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The federal government of Canada provided a sys-
tem for therapeutic access to cannabis in 2001
after a series of successful constitutional challenges
on cannabis prohibitions.1–3 Clinicians provide authoriza-
tions, rather than prescriptions, for medical cannabis owing
to its current status and regulation within Health Canada.4
Two decades later, the position of medical cannabis within
Canadian legislation, health care and society continues to
evolve.1,5,6 Driven largely by public awareness, anecdotes of
benet and expanded approvals for oral administration of
derivative products, medical cannabis has become an increas-
ingly prevalent treatment option for children with neuro-
developmental and life-limiting conditions including brain
and other cancers.4,5,7–11
Despite this trend, data on potential medical properties
and clinical applications of cannabis are generally lacking,
and standards regarding use in children are largely absent.4,5
Clinicians are practising, therefore, in a landscape dened by
high patient and caregiver interest, little medical data, and
tensions arising from an absence of regulations and treatment
Clinician views on and ethics priorities for authorizing
medical cannabis in the care of children and youth
inCanada: a qualitative study
Margot Gunning MSc, Ari D. Rotenberg BA, Lauren E. Kelly PhD, Bruce Crooks MD, Sapna Oberoi MD,
Adam L. Rapoport MD MHSc, S. Rod Rassekh MD, Judy Illes CM PhD
Competing interests: None declared.
This article has been peer reviewed.
Correspondence to: Judy Illes, jilles@mail.ubc.ca
CMAJ Open 2022 March 15. DOI:10.9778/cmajo.20210239
Background: The use of cannabis for medical purposes by pediatric patients is expanding across Canada; however, supporting evi-
dence, federal regulations and treatment guidelines are lacking. To understand factors affecting treatment decisions in this land-
scape, we sought to delineate clinician perspectives, ethics priorities and values for cannabis authorization.
Methods: We sampled participants purposefully through Canadian Childhood Cannabinoid Clinical Trials listservs, which include the
majority of pediatric oncologists and palliative care physicians practising in Canada, among many other pediatric physicians and clin-
icians. Inclusion criteria were being a practising clinician in Canada, involvement in the care of children and willingness to be inter-
viewed regardless of stance on medical cannabis. In November and December 2020, we conducted semistructured interviews focus-
ing on principles, values and priorities, including medical, professional, regulatory, evidentiary and social considerations, for
authorizing medical cannabis to children. Interviews were recorded, transcribed and analyzed by means of deductive and inductive
thematic methods.
Results: We conducted 18 interviews with a diverse group of clinicians representing a range of specialties within pediatric care,
including neurology, palliative care, oncology, family medicine and pharmacology. The interviews yielded 4 themes and 12 sub-
themes related to a priori (medical, professional, regulatory, evidentiary and social themes) and emergent themes. The 4 themes of
access, relationships and relational autonomy (autonomy within relationships), medically appropriate use and research priorities were
grounded in principles of harm reduction. Participants described problematic authorization procedures that negatively affect patient
use. Principles associated with relational autonomy were highlighted as a feature of open clinical communication. Benefits of appro-
priate medical uses weighed positively over risks, even in the context of potential effects on neurodevelopment. Participants
expressed that more research is essential to align medical cannabis with biomedical standards.
Interpretation: Clinicians reported pursuing ethical use of medical cannabis for pediatric patients and prioritizing their safety under
principles of harm reduction. There is a need for evidence about neurodevelopmental risks, support for research, treatment guide-
lines and greater knowledge about stakeholder perspectives to alleviate burdens related to use of medical cannabis for pediatric
patients in Canada.
Abstract
Research
Research
CMAJ OPEN, 10(1) E197
guidelines. In situations of clinical uncertainty or hesitancy,
principles of harm reduction, including pragmatism, human-
ism, focus on harms and prioritization of immediate goals,
can be used to facilitate treatment decisions that respect
patient dignity and safety.12,13
Past studies of factors affecting the views of clinicians on
medical cannabis treatment are limited but yield converging
results about knowledge base, legal regulations, authoriza-
tion procedures and medical context.14–19 These data are
derived primarily from clinicians specializing in pain medi-
cine, oncology, palliative care and family medicine.7,20–24
There appear to be limited data on the ethics priorities or
values that shape treatment decisions about medical cannabis
for children and on the effects of legalization of recreational
cannabis in Canada (Cannabis Act, Oct. 17, 2018).
