1. Californian vs. Federal Marijuana Laws, and Healthcare
By Oleg Nekrassovski
The present paper contrasts California’s Medical Marijuana Regulation and Safety Act
with marijuana enforcement provisions of the federal Controlled Substances Act; while
taking a look at the possible current and future effects of the two legislations on
healthcare in California, in particular, and the United States, in general.
Major Provisions of Each Legislation
California’s Medical Marijuana Regulation and Safety Act:
California’s Medical Marijuana Regulation and Safety Act was enacted on Sept. 11,
2015 and went into effect on January 1, 2016. It created a comprehensive state
licensing system for the commercial cultivation, manufacturing, testing, distribution, and
retail sale of medical marijuana (California NORML, 2015). However, the State of
California does not believe that it will set up the necessary regulations, information
systems, and agencies, to actually begin issuing licenses, until January 2018. Until
then, local governments are free to prepare for state licensing by adopting new
ordinances to license or permit local businesses (California NORML, 2015).
Marijuana enforcement under the Controlled Substances Act:
The Controlled Substances Act is a federal legislation which was first enacted in 1970,
and since then, has been amended multiple times (U.S. Department of Justice, Drug
Enforcement Administration, Office of Diversion Control, n.d.). And in 2009 and 2011,
the U.S. Department of Justice issued guidance to federal prosecutors regarding
marijuana enforcement under the Controlled Substances Act (Cole, 2013). This
guidance was aimed at helping to further the objectives, of the U.S. Department of
Justice, concerned with marijuana; in light of the fact that several states have earlier
enacted laws relating to the use of marijuana for medical purposes (Cole, 2013). In
addition, this guidance has been recently updated, owing to the fact that multiple states
have made ballot initiatives aimed at legalizing, under state law, the possession of small
quantities of marijuana, together with establishing mechanisms for the regulation of the
production, processing and sale of marijuana (Cole, 2013).
The updated guidance, for federal prosecutors, applies to all federal enforcement
activity, including criminal investigations, prosecutions, and civil enforcement, regarding
marijuana in all states (Cole, 2013). It notes that the Congress has decided that
"marijuana is a dangerous drug and that the illegal distribution and sale of marijuana is
a serious crime that provides a significant source of revenue to large-scale criminal

2. enterprises, gangs, and cartels” (Cole, 2013, p. 1). It also notes that the primary
objectives, of the U.S. Department of Justice, regarding marijuana enforcement are:
Preventing marijuana from being distributed to minors (Cole, 2013).
Preventing criminal enterprises, gangs, and cartels from being financed by any
revenue from the sale of marijuana (Cole, 2013).
Preventing marijuana, from states where, under state law, it is legal in some
form, from being diverted to other states (Cole, 2013).
“Preventing state-authorized marijuana activity from being used as a cover or
pretext for the trafficking of other illegal drugs or other illegal activity” (Cole, 2013,
p. 1).
Preventing the cultivation and distribution of marijuana from being accompanied
by violence and the use of firearms (Cole, 2013).
Preventing the use of marijuana from leading to drugged driving and other
adverse public health consequences (Cole, 2013).
Preventing marijuana from being grown on public lands (Cole, 2013).
Preventing the possession or use of marijuana on federal property (Cole, 2013.)
Finally, the updated guidance specifically elaborates on marijuana enforcement, by
federal prosecutors, in states whose laws authorize the cultivation and distribution of
marijuana for medical use. In particular, it advises federal prosecutors to avoid focusing
their marijuana enforcement efforts on seriously ill individuals or their individual
caregivers; while encouraging them to focus on large-scale, for-profit, commercial
marijuana enterprises, instead (Cole, 2013).
Effects of Each Legislation on the Quality of Patient Care
Background:
In oncology, marijuana or its derivatives may prove to be useful as antitumor agents, as
well as in the treatment of refractory cancer pain, and anticipatory and refractory
chemotherapy-induced nausea and vomiting (Wilkie, Sakr, & Rizack, 2016). However,
most of the data that suggests these possibilities comes from studies that are outdated,
were conducted on animals, or involved small clinical trials (Wilkie, Sakr, & Rizack,
2016).
Similarly, according to the National Institute of Drug Abuse (n.d.), marijuana contains
two chemicals of potential medical value: THC and CBD. THC may prove to be effective
in decreasing pain, inflammation, and muscle control problems. While CBD, which, by
itself, doesn’t affect the mind or behavior, may prove to be useful in “reducing pain and

