MedicalLarissa Hines, MD,a Jill Glick, Marijuana MD,b Kristin Bilka, MMS, PA-C, bfor John D. Lantos,Minors MDc May Be Considered Child Abuseabstract
The Food and Drug Administration categorizes marijuana (cannabis) as a Schedule I drug, meaning that it has no currently accepted medical use, a high potential for abuse, and no good data on safety. Other Schedule I “ ” drugs are heroin, lysergic acid diethylamide, peyote, methaqualone, and 3,4-methylenedioxymethamphetamine ( ecstasy ). The authors of some studies have shown that marijuana can reduce nausea and vomiting from chemotherapy, can improve food intake in patients with HIV, can reduce neuropathic pain, and may slow the growth of cancer cells. In many states, marijuana use is illegal. No state has approved its use for children. What, then, should doctors do if they become aware that parents are using marijuana to treat medical conditions in their children? What if the children have adverse reactions to the marijuana? In this Ethics Rounds, we present such a case and ask experts in child protection and child abuse to discuss the appropriate response.
aDepartment of Pediatrics, The University of Utah, Salt Lake City, Utah; bDepartment of Pediatrics, The University of The use of marijuana for medical the marijuana? In this Ethics Rounds, Chicago, Chicago, Illinois; and cDepartment of Pediatrics, purposes raises difficult scientific, we present such a case and ask experts Children’s Mercy Hospital, Kansas City, Missouri legal, and ethical questions. The in child protection and child abuse to All authors contributed to the design, drafting, and authors of some studies have shown discuss the appropriate response. review of the manuscript and approved the final that marijuana can reduce nausea and THE CASE manuscript as submitted. vomiting from chemotherapy, can DOI: https://doi.org/10.1542/peds.2017-4310 improve food intake in patients with Accepted for publication Dec 28, 2017 HIV, can reduce neuropathic pain, A 4-year-old boy with a curable and may slow the growth of cancer lymphoma was undergoing Address correspondence to John D. Lantos, MD, 1 Department of Pediatrics, Children’s Mercy cells. Nevertheless, in many states, chemotherapy as an outpatient. Hospital, 2401 Gillham Rd, Kansas City, MO 64108. marijuana use is illegal. No state has One evening, he was brought to the E-mail: [email protected] approved its use for children. The emergency department (ED) for PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, Food and Drug Administration (FDA) altered mental status and vomiting 1098-4275). categorizes it as a Schedule I drug, beginning that morning. The mother Copyright © 2018 by the American Academy of meaning that it has no currently reported that he had been acting Pediatrics accepted medical use, a high potential normal the day before. He had finished FINANCIAL DISCLOSURE: The authors have for abuse, and no good data on safety. 5 days of oral chemotherapy a few indicated they have no financial relationships Other Schedule I drugs are heroin, days before. The mother reported relevant to this article to disclose. ’ lysergic acid diethylamide, marijuana that he had received ondansetron FUNDING: No external funding. (cannabis), peyote, methaqualone, and “ ” at home but that it wasn t working. POTENTIAL CONFLICT OF INTEREST: The authors 3,4-methylenedioxymethamphetamine2 He continued to vomit in the ED. His have indicated they have no potential conflicts of ( ecstasy ). Glasgow Coma Score was 11 to 12 with interest to disclose. nonsensical speech. He had trouble What, then, should doctors do if focusing his eyes and his left pupil To cite: Hines L, Glick J, Bilka K, et al. Medical they become aware that parents are was notably larger than the right. A Marijuana for Minors May Be Considered Child using marijuana to treat medical computed tomography scan of his head Abuse. Pediatrics. 2018;142(4):e20174310 conditions in their children? What if revealed acute intracranial process. An the children have adverse reactions to EEG revealed unremarkable results. Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 4, October 2018:e20174310 ETHICS ROUNDS The results from his brain MRI were these studies have found that there is In this case it is important to weigh unchanged from those of a previous little agreement on what reasonable– not only the harm and/or potential study from a month before. suspicion means and at what level3 5 of for harm to the child from the His mental status improved certainty a report is indicated. The ingestion but also the harm and/ authors of 1 study showed that even or potential for harm by reporting throughout the night without specific ’ treatment. child abuse experts do not agree on to Child Protective Services. This where6 the threshold for reporting child s cancer is likely curable. His toxicology screen results were lies. Without a specific definition Cancer treatment can be toxic, and found to be positive