UNITED STATES DISTRICT COURT
I, Dr. Ernest H. Rosenbaum, declare as follows:
1. I am a physician licensed to practice in the States of California. I am Board-certified in Internal Medicine and Medical Oncology, with special interests in Medical Oncology, Hematology, and Preventive Medicine. I received my M.D. degree from the University of Colorado School of Medicine in Denver in 1956, after which I completed a one-year Internship at San Francisco General Hospital (1956-1957). This was followed by a residency in Internal Medicine, also at San Francisco General Hospital (1957-1958). I went on to complete a second residency, this one in Internal Medicine at Mount Zion Hospital and Medical Center in San Francisco (1958-1959). I have remained closely associated with that institution throughout my career.
2. After my formal training, I joined the United States Air Force, serving as Chief of Allergies and Air Force Polio Center, Internal Medicine from 1959 through 1961. Upon leaving the service, I was awarded a Fellowship in Hematology at the Blood Research Laboratory, New England Centers Hospital, Tufts University – School of Medicine (1961-1963). I studied molecular genetics, radioisotopes, immunology and biochemistry at the Massachusetts Institute of Technology
3. In 1963, I returned to San Francisco where I entered into private practice with the Hematology and Oncology Medical Association until 1994. In 1967, I accepted the position of Associate Chief of the Department of Medicine at Mount Zion Hospital and Medical Center in San Francisco, a position I held until 1990. For much of that time (1967-1989), I also served as Associate Chief and Hematologist at Mount Zion’s Department of Pathology and Laboratory Medicine.
4. During my tenure at Mount Zion, I have also held a variety of other positions and served as the Director or Co-Director of the Immunology Research Laboratory (1967-1976); Medical Oncology Service (1969-1976); and Cancer Immunology (1976-1979). From 1965 through 1974, I was Chief of Hematology and Oncology at Harkness Community Hospital. From 1980 through 1985, I served as Chief of Oncology at Marshal Hale Hospital; and from 1985 through 1990 as Chief of Oncology at French Hospital. From 1969 through 1986, I was Medical Director of the San Francisco Regional Cancer Foundation, and I am currently Medical Director of the Better Health Foundation in San Francisco. I am on the Attending Staff at California Pacific Medical Center, the largest private hospital in San Francisco, a position I have held since 1988. I am currently affiliated with the University of California School of Medicine – San Francisco; and UCSF-Mount Zion Comprehensive Cancer Center, California Pacific Medical Center (all located in San Francisco).
5. I am also Clinical Professor of Medicine at the University of California – San Francisco, a position I have held since 1984. I have held numerous faculty positions at that university since 1964. In 1970, I was Co-Founder of the Northern California Academy of Clinical Oncology. I am a member in good standing of the American College of Physicians, American Society of Clinical Oncology and the California Academy of Medicine. I have also been a member of the American Society of Internal Medicine and American Society of Preventive Oncology. In addition, I have provided expert medical testimony in legal proceedings.
6. I am the author or co-author of more than 20 books, all of them related to improving the health, treatment, and quality of life of cancer patients. These books include Living with Cancer, Nutrition for the Chemotherapy Patient, The Cancer Patient’s Guide to Social Services and Hospital Procedures, and A Comprehensive Guide for Cancer Patients and Their Families, which received the American Medical Writers Association Honorable Mention Award for Excellence in Medical Publication in 1982. Ten years later, in 1992, my co-authors and I received the same award for Everyone’s Guide to Cancer Therapy. I am also the author or co-author of almost 60 scholarly articles and research findings published in such professional journals as Archives of Internal Medicine, Cancer, The Lancet, Western Journal of Medicine, and the Journal of the American Medical Association (JAMA). I am also a frequent presenter and lecturer at conferences, seminars and training workshops on issues of living with cancer, cancer treatments, the importance of proper nutrition as a part of cancer care, coping with terminal illness, confronting death in a dignified and humane manner, minimizing the pain and suffering associated with cancer and cancer deaths, and medical/legal ethical considerations in caring for the dying.