3. inflammation, controlling epileptic seizures, and possibly even treating mental illness
and addictions” (National Institute of Drug Abuse, n.d.).
California’s Medical Marijuana Regulation and Safety Act:
As has already been shown, California’s Medical Marijuana Regulation and Safety Act
clearly seeks to increase the availability of marijuana and its derivatives, for medical
purposes (California NORML, 2015). However, since, at present, there is no conclusive
evidence regarding the efficacy of marijuana or its derivatives in the treatment or
alleviation of any medical conditions (Wilkie, Sakr, & Rizack, 2016; National Institute of
Drug Abuse, n.d.); it is unclear what, if any, effects this law already has or will have on
the quality of patient care in California.
Marijuana enforcement under the Controlled Substances Act:
As has already been shown, the primary objectives, of the U.S. Department of Justice,
regarding marijuana enforcement under the Controlled Substances Act, don’t have
anything to do directly with the actual or potential uses of marijuana for patient care
(Cole, 2013). Therefore, there is little, if any, reason to believe that these enforcement
guidelines have or will have any effect on the quality of patient care anywhere in the
United States.
Effects of Each Legislation on the Effectiveness of Health Care Organizations
California’s Medical Marijuana Regulation and Safety Act:
This legislation is already turning California’s marijuana industry, from a small-scale,
underground industry, into a legitimate, highly profitable, big business; a process which
is only expected to accelerate (Lovett, 2016). Hence, any Californian healthcare
organizations with financial stakes in the marijuana industry, are likely already becoming
better financed, and can be expected to become even more so, in the future. And it is
clear that better financed healthcare organizations are less likely to experience
budgetary stress. While budgetary stress often has grave consequences for the
effectiveness of healthcare organizations. For example, Mukamel, Zwanziger, &
Bamezai’s (2002) study, of Californian hospitals that were undergoing budgetary stress,
found that the hospitals under study responded to budgetary stress by cutting back on
clinical services; leading to an increase in mortality of their patients.
Marijuana enforcement under the Controlled Substances Act:
As has already been shown, the primary objectives, of the U.S. Department of Justice,
regarding marijuana enforcement under the Controlled Substances Act, don’t have

4. anything to do directly with the actual or potential uses of marijuana for patient care
(Cole, 2013). However, the Controlled Substances Act makes it clear that aiding or
abetting someone to unlawfully dispense, distribute, or possess marijuana, or conspiring
with someone to do the same, is a punishable offense (California Medical Association,
2011).
Given that physicians, in many states, are authorized to recommend marijuana to their
patients (National Conference of State Legislatures, 2016), they are well positioned to
aid, abet, or conspire with someone to unlawfully dispense, distribute, or possess
marijuana. While federal sanctions of physicians who commit such acts may seriously
compromise the effectiveness of healthcare organizations that employ them.
In particular, federal sanctions of physicians, who violate marijuana enforcement
provisions of the Controlled Substances Act, include:
Imprisonment (often extending for years), or a fine (often in the hundreds of
thousands of dollars), or both (California Medical Association, 2011).
Revocation of the physician’s registration with the Drug Enforcement
Administration (California Medical Association, 2011).
Mandatory exclusion from participation in Medicare and similar state-level
reimbursement programs (California Medical Association, 2011).
Hence, physicians, who violate marijuana enforcement provisions of the Controlled
Substances Act, may seriously undermine the effectiveness of healthcare organizations
that employ them by becoming unavailable for medical practice (due to imprisonment or
ineligibility to prescribe medications), and/or by putting their organizations at risk of
becoming excluded from Medicare and similar state-level programs (for those
organizations that participate in them).
There are some strong factors which may compel a physician to aid, abet, or conspire
with someone to unlawfully dispense, distribute, or possess marijuana. In particular,
marijuana is a popular, highly demanded, recreational drug, on which many people are
dependent (Office of National Drug Control Policy, 2010). In addition, some states are
known to have legal, “lucrative clinics with salaried physicians who specialize in
providing medical cannabis recommendations, potentially for undocumented medical
conditions” (California Medical Association, 2011, p. 4).

