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LEGAL USERS GUIDE  TO  THE

MICHIGAN MEDICAL MARIJUANA ACT 

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Keys to understanding the new 

Michigan Medical Marijuana Law

THIS INFORMATION AVAILABLE TO VISUALLY IMPAIRED 

 

T

he Initiative Legislation known as Proposition 1 was approved by 63% of Michigan voters. The measure is the law of the state, as of its effective date December 4, 2008; 10 days after the official declaration of the vote. Proposition 1 is to be cited as “The Michigan Medical Marihuana Act.”, and it will be placed into the Michigan Compiled Laws in Chapter 333.

The landslide approval of Proposition 1 registers a transformational shift in public attitudes that has occurred throughout America over the past four decades, and with the November 4, 2008 enactment of the Proposition1, Michigan and Maine voters joined a dozen states that have previously legitimized marijuana use, at least for medicinal purposes, in these past dozen years.

 

The Citizen Initiative Process: How the Act went from Idea to Ballot Question to Law

Medical Marijuana laws have been enacted in California(‘96), Alaska(‘98), Oregon(‘98), Washington(‘98), Maine(‘99), Nevada(‘99), Hawaii(00), Colorado(2000), Vermont(2000), Montana(’04), New Mexico(07), and Rhode Island(07). Four state legislatures enacted of these laws, and the balance were enacted though ballot initiatives. Arizona and Maryland have also passed laws that enable medical marijuana users, without legitimizing medical use. Michigan voters approved in each of five citywide medical marijuana votes, medical marijuana won in a landslide, with 62% in Flint in February 2007; with 63% in Traverse City and 61% in Ferndale in November 2005; with 74% in Ann Arbor in November 2004; and with 60% in Detroit in August 2004. These local initiatives were basically precatory in nature, making Marijuana law enforcement a lowest possible priority or forbidding the use of municipal resources, like court time, for enforcement in cases of medical use. Grass roots initiative petition drives during the 2000 and 2002 election cycles, called the Personal Responsibility Amendment Petitions, proposed full decriminalization for any adult use, and narrowly missed the target signature requirements for placement on the ballot. In 2007 the Michigan Coalition for Compassionate Care collected a half million signatures in favor of placing the issue before the legislature, or on the ballot.  The Michigan Constitution provides for Direct Democracy in the form of Initiative Legislation, [Article 2, Section 9]. When sufficient petition signatures are gathered, the legislature gets the opportunity to enact a proposal, within the 40 days, or to submit such proposed law to the people for approval or rejection at the next general election. It also had the right to place an alternate proposal on the ballot. It did neither, and the measure was placed on the ballot, where a record 68% of registered voters turned out to cast ballots. 4,801,850 people voted on the question. 3,008,980 people voted yes on Prop 1 (63%). 1,792,870 people voted no. About 200,000 people voted for president, but did not vote yes or no on this question. Initiative Legislation becomes law 10 days after the official declaration of the vote.

 

Three-Fourths Vote in each House is Needed for the Legislature to Amend or Repeal the Initiative

No law initiated or adopted by the people shall be subject to the veto power of the governor, and no law adopted by the people at the polls under the initiative provisions of this section shall be amended or repealed, except by a vote of the electors unless otherwise provided in the initiative measure or by three-fourths of the members elected to and serving in each house of the legislature. [1963 Michigan Constitution Article 2, Section 9]

The Phase In Process: Timing and Implementation of the defense and Registry ID Card Program

The effective date of the Act is December 4, 2008, and from and after that date one aspect of the Act will be operative. The affirmative defense may be asserted from that date forward. The Registry program, on the other hand, may take until April 2009 to implement. In the meantime, hearing will be conducted, and public input sought, with regard to implementation procedures. 

