Patients’ informed consent is a crucial patient right. Informed consent can only be obtained when patients are advised in a clear and understandable language which treatment options are available, as well as their alternatives, risks, prospects, and potential side effects, including those relating to refraining from treatment.1 Effects of patient education are well documented in the literature regarding various diseases and studies. Accessibility to information, especially online information gathering, has the potential of fostering greater patient engagement in health maintenance and care.2 In contrast to the abundant available information sources regarding medical cannabis therapy (MCT) in various languages, very little available information is easily accessible to the unilingual Arabic-speaking population (in Israel about 1.8 million people [about 24%] are non-Jews and include a number of different, primarily Arabic-speaking groups, each with distinct characteristics3). Without resources in a language that patients can read and understand, they cannot achieve the proper health literacy necessary to maintain good health, to make wise health decisions, and to make wise use of health services.4
The Israeli Ministry of Health instruction number 7/11 of February 20115 includes, under the topic standard of care, cultural competence training and an instruction to promote public health education in minority groups in Israel, also by facilitating collaborations with communities as well as with the local and the religious leadership. The instruction also recommends additional recruitment of professionals from diverse minority background.
New unpublished data (co-author R.K.) compared the differences in populations seeking MCT treatments in two clinics (about 17 km distance apart): one was located in Netanya, a Jewish-majority area, and the other in Qalansawe, an Arab-majority area. During the early days of MCT practice in Israel, out of an average of 20 patients per day visiting the Netanya clinic, ~1–2 patients requested MCT; today that average is ~4–6 patients/day. In contrast, no patients requested MCT in the early days at the Qalansawe clinic, and the current average is ~1–2 patients/day (out of an average 20 patients/day). This information demonstrates the gap in MCT-seeking patients for the Arab population when compared to the Jewish population living in relative proximity to them.
Cannabis (al-qinnab al-hindi in Arabic) was introduced into the Middle East mainly from India via Persia; the Greek physicians were familiar with the medicinal properties of the plant and incorporated the plant into their practice. Medical cannabis therapy was practiced by scholars in the medieval Islamic world; however, during the eighteenth and nineteenth centuries the cultivation and use of cannabis were prohibited. Medieval Arab scholars’ documented use of MCT dates from the eighth to the eighteenth centuries, and the Unani Tibbi (Arabic-traditional medicine)6–13 refers to the plant’s diuretic, anti-emetic, anti-epileptic, anti-inflammatory, and pain-killing properties. A seventeenth-century pharmacopeia written by al-Intaqui prescribed cannabis for a number of somatic ailments, but also pointed out its euphoric and lethargic effects.12 Despite the scarcity of works dealing with MCT in Unani Tibbi, eight Unani Tibbi formulas containing cannabinoids were documented by Dwarakanath in 1965.10 Currently, most Muslim majority countries enforce a strict prohibition on cannabis use as an axiom of the Islamic prohibition of narcotic or stimulant substances (haram); however, a reform of cannabis laws is under consideration in Iran.13
The holy Koran does not explicitly forbid cannabis12,13; therefore, the interpretation of the status of cannabis is very much reliant on the religious scholars’ interpretations. One interpretative category relevant to cannabis use for medical reasons is that of “emergency” (zarurat), thus allowing believers to use or to perform generally prohibited substances or acts if these are deemed necessary in situations of emergency, or absolute necessity. This approach is legitimatized based on a Koranic verse (al-kul maytah) and on an accepted tradition (hadith-e raf’) reiterating that forbidden acts are allowed in times of emergency, if they can be useful and save lives.13 One survey of religious scholars’ interpretations regarding cannabis revealed that the majority do not consider cannabis as haram, that is to say that it is not totally forbidden; furthermore, the majority of the scholars are of the opinion that if cannabis is used for medical purposes (which must be demonstrated and justified through scientific and medical research), there is no ban on its use (zarurat). This contrasts sharply with recreational use, for its intoxicating and inebriating properties. The same study noted that cannabis with high levels of cannabidiol (CBD) (and with no to very low levels of Δ-9-tetrahydrocannabinol [THC]) qualifies as a non-intoxicant substance, and is therefore not prohibited religiously.13 Nonetheless, there is a bias against cannabis in Muslim society in accordance with its stereotype (hashish, kif) for social-recreational use, which is generally forbidden. These combined factors may deter Muslim patients from considering or seeking MCT as a treatment option.