Our objective was to obtain a greater understanding of
how ethical priorities and values — mainly access, safety
and autonomy — affect clinician decision-making. The
importance of lling this knowledge gap lies in both prac-
tice considerations in this unregulated landscape and the
inherent vulnerability of children, whose capacity to under-
stand and participate in treatment decisions and provide
consent is still evolving.
Methods
Study design
We developed a qualitative study under a pragmatic frame-
work with the view that empirical evidence and a dynamic,
interactive and interdisciplinary process will most effectively
lead to solution-oriented action.25–28 Using semistructured
interviews, we facilitated exible and exploratory dialogues
with clinicians in which more nuanced thoughts and values
surrounding medical cannabis were highlighted and exam-
ined in depth.29 This study was reported according to the
Consolidated Criteria for Reporting Qualitative Research
(COREQ) checklist.30
Sample selection
We sampled participants purposefully through Canadian
Childhood Cannabinoid Clinical Trials (C4T) listservs. Cana-
dian Childhood Cannabinoid Clinical Trials is an academic
research team of youth, parents, clinicians and scientists
studying cannabis for medical purposes in children (www.
C4Trials.org). Its listservs include hundreds of Canadian clin-
icians working in various subspecialities related to pediatric
care, at various career stages and with different backgrounds
(e.g., English-speaking, French-speaking and multilingual
practitioners) in urban and rural communities across British
Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Que-
bec and Nova Scotia. The listservs include the majority of
pediatric oncologists and palliative care physicians practising
in Canada, among many other pediatric physicians and clin-
icians, such as psychiatrists, pain specialists, neurologists and
pharmacologists. Members are known to have views regarding
medical cannabis, and are often consulted by patients and
caregivers, or are active authorizers.
Participants were eligible if they were a practising clinician
(i.e., physician, pharmacist, clinician in allied health care)
involved in the care of children in Canada and were willing to
be interviewed regardless of their stance on medical cannabis.
Emails were sent to all members of the C4T listservs in
November 2020. Eligibility was conrmed before interviews
were scheduled. After individual interviews were scheduled, a
reminder email was sent 2days prior.
Data source
The interview guide was developed by M.G. and J.I. after
engagement with C4T. It was piloted through group and one-
on-one consultations with L.E.K., A.L.R., S.R.R., S.O., B.C.
and additional C4T members such as researchers and patient
advocates, and rened and nalized based on the feedback
received. The interview guide consisted of 13questions focus-
ing on principles, values and priorities, including medical, pro-
fessional, regulatory, evidentiary and social considerations, for
authorizing medical cannabis to children (Appendix 1, avail-
able at www.cmajopen.ca/content/10/1/E196/suppl/DC1).
We also collected information about participant gender, eth-
nicity, specialty, years in practice and location of practice.
One-on-one interviews were conducted in English by
M.G. in November and December 2020. Interviews were
conducted virtually on a video conferencing platform because
of recruitment challenges during the COVID-19 pandemic.
All participants provided verbal informed consent and were
reminded that they could decline to answer any question or to
end the interview at any time.
Data analysis
Interviews were audio-recorded, transcribed verbatim by a
professional service, checked manually, de-identied with the
use of alphanumeric codes and managed in NVivo 12 (QSR
International). We used deductive and inductive coding for
content analysis.31 M.G. and A.D.R. reviewed interviews and
eld notes to write memos capturing overarching narratives
before building the initial codebook around a priori (medical,
professional, regulatory, evidentiary and social themes) and
emergent themes, subthemes and factors using 4 interviews
selected with a random number generator.32–34 M.G. and
A.D.R. coded transcripts by paragraph using a rich coding
strategy that allowed for the attribution of more than
1 unique code per paragraph.33,34 We determined intercoder
reliability using the Cohen κ coefcient.33–35 Discrepancies
were discussed until consensus was reached. M.G. and A.D.R.
coded the remaining interviews independently, which allowed
for further renement of thematic codes.
We calculated the proportion of coded references as the
number of coded references per thematic code divided by the
total number of references. We identied major subthemes
and factors as the most frequently occurring subtheme and
factor under each theme and subtheme, respectively.
Ethics approval
This study was approved by the University of British Columbia
Behavioural Research Ethics Board (REB H20-03084).
Research
E198 CMAJ OPEN, 10(1)
Results
Interviews were conducted with 18participants representing a
range of specialties within pediatric care, including neurology,
palliative care, oncology, family medicine and pharmacology
(Table 1). Half of the cohort had been in practice for 10 or
more years. Eleven participants self-identied as male and 7 as
female. They were of white, Asian, Black and Latino ethnic-
ity. Participants represented 6provinces.
