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Proposition 64, Cannabis Legalization, and the California Secession Movement: Why Should Neurosurgeons Care?
Proposition 64, Cannabis Legalization, and the California Secession Movement: Why Should Neurosurgeons Care? Tobias A. Mattei
In a referendum on 9 November, 2016, the population of California approved by a 57% majority Proposition 64, which makes it legal for individuals 21 years or older to use and grow marijuana for personal consumption in the state.1 It has already been demonstrated that continuous long-term use of cannabis (a threshold of 5000 or more cannabis smoking episodes during a lifetime) is associated with deleterious effects on bone mineral density, leading to an increased risk of associated bone fractures (rate ratio of 2.17 in comparison with “nonheavy” users).2 Neurosurgeons should be aware of such facts not only because of the increased risks of osteoporotic compression fractures in cannabis users but also because of the possible need for more careful screening protocols for osteoporosis/osteopenia before spinal instrumentation in such patients. In terms of public safety, it is important to remember that cannabis has been reported as the second most commonly identified drug in blood samples of drivers involved in automobile accidents. It has been estimated that the risk of road crashes after a recent episode of cannabis use is increased by more than 2.4 fold.3 Several studies have demonstrated that cannabis consumption leads to a significant impairment of driving skills by increasing lane weaving and mean distance headway to the preceding vehicle.4 Besides the well-known acute effects of marijuana utilization on cognitive function and psychomotor skills, studies have also shown a significant long-term dosedependent impairment of such abilities extending several weeks after drug cessation.4 It has also been demonstrated that cannabis users have higher odds of abusing other drugs and becoming dependent on alcohol,5 as well as increased risks for long-term development of psychotic disorders.6 Another concern on the issue is that, in opposition to alcohol consumption, in which there is a relatively linear correlation between the amount of consumed drug, blood drug levels, and psychomotor impairment, there is no clear official scientific or legal consensus about the exact meaning of the term “marijuana intoxication”. In fact, the National Highway Traffic Safety Administration has already officially stated that it is “currently impossible to predict specific effects based on tetrahydrocannabinol carboxylic acid (THC-COOH concentrations)” (i.e., currently available chemical tests are unreliable for
WORLD NEUROSURGERY -: ---, - 2017
establishing whether a person is “driving under the influence” of marijuana).7 Ultimately, in light of the large extensive corpus of already available scientific evidence on the long-term detrimental effects of marijuana use, especially upon cognitive and psychomotor skills,3,4,8 a key question remains: Can professional societies, private companies, or regulatory agencies (such as the ACGME, which oversees postgraduate medical education in the United States), in order to maintain the professional performance of their members within standards of excellence, regulate the consumption of a substance that may be associated with increased risks of accidents, mistakes and undesirable adverse outcomes, but which is endorsed by the highest civil authorities? This assumes special importance taking into account possible liability issues, especially under the legal doctrine of respondeat superior, through which employers may be held accountable for the negligent or reckless behavior of their employees if the inappropriate conduct occurred within the scope of the individual’s employment. However, if employers are supposed to assume the police power abandoned by the state, can’t individuals pursue legal actions against those employers who discriminate against individuals on the basis of their free exercise of a lawful activity? Although, contrary to popular belief, none of the personal liberties secured by the U.S. Constitution apply to nongovernmental activities (i.e., the so-called “State Action Doctrine”), if such institutions are in any way related to the federal or state government (e.g., in the case of Veterans Affairs hospitals), it may be plausible to invoke, for example, the right to privacy (usually justified under the Due Process Clause of the 14th Amendment) against governmental actions that intrude in such personal matters. In fact, the problem of involuntary screening blood drug tests has been the topic of a recent decision by the U.S. Supreme Court. In Birchfield versus North Dakota, in a 7-to-1 majority, the Supreme Court determined that a North Dakota statute which criminalized the refusal of an individual to submit himself to a blood alcohol test (even if found driving intoxicated and having failed the field sobriety and breath test) violates the Fourth Amendment, which prohibits unwarranted searches and seizures.9
www.WORLDNEUROSURGERY.org
1
Figure 1. Supporters of the California secession movement (Calexit) make extensive use of the Bear flag (the original California flag), which is reminiscent of a short-lived, unrecognized breakaway state that lasted for 25 days in 1846 during the Mexican-American War.