Introduction to the Two Track Parallel Protections Established by the Act, and their Limits 

  • The medical use of marijuana is allowed under state law to the extent that it is carried out in accordance with the provisions of this act. All other acts and parts of acts inconsistent with this act do not apply to the medical use of marijuana as provided for by this act.
  • The Act sets up a Patient Registry ID Card program, administered through the Michigan Department of Community Health. The Act scheduled the program to be in operation by April 2009. To get a Registry ID Card the patient must get a written certification from a doctor stating the patient's debilitating medical condition and stating that, in the physician's professional opinion, the patient is likely to receive therapeutic or palliative benefit from the medical use of marijuana to treat or alleviate the patient's debilitating medical condition or symptoms associated with the debilitating medical condition. Under the Act, Doctors may certify qualifying patients for an expansive list of specified debilitating medical conditions, plus any other "chronic or debilitating disease or medical condition or its treatment…” that produces symptoms or side effects likes appetite loss; severe and chronic pain; severe nausea, seizures, severe and persistent spasms. A registered “Qualifying Patient” and a designated "Primary Caregiver" who have in their possession Registry ID Cards enjoy rebuttable presumptions of legitimacy for quantities not exceeding generous but specific statutory limits, and kept in locked facilities. Primary caregiver" means a person who is at least 21 years old and who has agreed to assist with a patient's medical use of marihuana. A registered primary caregiver may receive compensation for costs associated with assisting a registered qualifying patient in the medical use of marijuana. Any such compensation shall not constitute the sale of controlled substances.This creates a prophylactic immunity; the law specifically bars arrest, prosecution, criminal or civil penalty, disciplinary action, and bars seizure or forfeiture of medical use marijuana.
  • §  A stand alone "Medical Purpose Affirmative Defense" is established by the Act. It protects patients and primary caregivers, even if they do not have Registry ID Cards. The law entitles defendants with charges pending on December 4, 2008 to assert this defense. This defense very liberal, not difficult to assert and prove, and fully explained in "The Essentials of the Affirmative Defense" chapter of this title. Doctor must make a statement (written or oral) that supports assertion of the Affirmative Defense for an unlimited number of other serious for debilitating medical conditions. The Affirmative Defense applies so long as a physician has stated that, in the physician's professional opinion, after having completed a full assessment of the patient's medical history and current medical condition made in the course of a bona fide physician-patient relationship, the patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's serious or debilitating medical condition or its symptoms. This umbrella Affirmative Defense is the key to the Act. Using this defense, the specific limits give way to a reasonableness standard; not more than is reasonably necessary to ensure the uninterrupted availability of marijuana for the purpose of treating or alleviating the patient's serious or debilitating medical condition or symptoms of the patient's serious or debilitating medical condition. 

  • These disqualifying factors preclude any protections under the Act
    1. Smoking marijuana "in any public place";
    2. Smoking marijuana on any form of public transportation;
    3. Any use by a person who has no serious or debilitating medical condition; 
    4. Any conduct where being under the influence would constitute negligence or professional malpractice per se;
    5. Operating, navigating, or being in actual physical control of any motor vehicle, aircraft, or motorboat while under the influence of marihuana. 
    6. Any use or possession in a school bus;
    7. Any use or possession on the grounds of any preschool, primary, or secondary school;  
    8. Any use or possession in any correctional facility

The Short History and Background of Marijuana Laws and their Reform in Michigan

The Michigan Medical Marihuana Act is long in coming, and is likely to prove to most expansive in the nation for protecting qualifying patients, and at the same time the least susceptible to abuse by commercial interests. The Michigan law is beneficiary of lessons learned in pioneering states like California (‘96), Alaska (‘98), Oregon (‘98), Washington (‘98), Maine (‘99), Nevada (‘99), Hawaii (00), Colorado (2000), Vermont (2000), Montana (’04), New Mexico (07), and Rhode Island (07). Four state legislatures enacted of these laws, and the balance were enacted though ballot initiatives. Arizona and Maryland have also passed laws that enable medical marijuana users, without legitimizing medical use. Michigan voters approved in each of five citywide medical marijuana votes, medical marijuana won in a landslide, with 62% in Flint in February 2007; with 63% in Traverse City and 61% in Ferndale in November 2005; with 74% in Ann Arbor in November 2004; and with 60% in Detroit in August 2004. These local initiatives were basically precatory in nature, making Marijuana law enforcement a lowest possible priority or forbidding the use of municipal resources, like court time, for enforcement in cases of medical use. Grass roots Initiative petition drives in during the 2000 and 2002 election cycles, called the Personal Responsibility Amendment Petitions, proposed full decriminalization for any adult use, and narrowly missed the target signature requirements for placement on the ballot.