The median interview time was 34 (range 29–61) minutes.
Cohen κ tests yielded an overall unweighted κ statistic of
0.90, which indicated good reproducibility of the coding hier-
archy (Table 2).
Themes
Overarching principles of harm reduction unied 4 a priori
and emergent themes: access, relationships and relational
autonomy (autonomy within relationships), medically appro-
priate use and research priorities (Table 2). There were
12subthemes. Table 3 shows the proportion of interviews and
of coded references (n= 1886) supporting dominant sub-
themes and factors. Illustrative quotes are provided in
Table 4.
Access
Clinicians most frequently referred to the theme of access by
comparing medical cannabis to other therapeutics and how
Table 1: Demographic characteristics of study participants
Characteristic
No. (%) of participants
n = 18
Profession
Physician 16 (89)
Academic clinical researcher 1 (6)
Pharmacist 1 (6)
Specialty
Pediatric palliative care 7 (39)
Pediatric oncology 4 (22)
Other pediatric* 4 (22)
Family medicine 1 (6)
Clinical pharmacology 1 (6)
Research pharmacology 1 (6)
Years in practice
< 10 9 (50)
≥ 10 9 (50)
Gender†
Male 11 (61)
Female 7 (39)
Location of practice
Ontario 8 (44)
British Columbia 4 (22)
Manitoba 2 (11)
Saskatchewan 2 (11)
Alberta 1 (6)
Quebec 1 (6)
Ethnicity†
White 14 (78)
Asian 2 (11)
Black 1 (6)
Latino 1 (6)
*Includes pediatric neurology, general pediatrics and pediatric clinical
pharmacology.
†Self-identified.
Table 2: Coding hierarchy
Major theme; subtheme Factor
Access
Authorization burden • Supply and quality
• Clinician
• Financial
Law and policy burden • Federal
• Provincial
• Hospital policy
Patient burden • Pragmatic use
• Conditional rights
Relationships and
relational autonomy
Clinical communication • Individualistic approach
• Data transparency
• Informed consent
Clinical support • Support and guide use
• Responsibility to educate
• Referrals
Nonclinical communication • Misconceptions, misperceptions
• Public promotion of information
Medically appropriate use
Risk–benefit calculus • Harms
• Balance risk and benefit
Evidence-based treatment • Considered option
• Not considered option
Consumption • Various forms, routes, dosages
• Recommendations
Research priorities
Necessary research • Data from any scientific method
• Appropriate use
• Adverse effects
• Efficacy
• Safety
• Dosing
• Randomized controlled clinical
trials
Barriers to research • Study design
• Institutional
Research ethics • Ethical considerations
• Obligations
Research
CMAJ OPEN, 10(1) E199
unique barriers can interfere with patient safety (18 interviews
[100%]; 532 coded references [28.2%]). Obstacles to authori-
zation was a notable subtheme. Major factors influencing
authorization included considerations about product supply
and quality, professional reputation and knowledge required
to authorize. Participants also mentioned nancial obstacles
that patients and their families face, including high cost and
lack of insurance coverage (Table 4).
Law and policy burdens were described by clinicians as
regulations that impede authorization and patient access. Par-
ticipants most often cited negative impacts of federal regula-
tions on access (18 interviews [100%]; 99 coded references
[5.2%]). For example, participants explained that Health Can-
ada’s refusal to provide a Drug Identication Number for
medical cannabis lies directly upstream of authorization obsta-
cles. They described the impact of federal legalization of adult
use of recreational cannabis on patient access: although clini-
cal decision-making did not change, participants perceived a
decline in research barriers and in social and institutional
stigma. Minor factors (i.e.,provincial law and hospital policy)
were cited infrequently as factors affecting access (<5.0% of
coded references).
Within the subtheme of patient burden, participants cited
behaviours and rights that can create barriers to safe and
effective treatment (18 interviews [100%]; 108 coded refer-
ences [5.7%]). They suggested that patients and caregivers
nd and use cannabis for therapeutic purposes regardless of
authorization status or clinical guidance. Participants also
acknowledged that patients have a right to inquire about med-
ical cannabis, but their right to receive medical cannabis is
conditional on medical context.