For a long time, philosophers, political theorists, and lawmakers have recognized the existence of a salutary tension between individual liberties and social laws aiming to protect the broader public against possible injurious social effects of personal choices. Ultimately, the major challenge at every age and in every society has been how to properly determine where to draw the line beyond which one’s right to self-determination should be officially limited by the organized civil society taking into account the necessity of preserving the safety and welfare of others. As the American forerunner of an excessively libertarian and individualistic ad nauseam worldview that opposes most traditional social values that prioritize the collective safety and welfare, the most populous U.S. state has embarked on a perilous social experiment with unknown long-term health care and social consequences. Interestingly, such an egotistical wave has already sporadically manifested itself in the ‘Golden State’ in several other ways. A major one which has gained significant
REFERENCES
social momentum after the recent presidential election is a secession movement called Calexit (a label carefully selected to take advantage of the recent successful English secession movement, the Brexit - Figure 1). According to the campaign’s official website, “the United States of America represents so many things that conflict with Californian values, and our continued statehood means California will continue subsidizing the other states to our own detriment, and to the detriment of our children.”10 Similarly to what happened with the legalization of marijuana, the decision about exiting the Union (a matter without precedent in more than 200 years of the American constitutional experiment) is expected to be determined by popular vote, with the campaign organizers aiming to qualify the proposal as a citizen’s initiative on the November 2018 ballot, aiming for a vote on the independence question in spring 2019. As brilliantly stated by Dr. Hunt Bajer in the recent AANS presidential address, as neurosurgeons “we stand for something; we stand for excellence.”11 Nevertheless, it may be sometimes quite challenging to reconcile such an intense strife for excellence with an unrelenting and stubborn commitment to some extremist forms of individualistic and libertarian worldviews in which the right to self-determination becomes the supreme value that trumps all other social commitments. In this context, it may be opportune to remind ourselves of the wise words of the 17th century English poet John Donne12: “No man is an island, entire of itself; every man is a piece of the continent, a part of the main.” Or, as the English poet G. K. Chesterton once brilliantly warned13: “Whenever you remove any fence, always pause long enough to ask yourself why it was put there in the first place.”
mineral density and an increased risk of fractures. Am J Med. 2017;130:214-221.
5. Lynskey MT, Heath AC, Bucholz KK, Slutske WS, Madden PA, Nelson EC, et al. Escalation of drug use in early-onset cannabis users vs co-twin controls. JAMA. 2003;289:427-433.
1. California Proposition 64, Marijuana Legalization (2016). Available at: https://ballotpedia.org/Cali fornia_Proposition_64,_Marijuana_Legalization_ (2016). Accessed December 12, 2016.
3. Mura P, Brunet B, Favreau F, Hauet T. Cannabis and road crashes: a survey of recent French studies. Ann Pharm Fr. 2006;64:192-196.
2. Sophocleous A, Robertson R, Ferreira NB, McKenzie J, Fraser WD, Ralston SH. Heavy cannabis use is associated with low bone
4. Bondallaz P, Favrat B, Chtioui H, Fornari E, Maeder P, Giroud C. Cannabis and its effects on driving skills. Forensic Sci Int. 2016;268:92-102.
2
www.SCIENCEDIRECT.com
6. Wilkinson ST, Radhakrishnan R, D’Souza DC. Impact of cannabis use on the development of psychotic disorders. Curr Addict Rep. 2014;1: 115-128.
-: ---, - 2017
WORLD NEUROSURGERY
World Neurosurgery News
7. National Highway Traffic Safety Administration (NHTSA), Drug and Human Performance Fact Sheet. Available at: www.nhtsa.gov/staticfiles/nti/ pdf/809725-DrugsHumanPerformFS.pdf. Accessed December 12, 2016.
ons/15pdf/14-1468_8n59.pdf. Accessed December 12, 2016. 10. The 2019 #Calexit Independence Referendum. Available at: http://www.yescalifornia.org. Accessed December 12, 2016.
8. Broyd SJ, van Hell HH, Beale C, Yücel M, Solowij N. Acute and chronic effects of cannabinoids on human cognition—a systematic review. Biol Psychiatry. 2016;79:557-567.
11. Batjer HH, Ban VS. The 2016 AANS presidential address: leading the way. J Neurosurg. 2016;125: 1325-1336.
9. “Birchfield v North Dakota.” No. 14e1468. Argued April 20, 2016—Decided June 23, 2016. Available at: https://www.supremecourt.gov/opini
12. Donne J. Devotions upon emergent occasions. Meditation XVII, 1624. Available at: http://www.ccel.org/d/ donne/devotions/. Accessed December 12, 2016.
WORLD NEUROSURGERY -: ---, - 2017
13. Chesterton GK. The drift from domesticity. In: The Thing. London: Sheed & Ward, p. 35, 1929. Available at: http://www.azquotes.com/quote/935154. Accessed December 12, 2016.