for cannabinoids. or cutoff for reasonable suspicion, the side effects, including nausea and After being presented with this there continues to be7 variability in vomiting, can be difficult to manage. information, the mother told the reporting practices. There are also These side effects can have significant doctors that she had purchased numerous reasons that physicians morbidity. The harm in reporting, marijuana edibles in another state may decide not to make a report, then, includes both the potential where the sale of marijuana is legal. even when there is a suspicion for harm to the child in being denied She had provided the edibles to the child abuse. These reasons include effective treatment, the psychological patient to help with his pain and familiarity with the family, previous harm to the mother in being accused nausea. negative interactions with Child of child abuse, and the burden on an
The child abuse team was consulted Protective Services,8 and resource already stretched and underfunded on whether to report the case to limitations. child protection system. There is Child Protective Services. The Child maltreatment is defined also a possibility that the child would child abuse team asked for an as a situation in which acts (or be removed from his family during ethics consultation. The question omissions) by a caregiver lead to an already stressful time, given the was should we report this as child harm or potential harm to the child. cancer diagnosis, which could cause abuse? Omissions can lead to charges of significant psychological harm. LARISSA HINES, MD, COMMENTS child neglect. Note that intent is not a part of these definitions. Many Now we must consider the ethical perpetrators of child abuse do not dilemma rather than just the legal Pediatricians who specialize in the have a specific intent to harm the mandate. We can consider both the evaluation of child abuse are often child. The majority of states have harm threshold and the best interest asked whether to report a family no laws regarding the obligation to standard. When considering the for suspected child abuse. Ethics report a suspected crime, except in harm threshold, harm was caused consultants can also be helpful in the case of child abuse. to this child, as evidenced by the these situations. ’ altered mental status, from which The question raised by this case, he fully recovered. This mother has Each state has mandatory reporting then, is whether the mother s actions done a good job caring for this child laws. They vary slightly from rise to the level of harm that would who has cancer. However, she gave state to state. In general, medical “ ” mandate a report to Child Protective him a Schedule I narcotic, legally professionals are required to report “ ” Services. available in some states to purchase if they have a reasonable suspicion To answer this, we first have to but illegal here, as a part of caring or reason to believe that abuse has determine if harm or potential harm for him, which, instead of helping occurred. Each state uses different occurred to the child. This child was him, caused him harm. However, specific terminology. However, the seen in the ED and admitted to the given her previous good care of the general principle is the same. To hospital because of the change in child, prompt response to his side adhere to this mandate, we must mental status, which was presumably effects, and apparent intentions that first understand what a reasonable secondary to the marijuana ingestion. she wants to continue to do what is suspicion is and what constitutes Although the symptoms improved, right for the child, it is, in my opinion, child abuse. the giving of marijuana to a child in the best interest of this child to Many authors have attempted to should be considered as harm to the have his mother continue to direct define and understand reasonable child, in much the same way that his medical care, on the condition suspicion. Study authors have bruises or fractures, which go away, that she does not continue to give sought to define reasonable are considered to constitute harm. him tetrahydrocannabinol and cause suspicion and determine thresholds The fact that the child recovered him more harm, at which point this would not only be considered above for reporting among community without any apparent sequelae is ’ professionals, general physicians, and not relevant to the mandate for the legal threshold for reporting subspecialists. The authors of each of reporting. but also no longer in the child s Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 HINES et al best interest. Although intent is not scenario above and in any question We are aware of the drastic an explicit component of reporting of medical neglect, it must be consequences that may follow a laws, it is ethically relevant. This considered. report to child protection. These mother was clearly trying to help consequences could affect the As mandated