I, Dr. Marcus A. Conant, declare as follows:

1. I am a physician licensed to practice in the State of California and a clinical professor of dermatology at the University of California Medical Center in San Francisco ["UCSF"], where I have taught for more than 30 years. I am also Medical Director of the largest private HIV/AIDS practice in the San Francisco Bay Area. Since establishing that practice, my colleagues and I have treated some 5,000 HIV-infected men and women, and we currently provide care for approximately 3,000 AIDS patients in both our clinic and our research facility.
2. I received a bachelor's degree in 1957 and a doctorate in 1961, both from Duke University. I subsequently completed an internship in internal medicine at the Duke University Medical Center (1961-1962), and a residency in dermatology at UCSF in San Francisco (1964-1967). I received further training at the School of Aerospace Medicine in San Antonio, Texas, and served in the United States Air Force from 1962 to 1964, as both a Medical Officer and a Flight Surgeon. I continued to serve as an Air Force Reserve Officer until 1967.
3. Since joining the UCSF faculty as a Clinical Instructor in 1967, I have held numerous positions, including Assistant Clinical Professor, Associate Clinical Professor, and Clinical Professor of Dermatology, a post I have held since 1984. I was Chief of both the Dermatology Clinic and the Dermatology Inpatient Service from 1967 through 1970, Co-Director of the Medical Center's Kaposi's Sarcoma Clinic (1981-1985), and Director of its AIDS Clinical Research Center (1983-1985). I am currently an Adjunct Professor at its Mount Zion Medical Center as well.
4. Throughout my career, I have also been a consultant to numerous agencies and service providers, both public and private, including San Francisco General Hospital, the U.S. Public Health Service Hospital, UC Medical Center's Director of Hospitals and Clinics, and the California State Assembly Ways and Means Committee's AIDS Task Force. I have been appointed to similar task forces and committees of the Fifth Congressional District, the California State Department of Health Services, the California Medical Association, the San Francisco Medical Society, the American Academy of Dermatology, and the City of San Francisco. In 1983, I represented the United States at the World Health Organization meeting on AIDS. I served as Medical Director of the National Public Health Project Against AIDS for several years. I am currently a member of United States Senator Dianne Feinstein's AIDS Committee.
5. I have authored and co-authored some 70 articles in scholarly and professional journals, most of which deal with the diagnosis and treatment of AIDS and AIDS-related conditions. My work has been published in the Journal of the American Medical Association, New England Journal of Medicine, Western Journal of Medicine, Journal of the American Academy of Dermatology, Journal of Infectious Disease, American Journal of Clinical Pathology, Journal of Clinical Immunology, Journal of Osteopathic Medicine, American Journal of Oral Medicine, Public Health Reports, Clinical Research, American Journal of Pathology, and The Lancet. My colleagues and I have contributed chapters to medical textbooks, research publications, clinical protocols and conference reports. I am a frequent presenter at national and international conferences and congresses.
6. Many of the therapies used in the treatment of AIDS-related conditions can cause symptoms and medical complications which themselves are physically painful and medically dangerous. The most frequently cited example is chemotherapy, which is often a first-line treatment in the aggressive treatment of cancer. Chemotherapy has also been used in the treatment of several common AIDS-related conditions, including lymphoma and Kaposi's sarcoma. Chemotherapy -- administering medications such as adriamycin, fluorouracil, cytotoxin and methotrexate, usually in combination -- has proven to be highly effective in the treatment of many cancers, extending lives and relieving the symptoms of many individuals whose conditions were once considered hopeless. These medications have been approved by the FDA. Nonetheless, chemotherapy protocols used in the treatment of cancer often cause nausea and retching which is sometimes thoroughly disabling. They can result in severe weight loss, which itself has troubling implications not only for the efficacy of the treatment, but for a patient's health generally. The medications are indeed toxic. Administration of these drugs always includes considering potential adverse effects, advising the patient of the risks and providing information and treatment to reduce harmful or undesirable side effects. Acknowledgment and clinical treatment of those effects are standard and necessary parts of the chemotherapy protocols.
7. Other drugs frequently prescribed in the treatment of AIDS-related conditions have the potential to cause adverse medical conditions. Among them are AZT, ddI, ddC and d4T, all of which are approved by the FDA. More recently, physicians have prescribed a class of drugs known as "protease inhibitors," often in combination with other medications. The results have been very promising. Physicians are seeing positive clinical results, and laboratory findings (blood tests) show remarkable improvements. Many patients report great relief from physical suffering. These drugs are now approved by the FDA. One common AIDS-related condition is wasting syndrome, which undermines both the immune system generally and a patient's ability to withstand the effects of other therapies. The FDA has approved the use of Somatropin (human growth syndrome), as well as Megace and Marinol, to reverse the disabling effects of wasting syndrome.