7. I have been practicing oncology for forty years. During that time I have worked daily with the myriad treatments and medications used to combat not only cancer but also the harsh side effects of cancer fighting agents, such as chemotherapy and radiation. In my lifetime I have witnessed tremendous advances in the medical profession’s ability to identify, treat, and cure a range of cancers. In addition, my patients are the beneficiaries of many powerful and effective drugs that have been developed to alleviate the nausea, vomiting, wasting, and pain caused by cancer and/or the cancer treatments, including surgery, chemotherapy, radiation therapy and immunotherapy. Notwithstanding these important scientific achievements, it is my professional opinion, forged by four decades of clinical experience, that marijuana has been -- and continues to be -- an important part of the physician’s armamentarium for treating certain cancer patients who suffer intractable nausea, vomiting, loss of appetite and/or pain when standard methods fail.
8. Cancer is the No. 2 killer in the United States second only to heart disease. An estimated 553,400 Americans will die from the disease this year – more than 1,500 persons every day. The lifetime risk of developing cancer is one in two for men, and one in three for women. By the year 2020, cancer is projected to become the leading cause of death in the U.S. There currently are ten million living Americans who have had cancer, and an additional seven million who have lived five years or longer after completing their cancer treatments and are considered cured.
9. We are getting quite good at treating most types of cancer. However, cancer treatment is a dehumanizing process for many patients, requiring them to grapple with therapeutic alternatives, undergo multiple drug regimens and endure grueling treatment schedules. To be sure, state-of-the-art drugs and medical technology have helped enormously to extend life expectancies, increase survival rates, and reduce the suffering of cancer patients. Nevertheless, a small but significant subset of cancer patients do not respond well to cancer fighting treatments and/or the conventional medications prescribed to treat their known side effects. Those patients are forced to endure unremitting nausea and vomiting, excruciating pain, and/or wasting (sometimes referred to as cachexia). Indeed, even with today’s state-of-the-art therapies, I have found that the three biggest physical hurdles facing cancer patients are pain, fatigue, and nausea/vomiting. These symptoms can impede a cancer patient’s ability to succeed in treatment by preventing them from obtaining proper nutrition and exercise, and sapping their strength and desire to persevere through therapies that frequently cause acute and chronic discomfort. Many such patients have found marijuana to be quite beneficial in alleviating these conditions.
10. From a medical-historical perspective, the fact that patients today have found marijuana to have medicinal efficacy is not surprising. Cannabis has been used for over 5000 years by many cultures for its healing value. It was used extensively in the 1920’s and 30’s as part of a combination of drugs to treat pain, and was a part of the U.S. Pharmacopoeia and National Formulary until 1941. From the 1850’s through 1937 with the passage of the Marijuana Tax Act, American pharmacies stocked and sold cannabis.
11. I first observed marijuana’s medicinal properties early in my career when treating patients afflicted with Hodgkins and Non-Hodgkins Lymphoma. I cared for a series of such patients who smoked marijuana to alleviate the nausea and vomiting caused by chemotherapy. Some of my patients even brought their cannabis to my office and ingested it immediately before or after the chemotherapy treatment. As I observed an increasing number of cancer patients obtain significant relief from marijuana, I began discussing their questions about marijuana with patients who suffered from unrelieved nausea and vomiting.
12. During this period I consistently observed the following: the patients who used marijuana to stem nausea and vomiting often successfully abated these serious, sometimes life-threatening symptoms; the patients’ appetites often returned; and the patients frequently were able to regain significant body mass – not uncommonly 20, thirty or even 40 pounds. With renewed appetite and weight these patients often regained the physical endurance, courage, and not least, the hope, to persevere with their cancer treatments and reap their long-term benefits.
13. During illness it is important to get calories, protein, fat, carbohydrates, vitamins and minerals that are necessary for energy, the repair of normal tissue, and the functioning of the immune system. Food and nutrition, in other words, play an essential role in the fight against disease. A primary duty of every oncologist is to monitor each patient’s ability to obtain and retain nutrition and to take measures to address an inability to do so. Unfortunately, nausea, vomiting, loss of appetite and weight loss – all of which impede patients’ ability to consume food and maintain physical strength -- are common side effects of a host of chemotherapy drugs, including, but not limited to Adrenocorticosteroids (Prednisone, cortisone, dexamethasone), Bicalutamide (Casodex), Bleomycin (Blenoxane), Busulfan (Myleran), Carboplatin (Paraplatin), Chlorambucil (Leukeran), Cisplatin (Platinol), Cycolphosphamide (Cytoxan, Neosar), Docetaxel (Taxotere), Fluorouracil (5-FU, Adrucil) and Floxuridine (FUDR), Paclitaxel (Taxol), and Tomoxifen (Nolvadex) – to name but a few.
