Are you now, or have you ever been, a member of...
John P. Morgan, M.D., is a Drug Policy Foundation Advisory Board member and a professor of pharmacology at the City University of New York Medical School. Queens College sociology professor Lynn Zimmer contributed to this article.
people outside the medical profession may assume that prestigious medical publications are written objectively in an atmosphere free of conjecture or politics. My recent experience in writing chapters about drug dependence shows that objectivity goes out the window when illegal drugs are involved. Fortunately, in my struggle, reason won.
In 1974, Robert Berkow, the new editor-in-chief of The Merck Manual of Diagnosis and Therapy, asked me to contribute to the 13th edition. This general medical text, first published in 1899, is produced without profit by Merck, Sharpe and Dohme, a division of Merck and Co. The Manual covers most non-surgical aspects of medicine for a variety of readers. Probably more than a million readers, mostly physicians, medical students, nurses and lawyers, have purchased the current 15th edition, which is translated into French, German, Spanish, Italian, Chinese and Turkish.
For the 13th edition, I edited the existing chapters on drug dependence. They included overstrident warnings about marijuana and LSD that needed to be ameliorated in the light of evidence.
In editions 14 (published in 1982) and 15 (1987), I wrote the chapters on drug and alcohol dependence, and the 16th edition (due in 1991) will contain my updated versions.
Anti-Marijuana Forces Attack
In spring 1988, Berkow received telephone calls and letters criticizing the 15th edition chapter on marijuana. The critics were angered most by the following statements:
• that cannabis could be used without evidence of social or psychic dysfunction;
• that the use of the term "dependence" for many users is questionable;
• that the biologic hazards were relatively minor; and
• that opposition to the drug "rests on a moral and political and not a toxicologic foundation."
Members of anti-drug groups wrote to Berkow that the chapter was misleading, and they occasionally cited medical critics.
"Not only is the information on marijuana misleading and incorrect, but it ignores the large body of work that proves marijuana to be toxic and addictive," Elizabeth Houghton of Informed Networks, Inc., in Illinois wrote. She was joined by Alice Logsdon, Illinois Drug Education Alliance, who charged, "I know it is.. .not only inaccurate, [it is] dangerous."
"I had always assumed this to be an up-to-date, respectable, accurate manual," Anne Meyer of National Federation of Parents for Drug-Free Youth huffed. "However, my assumption was wrong." Meyer enclosed Peggy Mann's brochure How Much Do You Really Know about Marijuana?
A group of physicians who have consistently opposed marijuana reform/ normalization also wrote Berkow. Many of these critics enclosed studies, analyses or essays supporting their viewpoints. Berkow expressed to me and to the writers that he did not mind receiving the objections and evaluating the complaints.
"I also was distressed by the biased section on marijuana in the Merck Manual," Dr. Richard Schwartz of Vienna, Va., said, arguing, "The only losers by such biases are those with a cannabis abuse problem who turn to their physicians for help." Schwartz enclosed his own article on marijuana-induced problems.
"Cannabis is a dependence-producing drug, which induces impairment of neurotransmission in.. .areas of the brain with pleasure-reward mechanisms...," Dr. Gabriel Nahas, a Columb,ia University College of Physicians and Surgeons professor, erroneously concluded. Nahas is the author of several books emphasizing the dangers of marijuana and is an outspoken critic of any attempt at decriminalizing or normalizing marijuana. "To claim that chief opposition [to marijuana] rests on a moral and political, and not a toxicologic, foundation is to ignore toxicology."
Dr. Harold Voth, a Veterans Administration Hospital chief of staff in Topeka, Kansas, and co-author with Dr. Nahas of How to Save Your Child from Drugs, railed, "Whoever wrote that is badly informed or is a marijuana user advocate.... To say that the chief objection to the substance.. .is a moral or political one is utterly ludicrous and plays right into the hands of the promoters of the legalization of marijuana."
Workplace drug abuse consultant Dr. Robert Dupont made the following confession:
"When I was the director of the National Institute on Drug Abuse in 1975, I held similar views, I am now embarrassed to say. Today, however, to publish such views is truly appalling. Such an article as you have published would be more appropriate to High Times magazine.. .than to the prestigious Merck Manual."
"I am writing to loudly protest to you the obvious whitewash of the hazards surrounding marijuana use that appears in the current Merck Manual," said National Federation of Parents for Drug-Free Youth board member Dr. Eric Voth (no relation to Harold Voth). "It is clearly inaccurate, but worse than being inaccurate, it is in fact completely ignorant of the current state of the arts regarding marijuana."