Previously in Michigan, Legalization” and “Decriminalization” were popular trends with politicians until 1978, when the Jimmy Carter administration botched an undisciplined effort to promote more tolerant drug laws, which ended in the Peter Bourne/NORML scandal. That debacle set in motion a parental movement, from which evolved the prevailing tactical anti-drug mentality among entrenched incumbent politicians and challengers alike, which can be found in the modern politician’s playbook. All “street drugs” are lumped together and demonized as being isolated within the dangerous criminal underbelly of America. A candidate who is soft on marijuana is labeled as soft on drugs. Soft on drugs means soft on crime. A candidate labeled as soft on crime goes back to the private sector.

Marijuana use has a long tradition in cultures around the world, but personal consumption of cannabis was obscure in America. Hemp was a common industrial crop used for paper, sailcloth, and oil. Common hemp lacked the intoxicating properties of the cannabis strain Americans now call marijuana, which was used in medicinal elixirs but never caught on with smokers, who preferred tobacco. American marijuana laws started as race-based protectionist measures almost a century ago; these laws worked their way across the country, as reactionary trade barriers to stop industrious migrant Mexican Mestizos. These workers created price competition for local farm jobs, and brought marijuana, a common substance in Mexico, with them. From 1914 to 1932, over twenty-one states stopped the sale of marijuana along with other “narcotics”, one state outlawed its use, and four others banned it as a crop. The Uniform Narcotic Drug Act in 1932 and the passage of the Marihuana Tax Act were passed in 1937. Marijuana was demonized as a vice of the lower classes, black musicians, and Mexicans. Marijuana was obscure. Its users were rare and marginal, on the fringes of society. Only when the baby boom generation hit young adulthood did all that change.

In 1972, the Michigan Supreme Court issued a scathing opinion in the aftermath of the 1969 arrest, conviction, and long prison sentence of popular rock band MC-5 manager John Sinclair for having shared two joints to an undercover agent provocateur, then a 10 year felony. The incident drew attention to the potential for drug law enforcement abuse, and for years the decriminalization movement was able to ride the tide of anti-war sentiment. The example of Mahatma Gandhi inspired civil disobedience tactics in the form of the perennial Ann Arbor Hash Bash on the University of Michigan campus. John Lennon and Yoko Ono even came to Michigan, in 1971, to hold a legendary rock concert to "Free John Sinclair!" The day before the concert, Lansing lawmakers produced ill-fated legislation reducing Marijuana use to misdemeanor status.  Shortly after the concert, Sinclair was freed on bond. In 1972 the Michigan Supreme Court ruled in People v. Sinclair, 387 Mich. 91 (1972) that Michigan’s classification of marijuana was unconstitutional, effectively decriminalizing possession for about a week while the Michigan Legislature scrambled to enact a conforming statute. Dicta in the opinion that freed Sinclair read the riot on drug laws, declaring the principal danger of marijuana use was not physical or mental side effects; the danger was that it made one vulnerable to the crushing power of a state willing to punish youthful indiscretion with loss of freedom and a ruined future. Back in 1978, before the Carter scandal triggered a political sea change, the Michigan Legislature enacted a medical marijuana law [MCL 333.7214] that established a medical use pilot program, which died on the vine 10 years later due to federal barriers to obtaining a marijuana supply for the program. Former Michigan Governor John Engler co-sponsored Senate Concurrent Resolution 473, a concurrent resolution passed by Houses on March 17, 1982 and the Senate on February 2, 1982. In 1978, when the Michigan Legislature passed the first Medical Marijuana Laws, it also enacted a comprehensive overhaul of draconian drug laws. This Act included the now familiar “escape clause” for first offenders at MCL 333.7411, which, in most drug possession cases, gives the court unfettered discretion to court to impose a period of probation without an adjudication of guilt (a delayed or deferred sentence), and unilaterally dismiss the case, even after a guilty verdict at trial and despite the People’s objection, after completion of probation term that was often without reporting and as short as 10 days. No fine, only costs, though a jail sentence could be imposed as part of the probation.