14. It is also incumbent upon the oncologist to alleviate pain. Albert Schweitzer, the noted humanitarian physician of the early 20th Century, observed that, “pain is an even more terrible lord of mankind than even death itself.” Pain is terrifying and debilitating. It can lead to depression, loss of appetite, fitful and disturbed sleep, irritability, impairments in perception and memory, and feelings of isolation. Those reactions, in turn, can strain and damage relations with family, friends and treatment professionals. Chronic pain can even erode the will to live. In my experience, an overwhelming majority of cancer patients will describe their greatest fear not as “death” but rather as “pain and suffering. Untreated pain, in short, is life threatening.
15. Pain can occur at any step in the course of dealing with some forms of cancer – during treatment that leads to remission or cure as well as in the terminal phase. For example, Cisplatin, Paclitaxel (Taxol) and Vincristine, three drugs used in chemotherapy, can cause neuropathy – severe pain in the extremities that can linger for several months after chemotherapy ends. Fortunately, most pain problems can be controlled with analgesics, particularly opioid analgesics. But these are powerful narcotics and some patients have difficulty tolerating them. Many opioid analgesics produce toxic side effects such as severe nausea and vomiting (like chemotherapy drugs), in addition to delerium, paranoia, confusion, and constipation. To help alleviate the side effects of their pain medications.many cancer patients have used marijuana as a part of their adjuvant therapy. Some patients have also found that marijuana helps relieve certain types of pain, including neuropathy and migraine, in turn allowing them to reduce the amount of opioid analgesics they take and, consequently, the severity of side effects they suffer.
16. Not all of my patients who use medical marijuana smoke it. Quite a number of patients do not like to smoke and so achieve the relief marijuana affords them by ingesting it in tea, tinctures, through suppositories, or in baked goods, such as brownies. There are both medical and practical reasons why patients may choose to use these non-smoking means of ingesting marijuana. For example, some patients may have compromised lungs such that smoking marijuana may further jeopardize their health. Fortunately, these alternate forms offer many patients the same kind of relief as smoked marijuana.
17. Cancer patients coping with their illness also face a myriad of psychological and emotional problems. For many, simply confronting the imminence of their death can cause severe depression and anxiety, which may further weaken their immune systems. For others, taking care of their day to day business, especially when it relates to their medical condition, such as applying for disability insurance, paying taxes, or drafting a will, can be overwhelming and stressful. It is my experience that often medicinal marijuana is effective for many patients to achieve an emotional balance and curb anxiety and depression, while avoiding the difficult side-effects of traditional anti-anxiety and anti-depression medications. For a subset of those individuals, marijuana has been shown to be an effective anti-depressant that they can tolerate.
18. In about 1972, I attended the national conference of the American Society of Clinical Oncology. One of the conference sessions concerned the treatment of nausea and vomiting of cancer patients. At this session, I spoke about my clinical experience with patients who successfully used marijuana to quell nausea and vomiting. Some colleagues were uncomfortable about my speaking openly, in such a public forum, on what they considered to be a taboo topic. They did not, however, dispute my findings. The unease many medical professionals felt in 1972 about openly discussing marijuana due to its prohibited status under federal law has continued to the present time. I believe many oncologists have at least some experience with patients’ successful use of marijuana to alleviate various symptoms, and there is some survey data to this effect. See Richard Doblin & Mark Kleiman, Marijuana as Antiemetic Medicine: A Survey of Oncologists’ Experiences and Attitudes, 9 J. Clinical Oncology 1314 (1991) (finding that more than 44% of oncologists surveyed had recommended marijuana to patients). I also believe that most oncologists are reluctant to acknowledge that they have discussed medical marijuana with their patients not only in public for attribution, but also in patients’ medical charts, perhaps out of fear of potential legal ramifications for themselves and/or their patients.