Table 3: Frequency of interviews and coded references
endorsing themes, and dominant subthemes and factors
Theme; subtheme; factor
No. (%) of
interviews
n = 18
No. (%) of
coded
references
n = 1886
Access 18 (100) 532 (28.2)
Authorization burden 18 (100) 269 (14.3)
Supply and quality 17 (94) 108 (5.7)
Relationships and relational
autonomy
18 (100) 526 (27.9)
Clinical communication 18 (100) 313 (16.6)
Individualistic approach 18 (100) 169 (9.0)
Medically appropriate use 18 (100) 487 (25.8)
Risk–benefit calculus 18 (100) 267 (14.2)
Harms 18 (100) 132 (7.0)
Balance risk and benefit 17 (94) 135 (7.2)
Research priorities 18 (100) 341 (18.1)
Necessary research 17 (94) 235 (12.5)
Data from any scientific method 15 (83) 61 (3.2)
Table 4: Illustrative quotes for dominant subthemes
Theme Subtheme Illustrative quote
Access Authorization burden [There is a] lack of consistency from one licensed producer to another, content is not
the same [which is different from other therapeutics]. The therapy and content might be
different one batch to other. It’s almost like witchcraft in some way. (Participant 02)
Money is the biggest [equity concern]. … For a child [for whom] I would [authorize] or
think of [authorizing medical cannabis], if the family doesn’t have … ways of getting it,
then we’re stuck. (Participant 05)
Relationships and
relational autonomy
Clinical communication Just being very transparent with families is important, and letting them know … the
evidence that you have for it [cannabis], certain scenarios that you think it is beneficial
in and why directly for the patient you think it is a good or it’s beneficial or not
beneficial. And then, helping to dispel some of their disbeliefs and asking … what their
knowledge is of medical cannabis. (Participant 09)
It’s really the parents who are making the third-party decision whether [the child is]
neurologically intact or not. The only difference is when we’re dealing more with
adolescents … they’re more capable. We definitely bring them in for the conversation
because … they’re capable. (Participant 05)
Medically appropriate
use
Risk–benefit calculus You start out with your most tried and true treatments and then you work up. Now,
that’s the approach in practice; what that means is the patients who are most severe
are most likely to reach third-, fourth-line treatments. So, they would be more likely to
be offered cannabis, but I’m not offering it because they’re severe. I’m offering it
because first-, second-line treatments [have] failed. (Participant 03)
Research priorities Necessary research I don’t think you need to have a direct comparison for efficacy. … Is it safe in the
context … even sort of more qualitative things would be fine. (Participant 07)
I don’t even know that [evidence] needs to be at the randomized controlled trial level.
We don’t even have well-designed prospective trials, we don’t have well-designed
retrospective trials, we don’t have anything to go by. (Participant 18)
Research
E200 CMAJ OPEN, 10(1)
Relationships and relational autonomy
Relationships and relational autonomy was the second
most commonly referenced theme (18 interviews [100%];
526coded references [28%]). The main subtheme was clinical
communication dened by an individualist approach: partici-
pants explained that they try to build conversations around
patient and caregiver needs and beliefs as much as possible,
while stressing the need for bidirectional judgment-free hon-
esty and trust (Table 4). Minor factors (<5.0% coded refer-
ences) were the importance of data transparency, and obtain-
ing informed consent from the patient or the surrogate
decision-maker.
Two additional subthemes were demonstrating clinical
support (17 interviews [94%]; 112 coded references [5.9%])
and addressing communication that patients and families
receive from outside clinical settings (e.g.,friends, Internet)
(18 interviews [100%]; 101 coded references [5.4%]). In the
context of clinical support, participants expressed a need to
follow the wishes of the patient and the caregiver, even if
those wishes were not supported by current medical evidence,
as well as the responsibility to educate themselves and to pro-
vide referrals. They further discussed correcting misconcep-
tions and misperceptions about medical cannabis that can
arise from nonclinical sources of communication.
Medically appropriate use
The third most commonly referenced theme was medically
appropriate use (18 interviews [100%]; 487 coded references
[25.8%]). Risk–benefit calculus was dominant here, with
potential harms of medical use compared to expected benets
(Table 4). Participants cited specic harms, including negative
impacts on neurodevelopment, drug–drug interactions and
the potential for addiction. Benets pertained to improve-
ments in quality of life and reducing harms in a safely moni-
tored way. Medical considerations that could mitigate risks
were the number of tried and failed therapeutic attempts, a
life-limiting prognosis, the presence of severe symptoms and a
shorter duration of use (Table 5).