In 2000, when MCL 333.7408a attached harsh license sanctions, including a period without restricted driving privileges, to marijuana convictions; deferred sentencing under section 7411 has been all the rage. Somewhat erratically applied for decades, as reserved for impressionable youths who showed promise (or were well connected), 7411 has become commonplace and is now the rule, not the exception. Section 7411 serves clients well as a formal diversion program that maintains the law’s deterrent effect and forces drug education, but does no real and lasting harm because it results in no discoverable public criminal record. The image of overwhelmed probation agents, their cabinets overflowing with probation files that reflect not only the prevalence of 7411 but a concurrent rise in relative arrest and prosecution rates for marijuana users, offers a grim testament to the futility of enacting criminal laws against conduct that is malum prohibitum but not malum in se. A limited government is ill-equipped to bear the strain of babysitting human beings who commit crimes, like smoking pot, but who are hardly “criminals” as the term is traditionally understood.

More recently, in 2004, the legislature amended the drunk driving laws at MCL 257.625(8), and that the crime of Operating While Intoxicated occurs the driver “…has in his or her body any amount of a controlled substance listed in schedule 1…”(marijuana), without regard to any level of actual intoxication. In absolute deference to the legislature, the Supreme Court ruled in People v Derror, 475 Mich 316 (2006) that MCL 257.625(8) does not require that a person be under the influence of a schedule 1 controlled substance to violate the statute. It merely requires that a person have any amount of a schedule 1 controlled substance in the person's body.” “It is irrelevant that an “ordinary” marijuana smoker allegedly does not know that 11-carboxy-THC could last in his or her body for weeks. It is also irrelevant that a person might not be able to drive long after any possible impairment from ingesting marijuana has worn off.” “A prosecutor is not required to prove beyond a reasonable doubt that the defendant knew that he or she might be intoxicated. Rather, the prosecutor need only prove that the defendant had any amount of a schedule 1 controlled substance in his or her body”. “It is irrelevant that the “ordinary person” cannot determine, without drug testing, when the schedule 1 substance is no longer detectible in the body.” wrote recently deposed Supreme Court Justice Cliff Taylor. The Michigan Medical Marijuana Act reverses this decision.

Currently first offense Marijuana possession is as one year misdemeanor, with second offense being subject to enhancement to twice that amount. Use of Marijuana is a 90 day misdemeanor. Possession with Intent to Deliver, and Manufacture and Delivery of Marijuana are 4 year felonies, doubled for subsequent offenses, and enhanced to 7 years for larger amounts. These laws are not amended by the Michigan Medical Marijuana Act. The Act merely establishes a specific immunity from arrest and forfeiture for patients and Primary Caregivers protected by the Registry ID Program, and establishes a medical purpose affirmative defense for anyone who can make a showing of certain facts in any case involving marijuana.

Operation of the Michigan Medical Marijuana Act

Law specifically authorizes medical use 

Section 7 (a) "The medical use of marihuana is allowed under state law to the extent that it is carried out in accordance with the provisions of this act."

 

Medical Use of Marijuana

"Medical use" means the acquisition, possession, cultivation, manufacture, use, internal possession, delivery, transfer, or transportation of marihuana or paraphernalia relating to the administration of marihuana to treat or alleviate a registered qualifying patient's debilitating medical condition or symptoms associated with the debilitating medical condition.