5. Effects of Each Legislation on Sustainability of Healthcare Organizations
Background:
Following Moizer and Tracey (2010), organizational sustainability will be defined here as
consisting of two mutually-dependent categories: financial sustainability and stakeholder
sustainability. Financial sustainability involves the organization's ability to generate
sufficient revenue through their business/commercial activities and/or receive
sufficient funds/donations, so as to continue organizational operations. As a
result, stakeholder sustainability involves the organization's ability to maintain
legitimacy/support among its "profit-relevant" stakeholders (such as investors and
customers) or its "social value-relevant" stakeholders (such as donors and funding
agencies).
California’s Medical Marijuana Regulation and Safety Act:
As already explained, thanks to this legislation, any Californian healthcare organizations
with financial stakes in the marijuana industry, are likely already becoming better
financed, and can be expected to become even more so, in the future. And it is clear
that better financed healthcare organizations are more likely to have better financial and
stakeholder sustainability.
Marijuana enforcement under the Controlled Substances Act:
As has already been shown, in those states where physicians are authorized to
recommend marijuana to their patients; they are automatically well positioned to violate
marijuana enforcement provisions of the Controlled Substances Act.
It has also already been shown that those physicians, who get federally sanctioned for
violating marijuana enforcement provisions of the Controlled Substances Act, will:
Experience the stigma of federal prosecution, which may also attach to the
healthcare organizations that employ them.
Become unavailable for medical practice (due to imprisonment or ineligibility to
prescribe medications).
Put their organizations at risk of becoming excluded from Medicare and similar
state-level programs (for those organizations that participate in them).
Hence, it is clear that physicians, who violate marijuana enforcement provisions of the
Controlled Substances Act, may seriously undermine both the financial and the
stakeholder sustainability of the organizations that employ them.

6. Ethical Issues that Could Arise Through Compliance with Each Legislation
Background:
It appears that an overwhelming majority of secular discussions, in the United States, of
ethical issues inherent in legalization and usage of marijuana, focus on the possible
health benefits versus health risks of marijuana usage (see, e.g., Clark, Capuzzi, & Fick,
2011; ProCon.org, n.d.) and, to a lesser extent, on its alleged ability to lead to excessive
numbers of prison sentences and consumption of other drugs (see, e.g., Sorkin, 2015),
and to environmental degradation (see, e.g., Thomson, 2013).
So, embarrassingly enough, apparently, only American writers with a clear religious
agenda, bother to address, the ethics of legalization and usage of marijuana, from the
perspective of moral philosophy. For example, both Brugger (2013) and pastor Bob
Enyart (2012) argue that the usage of marijuana, especially recreationally, is morally
wrong; simply because it leads to intoxication, which causes the user to lose full control
of their mental and moral faculties; thus, making them a danger to themselves and
others. However, even such writers heavily focus their treatises, on this subject, on the
possible risks and benefits, of marijuana usage, to individual health.
California’s Medical Marijuana Regulation and Safety Act:
As already explained, thanks to this legislation, any Californian healthcare organizations
with financial stakes in the marijuana industry, are likely already becoming better
financed, and can be expected to become even more so, in the future. However,
investing in the marijuana industry or receiving funds/donations from it may be viewed
as unethical by those who see the marijuana industry as an unethical industry.
Marijuana enforcement under the Controlled Substances Act:
The First Amendment to the Constitution of the United States grants physicians the right
to recommend consumption of marijuana, to their patients, as a form of medical
treatment (California Medical Association, 2011). Thus, allowing those physicians, who
feel that marijuana may be beneficial to the health of a particular patient, to recommend
marijuana to that patient.
Given that the First Amendment, for now, supersedes the Controlled Substances Act
and any recent rulings on it (California Medical Association, 2011); while marijuana
enforcement provisions of the Controlled Substances Act are purely prohibitive, in their
treatment of marijuana (California Medical Association, 2011); it is unclear what, if any,
ethical issues can arise for healthcare organizations or healthcare professionals from
complying with the marijuana enforcement provisions of the Controlled Substances Act.