19. This fear of speaking openly about the medicinal uses of marijuana is not limited to medical professionals. As an author of several books about cancer for lay audiences, I have included in my draft manuscripts various discussions about the medical efficacy of marijuana. My publishers, however, have frequently removed these passages from the galley proofs out of concern that publishing such information could cause legal problems for either the publishing house or myself and my coauthors. One such passage, though, survived the editor’s pen and found its way into print. In the chapter on “Nutrition for the Cancer Patient” in my book Cancer Supportive Care – A Comprehensive Guide for Patients and Family, (Somerville House 1998), I note with abundant caution that “[s]ome forms of marijuana – the natural tetrahydrocannabinol (THC) and synthetic Marinol -- may control nausea and vomiting. However, they can also cause drowsiness, dry mouth, dizziness, a rapid heartbeat and sweating. The use of marijuana to alleviate cancer therapy side effects is legal in some states.” (p.176).
20. From 1978 to the present day the federal government has operated the Single Patient Investigational New Drug compassionate access program for seriously ill patients whose physicians feel they could medically benefit from marijuana. In 1992, the government closed the program to new admissions. For those patients accepted into the program, the federal government provides them with a regular and consistent supply of marijuana cultivated on federal land in Mississippi and processed into marijuana cigarrettes for smoking. At the height of the program, over 30 patients were receiving federal shipments of marijuana. Only seven patients remain today.
21. For many years and until very recently, the federal government has refused to permit any human subject studies to assess the possible medical benefits of marijuana. Only in the last couple of years has the government permitted such research to be conducted, most notably in 1997 by authorizing Dr. Donald Abrams of the University of California, San Francisco General Hospital, to study the marijuana’s affect in treating pain on HIV/AIDS patients. It is my hope that a study like Dr. Abrams will shed additional light on our clinical experience, illuminate marijuana’s margin of safety in the treatment setting, and help explain the mechanisms by which marijuana alleviates the pain and suffering associated with cancer and other terminal illnesses In 2001, the County of San Mateo received marijuana cigarettes from the federal government in order to research the effect of marijuana on AIDS-related wasting in roughly 60 patients.
22. The role and importance of support groups for cancer patients (and other medically ill patients) cannot be overstated. I have co-authored an entire book on this subject, Everyone’s Guide for Cancer Therapy, and devote a full chapter to it in another book, Supportive Cancer Care. Groups provide an opportunity for people to see their own problems as others see them, through the eyes and ears of other group members. This provides a new perspective on their illness and reduces the inappropriate guilt that often besets cancer patients. They learn that many of their problems are due to cancer, rather than personal failings. By helping others who have less experience with it, group members develop and consolidate their own sense of personal competence in dealing with their illness. Groups also assist in developing a more active coping stance and in finding ways to address even the worst aspects of the illness, especially the fear of suffering, dying and death. Group discussions of these issues help members to experience shared anxiety and sadness. This can be invaluable to an individual who is about to sink into the despair that isolation causes. There is growing evidence that educational, supportive, and psychotherapeutic interventions for the medically ill have a range of positive effects, including stress reduction, improved coping, reduced pain, enhanced interaction with family and friends, improved interactions with health care professionals, and adherence to treatment. Social support also can be an important factor in mediating individuals’ ability to cope with stress.
23. There is no question in my mind that marijuana has a clinically useful and appropriate role for some terminally ill patients in the final months of life. I have seen and cared for countless terminally ill cancer patients who have used marijuana to alleviate pain, fear and stress associated with their disease. The marijuana, by their accounts and my observation, has relaxed them and improved the overall quality of their remaining days. It has helped allow them to divert their thoughts and precious energy away from their physical discomfort and emotional distress, focusing their physical and emotional strength on putting their life affairs in order, grieving with friends and family, and being fully present to experience the last journey of life without overbearing and unnecessary fear, bitterness, or suffering. As a direct result of marijuana use, some patients have been able to continue cancer treatments that they would have otherwise abandoned, keeping them on the path to recovery and wellness. Other patients have used marijuana to achieve desperately needed comfort at the end of life so that they could take responsibility for themselves and their affairs, exercise autonomy over their final days, and die with dignity and grace.
I declare under penalty of perjury under the laws of the United States and the State of California that the foregoing is true and correct to the best of my knowledge. Executed at ___________________, California, this ____ day of April, 2003.
ERNEST H. ROSENBAUM, M.D.
Copyright Women's Alliance for Medical Marijuana 2007 - 2008