 

Licensed Michigan Doctors Serve as Gatekeepers

Only a Physician licensed in Michigan can make a valid statement or certification, and nothing in the act allows any court to second guess a physician’s professional opinion. Doctors exercising independent responsible medical judgment are to the unquestioned gatekeepers to access under the Act, and the law provides that unless the physician fails to honestly make a professional evaluation of the patient, the Physician (MD or Osteopath) is immunized against legal or professional association sanctions that might otherwise result from their expressing of professional opinions regarding the medical efficacy of legitimate medicinal Marijuana use. It is up to each physician to form their own professional opinion on the efficacy of marijuana for medicinal use. The ADA also makes it inappropriate for a Doctor to be dismissive of a patient’s request of information, or to make social or moral judgments about the use of marijuana. The only questions are; what is the serious or debilitating medical condition, and is the patient likely to receive therapeutic benefit by using marijuana to treat or alleviate that condition or its symptoms. "Physician" means an individual licensed as a physician under Part 170 of the public health code, 1978 PA 368, MCL 333.17001 to 333.17084, or an osteopathic physician under Part 175 of the public health code, 1978 PA 368, MCL 333.17501 to 333.17556.

 

Verifying the Physician’s License

§  Verify a Doctor’s License online at Department of Community Health Web Site. See www.QualifyingPatient.com

§   Contact MDCH Phone: (517) 241-9427 Capitol View Building 201 Townsend Street, Lansing, Michigan 48913

 

Obtaining a Physician’s License in Michigan

Physicians licensed in jurisdictions outside Michigan can apply for a reciprocity license by filing an application packet, fee, and additional documents such as university transcripts, verifications from other states. Upon receipt of all required documents, your application will be reviewed, approved, and your license will be issued. This process generally takes 6 to 8 weeks.

Bureau of Health Professions Licensing for Health Care Professionals has Applications and information. Ph: (517) 335-0918 Fax: (517) 373-2179 Ottawa Building 611 West Ottawa Street, 1st Floor Lansing, MI 48933 [See www.Qualifyingpatient.com]

Physician Protections and requirements under the Michigan Medical Marihuana Act

A physician shall not be subject to arrest, prosecution, or penalty in any manner, or denied any right or privilege, including but not limited to civil penalty or disciplinary action by the Michigan board of medicine, the Michigan board of osteopathic medicine and surgery, or any other business or occupational or professional licensing board or bureau, solely for providing written certifications, in the course of a bona fide physician-patient relationship and after the physician has completed a full assessment of the qualifying patient's medical history, or for otherwise stating that, in the physician's professional opinion, a patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's serious or debilitating medical condition or symptoms associated with the serious or debilitating medical condition, provided that nothing shall prevent a professional licensing board from sanctioning a physician for failing to properly evaluate a patient's medical condition or otherwise violating the standard of care for evaluating medical conditions.

 

Physician Protections Under Federal Caselaw

Conant v. Walters, 309 F.3d 629 (2002)

On October 14, 2003, the US Supreme Court announced that it would not review a Ninth Circuit Appeals Court ruling that enjoined the federal government from punishing doctors who recommend medical use of marijuana to their patients. The case, appended to this publication, and the US Supreme Court’s tacit approval of it, provide protections far beyond anything a Michigan doctor will need to do to provide a patient with access under Michigan law.

The case established that doctors my:

  • Discuss the risks and benefits of medical marijuana fully and candidly with patients.
  • Recommend (or Approve, Endorse, Suggest, or Advise, etc.), in accordance with their own medical judgment the medical use of marijuana.
  • Make a Record in their patients’ charts, to verify discussions about and recommendations of medical use of marijuana.
  • Make and sign a state law certification or statement that they have recommended medical marijuana for particular patients, or made any other statement required under state law.
  • Testify in court or through written declaration about recommending medical marijuana for a certain patient.
  • Educate themselves about the medical benefits of marijuana, its various clinical applications, and different routes of ingestion.