Berkow responded calmly, professionally and responsibly to the virulent attacks that summer After sending the letters to me for a response, Berkow circulated all materials to his board of directors and a number of outside experts.
The single expert response I have seen was very supportive. University of Rochester psychiatrist Dr. Laurence Guttmacher stated, "[T]here is a great deal that is unknown.... The psychiatric effects are more unusual than usual.... I know of no data to support the concept of any physiologic dependence." He added, "Dr. Morgan does a nice job of highlighting this. I find his discussion reasonable and balanced."
Berkow sent Eric Voth and others a carefully reasoned, six-page, single-spaced letter. Using the available literature and the papers suggested, Berkow supported the chapter's assertions on cannabis dependence, functional and dysfunctional cannabis use, the gateway drug issue, and the absence of severe biologic damage.
Berkow criticized Voth for alarming lay people about the dangers of marijuana.
Eric Voth responded that the attack on marijuana originated with the lay people, not himself. According to Voth,
"A high official from the Office of Substance Abuse Prevention of the Alcohol, Drug Abuse and Mental Health Administration notified the president of a large, state, anti-drug abuse parents organization. She contacted me because of my expertise on drug abuse and more specifically, marijuana. I, in turn, contacted several ofmy colleagues, all noted authorities in the field, who all voiced concern over the article."
Voth took the opportunity to attack the chapter again, saying, "Whether intentional or not, the statements that equivocate and negate the significance of marijuana in the spectrum of drug abuse became ammunition for the prodrug, pro-legalization forces."
Berkow described to Eric Voth a slight textual modification that would appear in the 16th edition. Instead of "...but the chief opposition to the drug rests on a moral and political, and not a toxicologic foundation," the next edition would say "...but the major concerns remain social, psychologic, moral, and economic, rather than toxicologic."
Berkow received an implacably angry response from Nahas. Schwartz, on the other hand, graciously accepted Berkow's modification: "I really appreciated your letter to me and your reply to Dr. Voth. You are fair-minded and scientific. One could ask nothing more from my perspective."
Another Round of Attacks
In fall 1990, Berkow received a brief letter from Otto Moulton, a prolific dispenser of anti-drug information and head of the Committees of Correspondence. As editor of Drug Prevention Newsletter, Moulton identifies and chastises those who oppose his views. According to Moulton, any information that is not strongly anti-drug is inaccurate.
Moulton sent to Berkow the following letter, which is quoted in its entirety:
"I now better understand how the bogus information on marijuana ends up in Merck publications. This is not the first time these tricky drug experts have taken advantage of respected foundations and publications. If you feel the same as I do after reviewing this information about John Morgan, maybe you might consider updating the drug information in the next edition of the Merck Manual."
Moulton enclosed for Berkow a DEA criticism of my testimony in the medical marijuana case, a videotape of a talk I gave at a NORML conference, a Drug Policy Foundation letter listing me as an advisory board member and an unidentified report that criticizes me as a bogus pharmacologist because I teach at an "unaccredited medical school...."
(The CUNY Medical School is not accredited by the usual national medical school accrediting body. It recruits students from high school into a five-year baccalaureate program, which includes the first two years of medical school. CUNY medical students then enter most New York medical schools, public and private, at the third-year level. I have directed pharmacology instruction here for 13 years. More than 700 students have passed the pharmacology section of the National Medical Boards, and I am unaware of a student passing my course and ultimately failing the Board pharmacology section.)
Berkow's reply to Moulton in November 1990 reflected his weariness with Moulton's personal attacks, which had little to do with the substance of my writing. Berkow said, "Quite frankly, I have difficulty relating to your discussion of Dr. John Morgan as a 'tricky drug expert.' I have known John for a number of years and consider him to be an excellent pharmacologist and teacher, a man of integrity." (Readers will pardon me, in my own article, for leaving this in.)
Academic physician William Bennett (a nephrologist-pharmacologist, not a czar) joined Moulton in this second barrage. He apparently agreed with Moulton that the best strategy was to attack me. "His credentials as an expert seem exaggerated at best," Bennett wrote in January 1991. "It seems to me suspect to have an author of a chapter in a prestigious scientific publication be supported by NORML, a group dedicated to the legalization of illicit drugs...."
Berkow, perhaps annoyed by Bennett's conspiracy implication, replied, "I have no doubt that the text for the 16th edition of the Manual will be scientifically credible, whether Dr. Morgan 'has ties' or not to NORML."