Neurosurgery and Spine Specialists, Eastern Maine Medical Center, Bangor, Maine 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.wneu.2017.01.066
www.WORLDNEUROSURGERY.org
3
In a referendum on 9 November, 2016, the population of California approved by a 57% majority Proposition 64, which makes it legal for individuals 21 years or older to use and grow marijuana for personal consumption in the state.1 It has already been demonstrated that continuous long-term use of cannabis (a threshold of 5000 or more cannabis smoking episodes during a lifetime) is associated with deleterious effects on bone mineral density, leading to an increased risk of associated bone fractures (rate ratio of 2.17 in comparison with “nonheavy” users).2 Neurosurgeons should be aware of such facts not only because of the increased risks of osteoporotic compression fractures in cannabis users but also because of the possible need for more careful screening protocols for osteoporosis/osteopenia before spinal instrumentation in such patients. In terms of public safety, it is important to remember that cannabis has been reported as the second most commonly identified drug in blood samples of drivers involved in automobile accidents. It has been estimated that the risk of road crashes after a recent episode of cannabis use is increased by more than 2.4 fold.3 Several studies have demonstrated that cannabis consumption leads to a significant impairment of driving skills by increasing lane weaving and mean distance headway to the preceding vehicle.4 Besides the well-known acute effects of marijuana utilization on cognitive function and psychomotor skills, studies have also shown a significant long-term dosedependent impairment of such abilities extending several weeks after drug cessation.4 It has also been demonstrated that cannabis users have higher odds of abusing other drugs and becoming dependent on alcohol,5 as well as increased risks for long-term development of psychotic disorders.6 Another concern on the issue is that, in opposition to alcohol consumption, in which there is a relatively linear correlation between the amount of consumed drug, blood drug levels, and psychomotor impairment, there is no clear official scientific or legal consensus about the exact meaning of the term “marijuana intoxication”. In fact, the National Highway Traffic Safety Administration has already officially stated that it is “currently impossible to predict specific effects based on tetrahydrocannabinol carboxylic acid (THC-COOH concentrations)” (i.e., currently available chemical tests are unreliable for
WORLD NEUROSURGERY -: ---, - 2017
establishing whether a person is “driving under the influence” of marijuana).7 Ultimately, in light of the large extensive corpus of already available scientific evidence on the long-term detrimental effects of marijuana use, especially upon cognitive and psychomotor skills,3,4,8 a key question remains: Can professional societies, private companies, or regulatory agencies (such as the ACGME, which oversees postgraduate medical education in the United States), in order to maintain the professional performance of their members within standards of excellence, regulate the consumption of a substance that may be associated with increased risks of accidents, mistakes and undesirable adverse outcomes, but which is endorsed by the highest civil authorities? This assumes special importance taking into account possible liability issues, especially under the legal doctrine of respondeat superior, through which employers may be held accountable for the negligent or reckless behavior of their employees if the inappropriate conduct occurred within the scope of the individual’s employment. However, if employers are supposed to assume the police power abandoned by the state, can’t individuals pursue legal actions against those employers who discriminate against individuals on the basis of their free exercise of a lawful activity? Although, contrary to popular belief, none of the personal liberties secured by the U.S. Constitution apply to nongovernmental activities (i.e., the so-called “State Action Doctrine”), if such institutions are in any way related to the federal or state government (e.g., in the case of Veterans Affairs hospitals), it may be plausible to invoke, for example, the right to privacy (usually justified under the Due Process Clause of the 14th Amendment) against governmental actions that intrude in such personal matters. In fact, the problem of involuntary screening blood drug tests has been the topic of a recent decision by the U.S. Supreme Court. In Birchfield versus North Dakota, in a 7-to-1 majority, the Supreme Court determined that a North Dakota statute which criminalized the refusal of an individual to submit himself to a blood alcohol test (even if found driving intoxicated and having failed the field sobriety and breath test) violates the Fourth Amendment, which prohibits unwarranted searches and seizures.9
www.WORLDNEUROSURGERY.org
1
Figure 1. Supporters of the California secession movement (Calexit) make extensive use of the Bear flag (the original California flag), which is reminiscent of a short-lived, unrecognized breakaway state that lasted for 25 days in 1846 during the Mexican-American War.