Doctors are not protected if they do the following:

§  Prescribe medical marijuana, or even write a recommendation on an Rx form.

  • Assist any patient in obtaining marijuana. 
  • Cultivate or possess marijuana for patient use.
  • Physically assist patients in using marijuana.
  • Recommend marijuana without a justifiable medical cause.

The Certification Required to Obtain the Registry ID Card

Under the Act, Doctors are able to certify qualifying patients for an expansive list of specified debilitating medical conditions, plus any  other "chronic or debilitating disease or medical condition or its treatment that produces..." symptoms or side effects like appetite loss, severe and chronic pain; severe nausea, seizures, severe and persistent spasms.

Written certification means a document signed by a physician, stating the patient's debilitating medical condition and stating that, in the physician's professional opinion, the patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's debilitating medical condition or symptoms associated with the debilitating medical condition.

This Certificate is different from the statement of professional opinion, and does not necessarily support the alternative Medical Purpose Affirmative Defense.

 

The Medical Conditions that Support Certification

Qualifying Patient means a person who has been diagnosed by a physician as having a debilitating medical condition.

Debilitating medical condition means 1 or more of the following: [Section 3 (a)1]

(1) Specific Conditions

§  Cancer

§  glaucoma

§  positive virus, acquired immune deficiency syndrome

§  hepatitis C

§  amyotrophic lateral sclerosis

§  Crohn's disease

§  agitation of Alzheimer's disease

§  nail patella

§  or the treatment of these conditions.

(2) A chronic or debilitating disease or medical condition or its treatment that produces 1 or more of the following:

§  cachexia or wasting syndrome;

§  severe and chronic pain;

§  severe nausea;

§  seizures, including but not limited to those characteristic of epilepsy; or

§  severe and persistent muscle spasms, including but not limited to those characteristic of multiple sclerosis.

(3) Any other medical condition or its treatment approved by the state Department of Community Health.

The Medical Conditions that Support the Statement of Physician’s Professional Opinion

Doctors can also make statements (written or oral) that support asserting the alternative Affirmative Defense for an unlimited number of other serious for debilitating medical conditions. The Affirmative Defense applies so long as a physician has stated that, in the physician's professional opinion, after having completed a full assessment of the patient's medical history and current medical condition made in the course of a bona fide physician-patient relationship, the patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's serious or debilitating medical condition or its symptoms. This statement is different from the Certificate, and does not necessarily support approval of a Registry ID Card Application. A separate form is included for included for this statement in support of the Affirmative Defense.


 

Parties Protected by the Act

§  Patients – [affirmative defense only] a user or caretaker who possesses not more than an amount reasonably necessary to insure uninterrupted availability of marihuana for the purpose of treating or alleviating the patient's serious or debilitating medical condition or symptoms, uses for a medical purpose, whose doctor has stated is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's serious or debilitating medical condition or symptoms.

§  Registered Qualifying Patients [Section 3(f)]. "Qualifying patient" means a person who has been diagnosed by a physician as having a debilitating medical condition. [Section 9(b)]. Must have a registry identification card, or legal equivalent if department fails to issue.

§  Visiting Qualifying Patient - [Section 4(j)] "Visiting qualifying patient" means a patient who is not a resident of this state or who has been a resident of this state for less than 30 days. [Section 3(k)] A registry identification card, or its equivalent, that is issued under the laws of another state, district, territory, commonwealth, or insular possession of the United States that allows the medical use of marihuana by a visiting qualifying patient, or to allow a person to assist with a visiting qualifying patient's medical use of marihuana, shall have the same force and effect as a registry identification card issued by the department.

§  Primary Caregivers - [Section 4(e)]"Primary caregiver" means a person who is at least 21 years old and who has agreed to assist with a patient's medical use of marihuana.  A registered primary caregiver may receive compensation for costs associated with assisting a registered qualifying patient in the medical use of marijuana. Any such compensation shall not constitute the sale of controlled substances.

