protect citizens • In a liberal society, government does not need to interfere in what law abiding competent adults can or can’t do as long as there is no harm to others

22. Evaluate: Common Good • Laws based on morality • Murder, rape, theft, fraud • Immoral because of harm to others • Is marijuana prohibition based on morality? • Why is marijuana immoral? • Many users find pleasure in the experience • Why is it ok to experience pleasure from alcohol but wrong to experience pleasure from marijuana?

23. Evaluate: Respect for Public Institutions • Public health as an institution and judging the public health action (prohibition vs legalization) in relation to professional and civic roles • Does the institution demonstrate values such as honesty,transparency, trustworthiness • Role of public health after legalization: • Assessment—monitoring patterns of use, prevalence of use and health effects • Policy development—regulation to protect public health and safety. Includes mass education and prevention efforts • Assurance—ensuring a competent workforce including educating healthcare workers, developing screening tools and evaluation of public risk

24. Justification • Effectiveness of public health goals • Status quo will not reach public health goals • Experts have suggested solutions • IF public health is willing to try new innovative tools • Proportionality • Benefits of reform may include less for non-violent drug use, reduced prison population, increase in state revenue • Necessity • Reform is necessary because the war on drugs has produced negative outcomes • There needs to be a shift from pitting morality and health (prohibition) against liberty and safety (reform) (Kleiman)

25. Justification • Laws should be the least restrictive and the least intrusive • Prohibition is neither • Legalization puts more restrictions on youth access

26. Discussion & Conclusion • Public health goals and legalization are not mutually exclusive • The time for marijuana reformation is now • Do not need to use alcohol and tobacco as the model • Public health ought to promote innovative approaches to reform • Current laws are unjust • Current laws do not protect minors • Use does not automatically mean abuse • Individuals have a right to make their own decisions including what they ingest • Reformation ought to promote the greatest good for the greatest number • Communities should have local control

27. References • Aldcroft, A. (2012, July 13). Measuring the four principles of Beauchamp and Childress. Retrieved March 12, 2016, from Biomed Central: http://blogs.biomedcentral.com/bmcseriesblog/2012/07/13/measuring-the-four-principles-of-beauchamp-and-childress/ • American Civil Liberties Union. (2015). Marijuana Arrests Numbers. Retrieved March 2, 2016, from ACLU: https://www.aclu.org/gallery/marijuana-arrests-numbers • American Public Health Association. (2014, Nov 18). Regulating Commercially Legalized Marijuana as a Public Health Priority. Retrieved March 12, 2016, from American Public Health Association: http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/23/10/17/regulating-commercially-legalized-marijuana-as-a-public-health-priority • Bandow, D. (2012). From Fighting the Drug War to Protecting the Right to Use Drugs. In F. McMahon, Towards a Worldwide Index of Human Freedom (pp. 254-280). Canada: Fraser Institute. • Bernheim, R. G. Ethics in Public Health Practice and Management. In C. B. Lloyd F. Novick (Ed.), Public Health Administration (Second ed., pp. 149-160). Jones and Bartlett Publishers. • Bonde, S., & Firenze, P. (2013, May). A Framework for Making Ethical Decisions. Retrieved Feb 28, 2016, from Brown University: https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions • Caulkins, J. P. (2014). Effects of Prohibition, Enforcement and Interdiction on Drug Use. London School of Economics and Political Science, Expert Group on the Economics of Drug Policy. LSE Idea. • Centers for Disease Control and Prevention. (2016, Jan 12). Data Search Substance Abuse. Retrieved Jan 11, 2016, from HealthyPeople2020: http://www.healthypeople.gov/2020/data-search/Search-the-Data/page/3/0?nid=&items_per_page=10&pop=&ci=&se=&f%5B%5D=field_topic_area%3A3500 • Doyle, J., Evins, E., Miron, J., Grant, I., & McKinley, S. J. (2014, Oct 8). Legalizing Marijuana: The Public Health Pros and Cons. The Forum at Harvard School of Public Health Legalizing Marijuana: The Public Health Pros and Cons. (S. Malone, Interviewer, & S. Malone, Editor)

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