8. As with all medications, further research is essential to our understanding of these medications. As research continues, the use of these medications (e.g., dosages, means of ingestion, combination therapies) will be refined to maximize the potential for treatment and minimize adverse reactions. That is the very nature of research. There are always risks. As scientists, we identify those risks and provide information to reduce and ultimately eliminate those risks. As healers, we advise our patients accordingly and work with them to address their individual medical needs. Caution and candor are essential to maintaining scientific integrity and providing effective treatment.
9. Medical marijuana has been used extensively by physicians throughout the United States in the treatment of cancer and AIDS patients. It stimulates the appetite and promotes weight gain, in turn strengthening the body, combating chronic fatigue, and providing the stamina and physical well-being necessary to endure or withstand both adverse side effects of ongoing treatment and other opportunistic infections. It has been shown effective in reducing nausea, neurological pain and anxiety, and in stimulating appetite. When these symptoms are associated with (or caused by) other therapies, marijuana has been useful in facilitating compliance with more traditional therapies. It may also allow individual patients to engage in normal social interactions and avoid the despair and isolation which frequently accompanies long-term discomfort and illness. In glaucoma patients, marijuana has been effective in decreasing inter-ocular pressure. The evidence behind these findings is both scientific and anecdotal. The research in this area has been documented and published in the leading scientific journals, including the New England Journal of Medicine and Annals of Internal Medicine.
10. In my practice, marijuana has been of greatest benefit to patients with wasting syndrome. I do not routinely recommend marijuana to my patients, nor do I consider it the first line of defense against AIDS-related symptoms. However, for some patients, marijuana proves to be the only effective medicine for stimulating appetite and suppressing nausea, thus allowing the AIDS patient to recover lost body mass and become healthier. Likewise, for some of my patients undergoing chemotherapy, when conventional drugs fail to relieve the severe nausea and vomiting, I often find that marijuana provides the patient with the ability to eat and to tolerate aggressive cancer treatments. As with any medication, I am aware of the potential for abuse and I am cautious in the information I provide. Some of my patients are using marijuana, which I learn in the course of my treatment. I advise those patients of the risks that marijuana may pose. In some instances, I have counseled patients to discontinue or decrease their use of marijuana. In patients with a history of substance abuse, I am especially vigilant in recommending caution. Physicians have always been held to that standard, whether the medication is Valium, morphine, Xanax, or marijuana. Safeguards to decrease the incidence and effects of substance abuse are already in effect. Medical practices in prescribing and recommending all treatments are monitored and subject to professional and legal guidelines.
11. It is the sanctity of the doctor-patient relationship that enables this counseling and guidance to take place. The unique nature of that relationship has been recognized throughout history. Legally, ethically and clinically, a physician has unique duties to a patient in his or her care. When I treat a patient with a potentially terminal condition, I provide the information and treatment that can literally determine whether my patient lives or dies. My duty is to provide accurate and complete information and treat each patient according to his or her individual symptoms, medical history and clinical responses. Each patient's medical needs are unique, as are his/her responses to specific therapies. Confidential communication is essential to this process.
12. As a physician responsible for the care and well-being of my patients, I cannot ignore information which might affect my assessment of a patient's condition or assist me in providing the best care possible. If I have knowledge that a patient is smoking marijuana, I would be seriously remiss if I failed to address the medical consequences with that patient. If I have information that limited use of marijuana may provide relief from disabling symptoms, I feel duty-bound to provide that information. If I believe, in my clinical judgment, that the risks to that patient may be reduced if the marijuana is ingested by means other than smoking (e.g., by eating baked goods or drinking a tea with marijuana infusion), I have a duty to provide that information as well. That knowledge is based on my scientific knowledge, clinical judgment, and common sense.
13. My knowledge and clinical judgment are informed by all credible sources, including the federal Food and Drug Administration. I was one of the principal investigators of an FDA-supervised trial conducted by Unimed, Inc. on the safety and efficacy of Marinol as an appetite stimulant in HIV/AIDS patients suffering from wasting syndrome. Marinol is a form of THC, one of the key active components of marijuana; it is essentially a marijuana extract. It was approved by the FDA five years ago, and has been widely prescribed by physicians treating both AIDS and cancer patients.
14. The current edition of the Physician's Desk Reference, the most widely-used and comprehensive authority on prescription medications, states that:

    Marinol (dronabinol) is indicated for the treatment of:

    1. anorexia associated with weight loss in patients with AIDS; and
    2. nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments.(1)

    Stedman's Medical Dictionary, another highly respected and widely-used reference work, as part of its definition of "cannabis," includes the following:

    C[annabis] was formerly used as a sedative and analgesic; now available for restricted use in management of iatrogenic anorexia, especially that associated with oncologic chemotherapy and radiation therapy. (2)

    I am aware of no medical report that would indicate serious adverse effects arising from the clinical use of Marinol.
15. I am aware, however, that Marinol (like any medication) is not effective in treating all patients. In some cases, the reason is simple: Marinol is taken orally, in pill form. Patients suffering from severe nausea and retching cannot tolerate the pills and thus do not benefit from the drug. There are likely other reasons why smoked marijuana is sometimes more effective than Marinol. The body's absorption of the chemical may be faster or more complete when inhaled. Means of ingestion is often critical in understanding treatment efficacy. Research has revealed, for example, that insulin, which is critical in the treatment of diabetes, is rendered ineffective when taken orally. Medications commonly used to treat asthma and lung infections are routinely administered through inhalers. Marinol is not currently available in any form other than pills. These are scientific facts which inform my clinical practice. I cannot ignore them or deprive my patients of that knowledge.
16. I am aware that federal government officials have issued threats of criminal, civil and administrative sanctions against physicians who recommend the use of marijuana or counsel and advise patients regarding the clinical risks and benefits of marijuana. They have repeatedly stated that providing counsel and advice regarding the clinical use of marijuana is a violation of federal law. I see these public pronouncements as a threat to the integrity of my medical practice. While there are certainly limitations on my ability to obtain or prescribe medications, I cannot ethically withhold information or scientific data which may be of benefit to my patients. If I am prohibited from advising my patients on any matter affecting their health, I am unable to exercise clinical judgment and provide effective treatment.
17. Such interference in my communications with individual patients can do immeasurable damage to my relationship with specific patients, thereby undermining my ability to provide effective treatment generally. Without the element of mutual trust and protected confidentiality, many of my patients will be unable or unwilling to provide me with information essential to my medical assessment. As a result, I am disarmed in my struggle against illness and suffering. They are deprived of basic medical information which could inform their behavior and relieve their disabilities. In light of the recent government threats, I have already limited my discussions with patients and directed my staff (including other physicians) to use extreme caution when obtaining medical histories or answering patient inquiries about marijuana. Even this degree of wariness and apprehension has a chilling effect on my rapport with patients. They see me as part of their fight for life. Government threats disarm me in that struggle, and it is my patients who will ultimately suffer.
18. I have already stated that marijuana has proven effective in addressing many symptoms caused by medically prescribed treatments. The adverse affects of these therapies are particularly troubling to both the patient and the physician. In my practice, I frequently recommend treatments which, in the short term, may result in increased discomfort and visible suffering. They may also have adverse implications for the patient's long-term health. I cannot, in good faith, recommend these procedures and medications without a professional commitment to decrease, prevent or reduce the effects of these conditions.
19. Failure to consider every possible means of alleviating adverse side effects has very serious implications. When a patient can no longer tolerate the adverse consequences, she or he will cease treatment. I have seen it many times in my own practice and my colleagues report it consistently. It is a tragic fact which we monitor and assess constantly. In the case of chemotherapy and many AIDS medications, terminating treatment can mean an early and often painful death. It results in hopelessness where there should be, or could be, hope. As a scientist and a healer, preventable suffering and unnecessary despair are unacceptable.

I declare under penalty of perjury under the laws of the United States of America and the State of California that the foregoing is true and correct to the best of my knowledge, and that this declaration was executed this 14th day of February, 1997 in San Diego, California.

Marcus A. Conant, M.D.

Notes

1. "Iatrogenic" conditions are those which result from medical treatments or procedures, such as chemotherapy-related nausea or weight loss. (Back)
2. Spraycar, M. (ed.), Stedman's Medical Dictionary, 26th edition (1995: Williams & Wilkins), p. 269. (Back)