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NATIONAL HARBOR, Md. -- The American Medical Association (AMA) should work to educate physicians and the public on the health risks of cannabis to children as well as potential risks to people who are pregnant or breastfeeding, members of the AMA House of Delegates voted Monday.

"My patients are often surprised to hear me say that cannabis should not be used during pregnancy," said Albert Hsu, MD, of Columbia, Missouri, a delegate for the American Society of Reproductive Medicine who was speaking for himself. "My lonely voice is drowned out by TikTok, social media, and all the others advertising cannabis to my patients, including those who are pregnant."

"I try to tell my patients that taking a neuroactive drug while the fetal brain is under development is simply not a good idea," he added. However, "my patients are inundated with marketing on the wonderful health-promoting benefits" of cannabis. Hsu was speaking against a motion by the Ohio delegation to delete a reference committee recommendation that the AMA "support using existing AMA channels to educate physicians and the public on the dangers of cannabis to children and people who are pregnant or breastfeeding."

Concerns About the Evidence

"The concern with this [recommendation] is that the data on actual dangers is limited to Level 2 or worse, similar to what exists for Tylenol or epidurals in pregnancy," said Tani Malhotra, MD, a maternal/fetal medicine physician in Parma, Ohio, who spoke for the delegation. "I'm not condoning cannabis use in pregnancy, but rather, urging that we recognize the limitations of data. As physicians, we must be careful not to confuse association with causation, especially as the overwhelming majority of pregnancy criminalization cases are related to allegations of substance use."

Woody Jenkins, MD, of Stillwater, Oklahoma, who spoke for the Oklahoma delegation, agreed with Hsu. "Oklahoma has created the world's wildest weed market, and from where I work in rural Oklahoma, we have a serious problem," he said. "Our state has earned the name 'Toke-lahoma,' with roughly 11,000 licensed cannabis dispensaries and nearly 10% of the population in medical cannabis programs. In Oklahoma, we've seen consultants for dispensaries help staff and customers choose the best strains for their conditions. This is being pushed as science and gets amplified through social media."

"It is just wrong to go to a bowling alley where children are exposed to TVs showing cannabis dispensary advertisements," added Jenkins. "Science, not public opinion or a personal agenda, should guide local and state policy; we oppose this motion to delete."

Frank Dowling, MD, an addiction and psychiatric medicine physician from Islandia, New York, who was speaking for himself, disagreed. "The way this is worded, I can easily see overzealous prosecutors saying, 'The AMA talks about the dangers of cannabis and that's the policy,' as opposed to 'Let's educate about risks.'"

"I could cite six different examples of people struggling with an ethical and moral dilemma of being forced to work for a police state to report pregnant women or women who have given birth just because they may have used a substance without knowing they were pregnant -- and stopping when they did," said Dowling. "I don't believe that's what was intended in this writing here, but the fear is this becomes part of that arsenal."

The delegates voted 274-332 not to delete that recommendation; they also voted in favor of referring back to the AMA Board of Trustees a recommendation that the AMA "support and encourage state regulation of therapeutic claims in cannabis advertising."

"I used to work for state regulation, and I am concerned about the state of the science," said Arlene Seid, MD, of Grantham, Pennsylvania, a delegate for the American Association of Public Health Physicians who was speaking for herself. "Without good state of the science you end up with bad state regulation. For these reasons I support referral."

Resolution on Physician-Assisted Suicide

Delegates also discussed a asking that the AMA reconsider its position on physician-assisted suicide, also called medical aid in dying. The resolution noted that the association's current position is that "physician-assisted suicide is fundamentally incompatible with the physician's role as healer," and it suggested that the AMA "study changing our existing position on medical aid in dying, including reviewing government data, health services research, and clinical practices in domestic and international jurisdictions where it is legal.

"When I was president of the Massachusetts Medical Society, we addressed these issues at great length in our House of Delegates, and found that one of the major problems that we had were simply the labels that were being applied," said Hank Dorkin, MD, of Newton, Massachusetts, a Massachusetts delegate who was speaking for himself. "One group finds 'physician-assisted suicide' to be absolutely insulting, and the other group finds the term 'medical aid in dying' just as insulting -- after all, they spent their whole careers caring for dying patients. How dare someone conflate it, that the only thing considered medical aid in dying is writing such a prescription?"

"We ended the problem by simply defining what this was -- the act of the physician writing the prescription, rather than referring to it with labels," he said. "I think what we need to do is concentrate on the issue at hand and try to avoid the labels, but I think the AMA has to come up with a better label than the ones that have been used to date."

New Label Proposed

Dorkin proposed "end-of-life expanded treatment options" as a possible new label, and also urged the AMA to adopt policy opposing criminal or civil penalties against physicians who participate in medical aid in dying.

Michael Brisman, MD, of Old Westbury, New York, liked the proposal.

"I do think the way we use the terms matters. 'Physician-assisted suicide' is problematic because we don't want to help someone whose girlfriend just broke up with them, but someone who's on the verge of death an hour later and is in excruciating pain, helping them is perfectly reasonable," said Brisman, a New York State delegate who was speaking for himself. "I certainly think that not holding criminal charges against doctors who are trying to help their dying terminal patients is very appropriate."

The delegates ended up voting in favor of Dorkin's proposals, but later voted to send that portion of the resolution -- along with other parts of it -- to the Board of Trustees for further study.

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