Professor Bennett did not include documentation of my mistakes but did accuse me of failing to provide significant information on the health risks of marijuana. He sent copies of his letter to Moulton, to two physicians on the staff of the Association of American Medical Colleges, to the president and CEO of Merck, and to a colleague of mine who is a professor of pharmacology at Bennett's medical school. In response, Berkow told Bennett, "I can assure you that I informed each and every member of the editorial board fully of the correspondence that I had received criticizing that chapter...and that we discussed it fully."
After Berkow shared with me Bennett's correspondence, I wrote Bennett at great length on Jan. 24. I complained directly to Bennett of his ad hominem attacks, carefully explaining the function and structure of my school. I told him that my talk at NORML was the same material on misrepresentation of cannabis potency that I presented at the International Conference on Cannabis Research in Crete in 1990. I reviewed the issues of pulmonary irritation, immunopathic and reproductive effects, and reviewed the concept of gateway drugs. I also opined that his prohibitionist stance was every bit as political as my anti-prohibitionist stance. In case this description seemed too polite, I closed with more aggression: "Constrain yourself from insulting me and trying to harm my career and livelihood on the mistaken beliefs that you know more than I (you do not), have attained a higher moral ground (you have not), and believe that you have discovered some conspirational secrets about me." I suggested he invite me to his medical school for a debate.
Bennett's response to me on Feb. 11 was more heated than his previous letters. Again, the professor decided to attack me instead of my positions. He stated:
"My major concern about you and your public pronouncements is that you have not revealed your conflict of interest. One does not publish in the scientific literature with an obvious conflict of interest without explicitly acknowledging it. I doubt that the editorial board of the Merck Manual knows about your political views. Certainly, if they did they could not support presumably unbiased articles on subjects of great importance without public disclosure.... Your failure to disclose your political and economic relationship is unethical and immoral.
"Contrary to your paranoid ravings, I have no political agenda.... [You are a] career associate professor, who publishes in slightly less than highly peer-reviewed journals.... I wouldn't dignify you or anyone like you, who is afraid to acknowledge obvious conflicts of interest, by inviting you to come to our university. You have my permission to send my correspondence to whomever you please.
"I also am interested that you ignore the reality of alcohol abuse in the United States and conclude that prohibition was a failure. Certainly, legalization didn't solve the problem. If you ever functioned as a doctor and experienced the tragedy of drug and alcohol use and abuse, you would see the folly of your legalization efforts.
"Come clean, Dr. Morgan, about your political agenda and your own drug use so that people who use the Merck Manual as an unbiased source of information know the real truth.
"It is interesting that your letter to me, with your title, says professor of pharmacology, when I cannot see from your CV that you have ever been promoted."
This letter infuriated me, but I tried not to respond in kind. The following is an excerpt of my response:
"The definition of the phrase ad hominem (to the man') encircles the process of attacking an opponent's character rather than answering his arguments. This is your second note, which contains almost nothing about drug toxicity, psychoactive drug use and drug policy. Instead, you respond to my arguments with transparent attempts to assassinate my character, call my motives into question, and insert me into some kind of conspiracy. Your list:
• I have a conflict of interest, including various political and economic agendas that I conceal from the editorial board of the Merck Manual and others.
• I am a 'career associate professor' who publishes in 'less than highly peer-reviewed journals.'
• In addition to concealing a political agenda, I won't come clean about my 'own drug use.'
• I have lied in my CV about promotion to full professor.
"Concealment: It is unclear to me what is secret about my political plan. I have never concealed any of my beliefs regarding drug policy or legaliza-tion/decrimmalization. I began speaking out for marijuana legalization in the late 60s and early 70s. I reviewed Dr. Nahas' first book in 1974 and felt that he was foolish and prejudiced and said so. My CV lists me as a member of the advisory board of the Drug Policy Foundation and a contributing editor of the International Journal of Drug Policy.
"Political Belief and Scientific
Bias: I share your concern about those with a political agenda writing in a distorted fashion about clinical and toxicological truth. It happens. However, the idea that my kind of policy idea is political and yours is not, is shallow. I have a political agenda because I want marijuana prohibition to end. You, who want marijuana prohibition continued and strengthened, have no political agenda?
"Although writers with my opinions could distort the truth, most distortions in the clinical toxicological literature (peer-reviewed and not) are placed by those like you who oppose the decriminalization of marijuana.
"In the early 1970s, Nahas published in two highly peer-reviewed journals his findings that heavy smokers of marijuana had impaired cellular immunity using a common in vitro test. These studies have never been replicated in 16 years and there is not a single study indicating clinical impairment in the immune system of light or heavy marijuana users. Today, Nahas and his followers never discuss the lack of replication, never discuss the lack of proof of clinical effect and always identify marijuana as an immunopathogen.
