Legalizing Medical Cannabis in Lebanon: the Complex Interface Between Medicine, Law, Ethics, and Economics

Abstract

In April 2020, after decades of discussions and controversy, the Lebanese parliament voted a law legalizing the cultivation, production, and sale of cannabis for medicinal purposes. Although the law leaves several unanswered questions and awaits implementation, the symbolic nature of this step in recognizing a positive role of cannabis in the local economy is significant on a regional level. The Arab world has traditionally been conservative when it comes to all drugs-related policies. Cannabis is largely demonized with heavy sentences served to anyone suspected of using selling, let alone planting cannabis. Despite a few countries considered producers and consumers of substances, governing authorities have remained immune to the liberalization trend encountered in western countries. The social experiment taking place in Lebanon is fraught with risks, given the unstable political situation and chronic economic challenges. The reactions to the law have been mixed with several scientific bodies such as the Lebanese Psychiatric Society criticizing the absence of proper consultation of stakeholders. The absence of consistency in enforcing established drugs policies or seriously debating the decriminalization of cannabis use raises concerns over the establishment of a two-tier approach toward drugs, driven solely by economic imperatives.

Introduction

In addition to its recreational effect, cannabis is increasingly considered a complex plant with multiple properties. Scientific research on the potential use of cannabis or its components in the medical realm has confirmed therapeutic benefits in some disorders (cancer, epilepsy, multiple sclerosis, HIV/AIDS, etc.).¹ The recent legalization trend, mostly in leading developed economies, has allowed for further enquiry into the therapeutic potential of these components, most specifically tetrahydrocannabinol (THC) and cannabidiol, in well-studied pharmacological formulation under medical supervision.² In parallel, mental health clinicians and researchers have continued to document the harms of cannabis for a significant minority of people who use it. Psychiatric disorders associated with cannabis extend beyond addiction to anxiety, depression, and psychosis.³ Accordingly, controversy persists globally on the costs and benefits of legalization and decriminalization of cannabis cultivation and use.⁴

Cannabis Legalization and/or Decriminalization Around the World

To date, formal steps to legalize cannabis have primarily taken place in high income countries.⁵ Public opposition toward laws regulating recreational cannabis use is often fueled by public security concerns, fear of antisocial behavior linked to trafficking, and the belief that it serves as a gateway to harder drugs.⁶ Besides limited shifts in patterns of use, the explosion in cannabis consumption predicted by some did not materialize. However, the impact of a change in legislation on public health is still closely monitored. In addition, it is unclear how different societies may be affected by increased availability of cannabis. This is particularly the case for countries with weakened state structure, fragile health systems, and exposure to political conflict.

Cannabis Use Backgrounds in the Lebanese Society

Lebanon is an Eastern Mediterranean nation with a heterogeneous cultural background facing a serious economic crisis.⁷ Its Bekaa Valley is considered a major center of cultivation of cannabis (Afsahi and Darwich 2016). Cannabis was certainly regarded negatively in the public sphere with the term “Hashash” (consumer of Hashish) used derogatorily (The National Mental Health Programme). The purpose behind actively raising the issue of legalizing cannabis cultivation has been recently related to the acute economical crisis the Lebanese society has been struggling through for more than a year.⁸ The former Lebanese economy minister Raed Khoury had gone as far as predicting that medical cannabis exports could generate 1 billion dollars per year in revenue for the Lebanese state. The political dimension of such calls was also significant, given the concentration of cultivation in parts of the country with distinct social and political influences.⁹ However, success in the legalization of any substance carries with it a logistical challenge that relies principally on the presence of a strong state apparatus able to guarantee trusted sources of production and safe distribution networks, which is far from being readily available in the case of Lebanon.

Scientific Societies' Statements

The Lebanese Psychiatric Society (LPS) is the official scientific body accredited by the Lebanese order of physicians. It released a widely disseminated public statement on March 4, 2020 ahead of the parliamentary vote:

“… the LPS would like to remind the public opinion of the evidence-based scientific facts related to cannabis use and misuse”… “It is important to emphasize that the harms of cannabis, in its natural form, are well known for at least a considerable proportion of people who use it. Mental disorders related to or induced by cannabis include addiction, anxiety, depression and psychosis”… “Accordingly, it is highly interesting for the LPS to notify the Lebanese society that the current draft law regarding the legalization of cannabis concerns its cultivation for medical use only and does not address the recreational use of cannabis”… “Furthermore, with the absence of any guarantee that this current draft law will benefit farmers and will not increase the prevalence of cannabis-use related disorders, the LPS encourages further assessment, from all involved parties, of such legalization.”¹⁰

In parallel, the Lebanese National Consultative Committee on Ethics having been officially consulted by Parliament recommended the restriction of medical cannabis product to conditions where benefit is already established, such as chemotherapy-induced nausea, appetite loss in patients with HIV, and muscle spasticity in patients with multiple sclerosis.^1,11–13 It also advocated that this step be accompanied by the decriminalization of personal use for recreational purposes.