For a long time, philosophers, political theorists, and lawmakers have recognized the existence of a salutary tension between individual liberties and social laws aiming to protect the broader public against possible injurious social effects of personal choices. Ultimately, the major challenge at every age and in every society has been how to properly determine where to draw the line beyond which one’s right to self-determination should be officially limited by the organized civil society taking into account the necessity of preserving the safety and welfare of others. As the American forerunner of an excessively libertarian and individualistic ad nauseam worldview that opposes most traditional social values that prioritize the collective safety and welfare, the most populous U.S. state has embarked on a perilous social experiment with unknown long-term health care and social consequences. Interestingly, such an egotistical wave has already sporadically manifested itself in the ‘Golden State’ in several other ways. A major one which has gained significant
REFERENCES
social momentum after the recent presidential election is a secession movement called Calexit (a label carefully selected to take advantage of the recent successful English secession movement, the Brexit - Figure 1). According to the campaign’s official website, “the United States of America represents so many things that conflict with Californian values, and our continued statehood means California will continue subsidizing the other states to our own detriment, and to the detriment of our children.”10 Similarly to what happened with the legalization of marijuana, the decision about exiting the Union (a matter without precedent in more than 200 years of the American constitutional experiment) is expected to be determined by popular vote, with the campaign organizers aiming to qualify the proposal as a citizen’s initiative on the November 2018 ballot, aiming for a vote on the independence question in spring 2019. As brilliantly stated by Dr. Hunt Bajer in the recent AANS presidential address, as neurosurgeons “we stand for something; we stand for excellence.”11 Nevertheless, it may be sometimes quite challenging to reconcile such an intense strife for excellence with an unrelenting and stubborn commitment to some extremist forms of individualistic and libertarian worldviews in which the right to self-determination becomes the supreme value that trumps all other social commitments. In this context, it may be opportune to remind ourselves of the wise words of the 17th century English poet John Donne12: “No man is an island, entire of itself; every man is a piece of the continent, a part of the main.” Or, as the English poet G. K. Chesterton once brilliantly warned13: “Whenever you remove any fence, always pause long enough to ask yourself why it was put there in the first place.”
mineral density and an increased risk of fractures. Am J Med. 2017;130:214-221.
5. Lynskey MT, Heath AC, Bucholz KK, Slutske WS, Madden PA, Nelson EC, et al. Escalation of drug use in early-onset cannabis users vs co-twin controls. JAMA. 2003;289:427-433.
1. California Proposition 64, Marijuana Legalization (2016). Available at: https://ballotpedia.org/Cali fornia_Proposition_64,_Marijuana_Legalization_ (2016). Accessed December 12, 2016.
3. Mura P, Brunet B, Favreau F, Hauet T. Cannabis and road crashes: a survey of recent French studies. Ann Pharm Fr. 2006;64:192-196.
2. Sophocleous A, Robertson R, Ferreira NB, McKenzie J, Fraser WD, Ralston SH. Heavy cannabis use is associated with low bone
4. Bondallaz P, Favrat B, Chtioui H, Fornari E, Maeder P, Giroud C. Cannabis and its effects on driving skills. Forensic Sci Int. 2016;268:92-102.
2
www.SCIENCEDIRECT.com
6. Wilkinson ST, Radhakrishnan R, D’Souza DC. Impact of cannabis use on the development of psychotic disorders. Curr Addict Rep. 2014;1: 115-128.
-: ---, - 2017
WORLD NEUROSURGERY
World Neurosurgery News
7. National Highway Traffic Safety Administration (NHTSA), Drug and Human Performance Fact Sheet. Available at: www.nhtsa.gov/staticfiles/nti/ pdf/809725-DrugsHumanPerformFS.pdf. Accessed December 12, 2016.
ons/15pdf/14-1468_8n59.pdf. Accessed December 12, 2016. 10. The 2019 #Calexit Independence Referendum. Available at: http://www.yescalifornia.org. Accessed December 12, 2016.
8. Broyd SJ, van Hell HH, Beale C, Yücel M, Solowij N. Acute and chronic effects of cannabinoids on human cognition—a systematic review. Biol Psychiatry. 2016;79:557-567.
11. Batjer HH, Ban VS. The 2016 AANS presidential address: leading the way. J Neurosurg. 2016;125: 1325-1336.
9. “Birchfield v North Dakota.” No. 14e1468. Argued April 20, 2016—Decided June 23, 2016. Available at: https://www.supremecourt.gov/opini
12. Donne J. Devotions upon emergent occasions. Meditation XVII, 1624. Available at: http://www.ccel.org/d/ donne/devotions/. Accessed December 12, 2016.
WORLD NEUROSURGERY -: ---, - 2017
13. Chesterton GK. The drift from domesticity. In: The Thing. London: Sheed & Ward, p. 35, 1929. Available at: http://www.azquotes.com/quote/935154. Accessed December 12, 2016.
Neurosurgery and Spine Specialists, Eastern Maine Medical Center, Bangor, Maine 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.wneu.2017.01.066
www.WORLDNEUROSURGERY.org
3