"The most obvious political act regarding drug policy is to speak and write uncritically. To accept that marijuana has immune hazard and is a gateway drug and to write this without examining the evidence is the most crass political act imaginable. To accept a finding uncritically because of a prior belief is a serious defect in a medical scientist.
"Economic Bias: I'm not sure what my economic biases might be. NORML does not pay me for the talks I have given, although they once paid my travel expenses to give a talk and appear on a television program. The Drug Policy Foundation has given me $200 per year to attend the annual meeting as a Board member.
"My Academic Rank: I became an assistant professor of pharmacology and medicine in Rochester in 1972. I was promoted to associate professor at the Sophie Davis School of Biomedical Education (now the CUNY Medical School) in 1977. I was awarded early tenure in 1980, and promoted to professor in 1982. My CV is very clear about this progression. Why do you read so carelessly?
"My latest publications have been in JAMA, The Journal of Clinical Psychopharmacology, and The American Journal of Drug Abuse. I have frequently published essays and ideas about drug policy and drug testing in behavioral science, law and other journals, which you probably regard as 'slightly less than highly peer-reviewed journals' Since you've not read the articles, I'll not worry further about your regard of them.
"My Drug Use: I'm very impressed with your daring me to come clean about my 'own drug use.' Since I have never met you at an opium den, a crack house, a shooting gallery or a drunken revel or shared a joint with you, I'll assume that you know nothing about me or my 'drug use.' You must have raised this issue solely on the basis of my opposition to current drug policy. Therefore, you also must dare George Shultz, Hugh Downs, Gore Vidal, Kurt Schmoke, Carl Sagan, Anthony Lewis and Federal Judge Robert Sweet to come clean about their drug use. I'm sure that in the middle of a debate when your apparent lack of information about drugs and drug policy emerges, you can always accost your opponent and demand that he come clean about his drug use. Well, I'm not sure that taking a public stance requires me to talk about personal issues of a sensitive nature, but we'll see. Perhaps I'll ask you about your tendency to become sexually excited by urination. This phenomenon — called urolagnia — could be the basis of your interest in nephrology, couldn't it?
"You express the idea that those who practice medicine 'experience the tragedy of drug and alcohol use and abuse' and therefore know the folly of legalization. I practiced medicine from 1965-1977 in both medical school and military environments. My last clinical job before I left Rochester was in a storefront clinic devoted to adolescents and young adults often with drug and alcohol problems. I saw nothing to indicate that the criminalization of marijuana and heroin helped my patients. I came to believe that prohibition, which guarantees contaminated drugs of uncertain quality and potency, and the threat of criminal action represented the important dangers to them.
"Alcohol Prohibition and Alcohol Abuse: Although your expression is unclear, you try to make some point about alcohol abuse and Prohibition. I certainly agree that legalization did not solve the alcohol problem. Do you think that criminalization did? Do you think that Prohibition should be counted a success? In 1930, a seller of a medicinal tonic used as an alcoholic beverage adulterated the mix with a neurotoxin and paralyzed 50,000 Americans. This occurred while Prohibition decreased the amount of beer consumed, but contributed to an increase in distilled spirit consumption and an increase in cirrhosis after 1922.
"Conclusions: You have, on the basis of careless reading and hatred, accused me of lying about my academic rank, and because I have different views than you about drug policy, you accuse me of being an illegal drug user. Without documenting any distortions on my part, you accuse me of hidden political and economic agendas. You do all this, I suspect, without informing yourself of the scientific basis for evaluating marijuana's clinical toxicity. Then, when I challenge you to debate these issues, you demur. You must wish to function in the arena of poison-pen endeavors, and hide away from public debate."
Professor Bennett did not reply to me. When prohibitionists like Bennett, Nahas, Moulton and others fail to achieve their goals with unskilled sciertee and faulty rhetoric, they move quickly to insult, invective and personal attack.
The clearly noble person in this story is Robert Berkow who wrote to Bennett on March 22. Berkow once again committed to insuring the integrity of the text. He closed thus:
"Of particular concern to me is the nature of your complaints in your correspondence. They take the form of attacks on Dr. Morgan and could be characterized as attempts at character assassination.... Yet what are the charges against Dr. Morgan? I don't see that the fact that he lends support to NORML isper se disreputable.... He has written several letters explaining what his titles are, what his program is all about, etc.... Having lived through the McCarthy era, I am very sensitive to the possibilities of character assassination. ..charges of guilt by association, etc. I will not participate in such behavior."
Robert Berkow, The Merck Manual of Diagnosis and Therapy, 15th Edition, Merck Co., 1987.