reporters, we are her son feel better and not trying to “ patient, the parents, the family, and required to call Child Protective harm him. Although her intent was ” the doctor. When we get it right, we Services if we have reasonable cause ’ not to harm, her failure to disclose can halt ongoing maltreatment and to believe that abuse or neglect what she had done initially made ensure a child s safety. But reporting has occurred. Reasonable cause to this clinically more complicated and can also be an adverse event. It can believe means that a person with the “ ” potentially risky and/or harmful to lead to the parent being permanently same level of education and training the patient. Being forthcoming when labeled as a perpetrator, regardless would arrive at the same conclusion using treatments beyond what the of the type of maltreatment. The on the basis of the facts presented. medical team recommends or knows child may be removed from the In some clinical scenarios, the about can present a problem due to home for days or months during threshold to report is well defined. intended consequences, potential the investigation. The physician- If, for instance, an infant presents cross reactions, and other unforeseen family relationship may be damaged, with unexplained bruising and brain consequences. strained, or severed. The parents injury or a child discloses child sexual may never trust a physician again. Although there is a legal mandate abuse, one clearly must report. In The physician may hope for a specific to report, ethically, it would be other cases, such as this one, the intervention as a result of reporting, appropriate to forego reporting. threshold for reporting is fuzzy. only to find child welfare moving in There is no clear answer in this case, Our interdisciplinary child advocacy a different direction. The physician and the decision must be a judgement team meets weekly to review all may sense a loss of control of the call by the providers involved in the consultations of the previous process after the filing occurs. the case. Overall, looking at the ’ week. The most intense discussions A substantiated or indicated report total picture and giving the mother arise from cases in which there is can impact the parents livelihood the benefit of the doubt, I would ambiguity and disagreement about if they are teachers, child care not report in this case. Instead, I our obligation to report a family providers, or in other professions would counsel the mother about the to the child protection authorities. that require background checks. dangers of using marijuana to treat Different child maltreatment her son and give her a stern warning categories require a different Given all of this, should we report that, if this happens again, we would decision algorithm: in the case of this mother for giving her child an be compelled to report her to child a child with physical injuries, we admittedly illegal substance that protection. consider the age of the child, the apparently caused harm? DR JILL GLICK, MD, AND MS KRISTEN nature of the injury, the history BILKA, PA, COMMENT Marijuana legalization is a provided and its plausibility, controversial topic. Study authors the ways in which the caretaker have shown that the 2 main recognized and responded to the cannabinoids from marijuana In the Child Abuse9 Prevention and injury, and any additional clinical reduce nausea and vomiting from Treatment Act, child abuse and findings, such as other occult injuries. “ chemotherapy, improve food neglect are defined as, at a minimum, When determining our obligation intake in patients with HIV, reduce any recent act or failure to act on the to report, we consciously exclude neuropathic pain, and 10may slow the part of a parent or caretaker which previous child welfare involvement growth of cancer cells. results in death, serious physical and avoid speculation about the ” “ or emotional harm, sexual abuse or intent to harm. In cases of medical Still, marijuana is categorized exploitation or an act or failure to neglect, by contrast, we must as a Schedule I drug by the FDA ” act which presents an imminent risk consider whether the provision of (along with heroin and lysergic of serious harm. In the Child Abuse questionable medical care or lack acid diethylamide), indicating no Prevention and Treatment Act, a thereof resulted in harm or potential medicinal use. Nevertheless, 29 states minimal federal standard is defined harm to the child. We consider have legalized medicinal use of this and then each state is required to parental capacity to understand the substance. In most of those states, develop its own definitions of child need for treatment, any barriers it is only legal for adults. Currently, to care, and the resulting harms to abuse and neglect. Note that the ’ legal marijuana for medicinal use legal definition of child abuse does the child. In these situations, we do by children is limited to just a few not