The subtheme of evidence-based treatment outlined the
conditions for which medical cannabis may be considered
an appropriate treatment option, not as a rst-line option
but, rather, as a low-priority symptom management tool.
Commonly cited treatment contexts included cancer-
related symptoms, seizure disorders, chronic nausea and
chronic pain.
Consumption captured clinical deliberation over the for-
mulation (Δ-9-tetrahydrocannabinol–cannabidiol ratio) and
route of administration. Nuances of dosing and recommenda-
tions against smoking dominated this subtheme.
Research priorities
Participants believed that research was necessary for authoriza-
tion of medical cannabis to children, expressing an urgency for
more data in general, from any scientic method, in any popu-
lation (Table 4). They expressed that studies directed at spe-
cic and diverse pediatric populations and conditions, as well
as systematic investigations of adverse effects, efcacy, safety
and dosing, would raise the evidentiary standard for medical
cannabis to the standard to which therapeutics are generally
held (Table 6). More than half of participants (n = 13)
expressed the need for randomized controlled clinical trials.
The subthemes of barriers to research and research ethics
each represented less than 5.0% of coded references but
reected important concerns for developing future studies.
Barriers to research included funding difculties and study
design considerations. Research ethics focused on the obliga-
tion to conduct studies in pediatric populations and special
ethical considerations therein, such as a greater respect for
impact on neurodevelopment.
Interpretation
The clinicians who participated in our study were critical of
Canada’s medical cannabis landscape, expressing that regula-
tory obstacles impose downstream challenges to safe and con-
trolled access for pediatric patients. Medical cannabis is held
to the same evidence-based, biomedical standards as other
treatments but cannot currently meet them. Participants iden-
tied a need to address access barriers and conduct further
research. The ethics values that affect clinical decision-making
about medical cannabis are perhaps unsurprising and reect
the importance of evidence-based treatment decisions, risk–
benet calculus, respecting relationships and autonomy, and
informed choice. The ndings highlight the signicance of
Table 6: Research necessary for clinical consideration of
authorizing medical cannabis
Factor
No. (%) of
interviews
No. (%) of coded
references
Data from any scientific
method
15 (83) 61 (3.2)
Appropriate use 10 (56) 42 (2.2)
Adverse effects 11 (61) 41 (2.2)
Efficacy 10 (56) 23 (1.2)
Safety 10 (56) 23 (1.2)
Randomized controlled
clinical trials
13 (72) 19 (1.0)
Dosing 9 (50) 19 (1.0)
Table 5: Medical considerations affecting risk–benefit
calculus and the decision to authorize medical cannabis
Medical profile
characteristic
No. (%) of
interviews
No. (%) of coded
references
No. of therapeutic attempts 16 (89) 46 (2.4)
Prognosis 16 (89) 46 (2.4)
Symptom severity 13 (72) 25 (1.3)
Duration of use 3 (17) 3 (0.2)
Research
CMAJ OPEN, 10(1) E201
interpersonal values such as quality of life in end-of-life and
oncology settings,7,15 and the need for methodologically sound
systematic studies.7,19,21–24,36–39
The results of this study align with those of previous stud-
ies of clinician attitudes toward medical cannabis. Concerns
remain about barriers to access, including supply, quality and
nancial burdens, identied in surveys among Canadian clin-
icians before legalization.5,6,36,40 Insufcient regulations and
policies continue to place a disproportionate responsibility on
clinicians and create additional access barriers.21,23,24 For
example, medical cannabis has not undergone Health Cana-
da’s drug review and approval process and lacks a Drug Iden-
tication Number, which means that it has to be authorized,
not prescribed. This has ramications for clinicians, insurance
providers, and patients or caregivers.4,37
Seminal to our ndings is the potential benet of a harm-
reduction approach to manage behaviours that pose a risk to
health in societal and clinical settings.13,41–43 For example,
harm-reduction techniques have been applied to reduce prob-
lematic use of substances including cannabis by youth.43–45
Medical cannabis itself has been used as a substitute for pre-
scription opioids and other drugs to reduce harm.46–48
Taken as a narrative whole, the present ndings reect
harm-reduction principles of pragmatism, humanism, focus
on harms and prioritization of immediate goals.12,13 Partici-
pants acknowledged that pediatric patients may use cannabis
for perceived medical purposes regardless of access barriers.
The results show that, in the face of pragmatic use, clinicians
can use harm-reduction strategies to prioritize patient safety.