7. References
Brugger, C. (2013). Legalization of marijuana: Some ethical reflections on pot smoking.
Retrieved from http://www.cultureoflife.org/2013/02/20/legalization-marijuana-
some-ethical-reflections-pot-smoking/
California Medical Association. (2011). Physician recommendation of medical cannabis.
Retrieved from http://mbc.ca.gov/Licensees/Prescribing/medical_marijuana_cma-
recommend.pdf
California NORML. (2015). Cal NORML: A summary of the Medical Marijuana
Regulation and Safety Act (MMRSA). Retrieved from
http://www.canorml.org/news/A_SUMMARY_OF_THE_MEDICAL_MARIJUANA_
REGULATION_AND_SAFETY_ACT
Clark, P. A., Capuzzi, K., & Fick, C. (2011). Medical marijuana: Medical necessity
versus political agenda. Medical Science Monitor, 17(12), RA249-RA261.
doi: 10.12659/MSM.882116
Cole, J. M. (2013). Memorandum for all United States attorneys: Subject: Guidance
regarding marijuana enforcement. Washington, D.C.: U.S. Department of Justice,
Office of the Deputy Attorney General. Retrieved from
https://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf
Enyart, B. (2012, May 19). Why marijuana should be illegal. The Huffington Post.
Retrieved from http://www.huffingtonpost.com/bob-enyart/why-marijuana-should-
be-i_b_1340311.html
Lovett, I. (2016, April 11). In California, marijuana is smelling more like big business.
The New York Times. Retrieved from http://www.nytimes.com/2016/04/12/us/in-
california-marijuana-is-smelling-more-like-big-business.html?_r=1
Moizer, J., & Tracey, P. (2010). Strategy making in social enterprise: The role of
resource allocation and its effects on organizational sustainability. Systems
Research and Behavioral Science, 27(3), 252-266. doi: 10.1002/sres.1006
Mukamel, D. B., Zwanziger, J., & Bamezai, A. (2002). Hospital competition, resource
allocation and quality of care. BMC Health Services Research, 2(10), 1-9. doi:
10.1186/1472-6963-2-10
National Conference of State Legislatures. (2016). State medical marijuana laws.
Retrieved from http://www.ncsl.org/research/health/state-medical-marijuana-
laws.aspx

8. National Institute of Drug Abuse. (n.d.). DrugFacts: Is marijuana medicine? Retrieved
July 18, 2016 from https://www.drugabuse.gov/publications/drugfacts/marijuana-
medicine
Office of National Drug Control Policy. (2010). What Americans need to know about
marijuana: Important facts about our nation’s most misunderstood illegal drug.
Retrieved from https://www.ncjrs.gov/ondcppubs/publications/pdf/mj_rev.pdf
ProCon.org. (n.d.). Should the government prohibit physicians from recommending
medical marijuana? Retrieved July 20, 2016 from
http://medicalmarijuana.procon.org/view.answers.php?questionID=000627
Sorkin, A. R. (2015, January 12). Ethical questions of investing in pot. The New York
Times. Retrieved from http://dealbook.nytimes.com/2015/01/12/ethical-questions-
of-investing-in-pot/?_r=0
Thomson, A. (2013). The ethics of legalizing medical marijuana. Retrieved from
http://www.brandeis.edu/ethics/ethicalinquiry/2013/July.html
U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion
Control. (n.d.). Title 21 United States Code (USC) Controlled Substances Act –
Section 801. Retrieved from
http://www.deadiversion.usdoj.gov/21cfr/21usc/801.htm
Wilkie, G., Sakr, B., & Rizack, T. (2016). Medical marijuana use in oncology: A
review. JAMA Oncology, 2(5), 670-675. doi:10.1001/jamaoncol.2016.0155