include intent; however, in the consider the caretaker s intent. situations, such as the use of cannabis Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 4, October 2018 3 oil for children with intractable In summary, when approaching how Doctors who care for children with seizures. to define the threshold to report diseases or symptoms for which a family to a child welfare system, cannabinoids might be an effective The use of marijuana in any context we must first take into account our treatment have a duty to advocate for is laden with ethical, legal, political, state laws. Our medical opinion, better studies of the efficacy of these economic, and even spiritual however, must be directed by agents in such clinical circumstances. ’ controversies. But the law is fairly many other factors, including an Thus, for children with intractable straightforward. The mother s use understanding of the circumstances seizures or with chemotherapy- and the motivation of the parent. induced nausea and vomiting, we of marijuana in this case was illegal. – And it seems to have led to harm. Child welfare systems rely on medical should have institutional review The mother knowingly took a risk providers to make clear statements board approved protocols in place, and crossed over a legal threshold regarding our medical opinion about and we should seek FDA approval ’ by purchasing marijuana. Each whether a child has been abused or for clinical trials. Children deserve state s child welfare system has neglected. This is a powerful role. We such advocacy, just as they deserve their own definitions of suspected might also use this case to advocate the best medical care that we can maltreatment, and, regardless of our for a change in state laws or policies provide. Nobody would be served ethical opinions, we are obligated regarding the well-intentioned use of by reporting this family to Child ’ to attempt to report this to the marijuana in dire circumstances such ProtectiveAll of the cases Services. in Ethics Rounds ’ child s state welfare system because as the ones that this mother faced. are based on real events. Some marijuana is illegal. We don t know JOHN D. LANTOS, MD, COMMENTS incorporate elements of a number what the response will be. Some state of different cases in order to better child welfare systems may not take highlight a specific ethical dilemma. the report. Many states do not accept Some cases beautifully illustrate reports for in utero exposure of the difference between legal ABBREVIATIONS infants to marijuana. considerations and ethical ones. It may be legally preferable to report That said, we ourselves would feel this family to Child Protective ’ ED: emergency department ambivalent about this case. We Services. It is not ethically preferable. ’ FDA: Food and Drug know that the mother s intent was Child protection laws mandate the Administration to help her child. We can t help but ’ reporting of suspected child abuse. ask ourselves whether, if we were in ’ Nevertheless, in many cases, the this mother s shoes, we would have REFERENCES provider has some discretion in done the same thing. We can t help deciding whether a report to child 1. Cassarett D. Stoned: A Doctor’s Case wondering how we would have felt protection agencies is obligatory. It for Medical Marijuana. New York, NY: if the boy had improved after eating is both necessary and appropriate Penguin Random House; 2015 marijuana macaroons. What if his for doctors to consider the anxiety had resolved, his appetite 2. MedShadow . Drug classifications. ’ circumstances of the case in deciding had improved, and he was no longer Available at: https://medshadow. whether to report. As we know, org/resource/drug-classifications- nauseous? 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Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 4, October 2018 5 Medical Marijuana for Minors May Be Considered Child Abuse Larissa Hines, Jill Glick, Kristin Bilka and John D. Lantos Pediatrics originally published online September 13, 2018;
Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2018/09/11/peds.2 017-4310 References This article cites 6 articles, 2 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2018/09/11/peds.2 017-4310#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Ethics/Bioethics http://www.aappublications.org/cgi/collection/ethics:bioethics_sub Child Abuse and Neglect http://www.aappublications.org/cgi/collection/child_abuse_neglect_s ub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml
Downloaded from www.aappublications.org/news by guest on September 24, 2021 Medical Marijuana for Minors May Be Considered Child Abuse Larissa Hines, Jill Glick, Kristin Bilka and John D. Lantos Pediatrics originally published online September 13, 2018;
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2018/09/11/peds.2017-4310
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
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