Clinicians take a humanistic approach in recognizing
patients’ rights to medical cannabis, and in striving for open
and transparent communication. To mitigate risks, clinicians
guide patients through treatment options with strong evi-
dence before considering medical cannabis as a symptom-
management tool. By understanding when and how patient
medical proles may allow potential benets of medical can-
nabis to outweigh risks, clinicians are able to prioritize imme-
diate treatment goals.
The expressed need for data, considered federal regulations
and a harm-reduction approach support interdisciplinarity in
the quest to resolve issues in Canada’s medical cannabis system.
Legislator, clinician, patient and key stakeholder views are criti-
cal to negotiate a system that aligns medical cannabis with treat-
ment standards that do not violate rights to access and safe-
guards patient health. Many critical issues remain to be explored
and addressed, including standardization of products available
to patients and researchers, clinician education on dosing and
adverse effects of medical cannabis, and clinical communication
approaches that are patient-centred and culturally sensitive.
Limitations
We were unable to recruit participants who do not consider
authorizing medical cannabis, and diversity was limited. We
did not return transcripts to participants and did not conduct
member-checking. It is possible that bias was introduced
owing to views and perspectives of the coders, who are both
white and of European background. We did not assess the
impact of patient demographic characteristics such as age and
gender on clinician decision to authorize. The method of semi-
structured interviewing yields a holistic, narrative understand-
ing of a topic but, by its nature, evolves during data collection.
Conclusion
Canadian clinicians described a treatment landscape for pediat-
ric use of medical cannabis that is in need of reform. Current
circumstances are fuelled by ineffective federal policies that pre-
vent quality assurance but allow for indirect access without clin-
ician involvement. Although clinicians reported approaching
this landscape using a pragmatic harm-reduction strategy, this
is untenable as a long-term solution. Changes to regulations
and more research are necessary to improve the care of children
and youth whose medical needs may include cannabis products.
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Afliations: Neuroethics Canada (Gunning, Rotenberg, Illes), Division
of Neurology, Department of Medicine, University of British Columbia,
Vancouver, BC; Department of Pediatrics and Child Health (Kelly), Uni-
versity of Manitoba; George & Fay Yee Centre for Healthcare Innovation
(Kelly), Winnipeg, Man.; Division of Hematology-Oncology (Crooks),
Department of Pediatrics, IWK Health Centre, Dalhousie University,
Halifax, NS; Department of Pediatric Hematology-Oncology-BMT
(Oberoi), CancerCare Manitoba, Winnipeg, Man.; Departments of Pae-
diatrics and of Family and Community Medicine (Rapoport), Faculty of
Medicine, University of Toronto; Emily’s House Children’s Hospice
(Rapoport), Toronto, Ont.; Division of Pediatric Hematology/Oncology/
BMT (Rassekh), Department of Pediatrics, University of British Colum-
bia, Vancouver, BC
Contributors: The following authors contributed equally (in alphabetical
order): Bruce Crooks, Sapna Oberoi, Adam Rapoport and Rod Rassekh.
Judy Illes, Lauren Kelly, Margot Gunning, Adam Rapoport, Rod
Rassekh, Sapna Oberoi and Bruce Crooks conceived and designed the
study. Margot Gunning acquired the data. Margot Gunning and Ari
Rotenberg analyzed the data. Margot Gunning, Ari Rotenberg and Judy
Illes interpreted the data and drafted the manuscript. All of the authors
revised the manuscript critically for important intellectual content,
approved the nal version to be published and agreed to be accountable
for all aspects of the work.
Funding: This work was supported by grant 707031 to Lauren Kelly
from the Canadian Institutes of Health Research and the Canadian
Cancer Society.
Content licence: This is an Open Access article distributed in accor-
dance with the terms of the Creative Commons Attribution (CC BY-NC-
ND 4.0) licence, which permits use, distribution and reproduction in any
medium, provided that the original publication is properly cited, the use
is noncommercial (i.e., research or educational use), and no modications
or adaptations are made. See: https://creativecommons.org/licenses/by-nc
-nd/4.0/.
Data sharing: Raw interview data and eld notes are not publicly avail-
able owing to privacy considerations.
Acknowledgements: The authors thank the participants for volunteer-
ing their time, members of the Canadian Childhood Cannabinoid Clini-
cal Trials team for feedback on study design, and Neuroethics Canada for
assistance with data analysis and feedback on the results.
Supplemental information: For reviewer comments and the original
submission of this manuscript, please see www.cmajopen.ca/content /10/1/
E196/suppl/DC1.