The Lebanese Parliament Vote

On the 26th of February 2020 the Lebanese Parliament's joint committee finalized the version of the law legalizing the local medicinal cannabis production.¹⁴ On the 21st of April 2020, the Lebanese Parliament approved the law for legalization of cannabis cultivation for medical purposes through a majority vote. The new cultivation law only applies to cannabis that contains <1% of THC. The new legal framework creates a commission with a regulatory authority to issue licenses for every stage of cannabis operations, including the import of seeds and saplings, planting and harvesting, manufacturing, and exports. With a clear focus on foreign markets, these licenses are intended to be awarded to selected Lebanese and foreign pharmaceutical companies as well as farmers, landowners, laboratories, and research centers that it deems qualified. The law does not specify the process by which medicinal cannabis will be made available to the public in Lebanon and does not address the legal status of recreational cannabis.¹⁵

Reception and Concerns

The legalization of cannabis cultivation needs to be controlled with high efficacy, which means that every phase of the product's cycle from the procurement of seeds to the state of an industrialized medical product should be monitored by the Lebanese government. Concerns in this dimension are due to the repeated failures of successive governments to implement a law banning smoking (law 174) in public places it enacted in 2011.¹⁶ In its current state the new law will prevent traditional cannabis farmers from being licensed due to them having criminal records or being subject to prosecution. A newly formed cooperative movement has already warned against the emergence of corporations that will buy land and implement industrial scale cultivation at the expense of the local population. Moreover, public opinion has been grossly led to believe that the new law is a step toward legalization and decriminalization of recreational grade cannabis. In fact, the law clearly stipulates that cannabis containing THC >1% remains absolutely illegal. What risks happening is for the price of recreational cannabis to rise or for local users to be presented with a lower quality product, given that the main fields will fall under state regulation targeting exportation.

Criticism of the law in its current form has come from diametrically opposed factions in Lebanese drugs treatment circles. Conservative centers driven by the abstinence-based ideology issued a statement warning of the confusion such a law may cause in terms of drug prevention and also raising concerns over increasing access to the drug for the more vulnerable consumers' categories, which are adolescents, young adults, and individuals with severe mental disorders. Harm Reduction-based nongovernmental organizations were equally dissatisfied with a law that ignores the need of addicts and does not address the ongoing criminalization of a substantive section of the population.

Global Implications

Lebanon has acquired a status of regional trailblazer on the matter of legalization of cannabis cultivation for medical purposes. With the law having been passed, there are several hurdles facing its implementation. A struggle between stakeholders is expected involving conflicting medical, legal, ethical, and economic considerations. In the mental health field psychoactive cannabis use is mostly perceived as harmful, given the negative prognostic impact in almost all psychiatric conditions. In law, it seems that legalization or decriminalization of cannabis may relieve an already overburdened legal and carceral system. However, the socioeconomic implications of mass cannabis consumption are still under investigation in societies where it is now legal. The direct economic gains for low- and middle-income countries that seek to supply industrialized nations, who are still the primary consumers of all forms of cannabis, are still unclear. Benefits need to be balanced against the indirect cost of increased use of cannabis locally, quantifiable in terms of economic productivity, loss of years of education, and rates of motor accidents.^17,18 Even a small increase in incidence and prevalence of psychiatric disorders leading to higher service utilization could drain already scarce resources. Accordingly, medical professionals in countries considering liberalizing cannabis legislation are ethically obliged to “First, do no harm” (primum non nocere) by inviting the authorities to prioritize the health, physical and mental, of the nation before any other consideration. A position it can only defend with the strength of scientific evidence and effective public communication.

Abbreviations Used

LPS

Lebanese Psychiatric Society

THC

tetrahydrocannabinol

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: El-Khoury J, Bou Khalil R, Nemer A, Richa S (2022) Legalizing medical cannabis in Lebanon: the complex interface between medicine, law, ethics, and economics, Cannabis and Cannabinoid Research 7:2, 119–121, DOI: 10.1089/can.2020.0108.