§  Physicians - [Section 3(f)]"Physician" means an individual licensed as a physician under Part 170 of the public health code, 1978 PA 368, MCL 333.17001 to 333.17084, or an osteopathic physician under Part 175 of the public health code, 1978 PA 368, MCL 333.17501 to 333.17556.

§  Bystanders and assistants – A person in the presence or vicinity of the medical use of marihuana in accordance with this act, or for assisting a registered qualifying patient with using or administering marihuana.

§  Providers of Paraphernalia for providing a registered qualifying patient or a registered primary caregiver with marihuana paraphernalia for purposes of a qualifying patient's medical use of marihuana.


 

General Scope of Legal Protections under the Act

 

All State Laws Inconsistent with Act Do Not Apply to Medical Use

"All other acts and parts of acts inconsistent with this act do not apply to the medical use of marihuana as provided for by this act." [Section 7(e)]

 

No Seizure or Forfeiture of Marijuana Supply

Any marihuana, marihuana paraphernalia, or licit property that is possessed, owned, or used in connection with the medical use of marihuana, as allowed under this act, or acts incidental to such use, shall not be seized or forfeited. [Section 4(h)]

 

Card not Probable Cause:

Possession /application registry identification card shall not constitute probable cause or reasonable suspicion, nor shall it be used to support the search of the person or property of the, or otherwise subject the person or property of the person to inspection by any local, county or state governmental agency. [Section 6(g)]

 

Act does not create special entitlements [Section 7(c)]

Nothing in t his act shall be construed to require:

§  A government medical assistance program or commercial or non-profit health insurer to reimburse a person for costs associated with the medical use of marihuana.

§  An employer to accommodate the ingestion of marihuana in any workplace or any employee working while under the influence of marihuana.

 

Parental Rights Protected [Section 4(C)]

                A person shall not be denied custody or visitation of a minor for acting in accordance with this act, unless the person's behavior is such that it creates an unreasonable danger to       the minor that can be clearly articulated and substantiated.




 

Specific Protections for Registry Participants

Presumption afforded to Registry Participants: [Section 4(d)] There shall be a presumption that a qualifying patient or primary caregiver is engaged in the medical use of marihuana in accordance with this act if the qualifying patient or primary caregiver:

(1)  is in possession of a registry identification card; and

(2)  is in possession of an amount of marihuana that does not exceed the amount allowed under this act. The presumption may be rebutted by evidence that conduct related to marihuana was not for the purpose of alleviating the qualifying patient's debilitating medical condition or symptoms associated with the debilitating medical condition, in accordance with this act.

 

Registered Qualifying Patient Protections for the Medical Use of Marihuana: [Section 4(a)]

A qualifying patient who

§  has been issued and possesses

§  a registry identification card

§  shall not be subject to

§  arrest,

§  prosecution, or

§  penalty in any manner, or

§  denied any right or privilege, including but not limited to

§  civil penalty or

§  disciplinary action by a business or occupational or professional licensing board or bureau

§  for the medical use of marihuana in accordance with this act

Amount Allowed

The qualified user may possess an amount that does not exceed:

§  2.5 ounces of usable marihuana,

§  12 marihuana plants ( if the qualifying patient has not specified that a primary caregiver will be allowed under state law to cultivate marihuana for the qualifying patient)

§  Kept in an enclosed, locked facility. "Enclosed, locked facility" means a closet, room, or other enclosed area equipped with locks or other security devices that permit access only   by a registered primary caregiver or registered qualifying patient.

§  Any incidental amount of seeds, stalks, and unusable roots shall also be allowed under state law and shall not be included in this amount.

 

Primary Caregivers Protections for acts related to the Medical Use of Marihuana

A primary caregiver who has been: [Section 4(b)]

§  issued and possesses a registry identification card

§  shall not be subject to arrest,

§  prosecution, or

§  penalty in any manner, or

§  denied any right or privilege, including but not limited to

§  civil penalty or

§  disciplinary action by a

§  business or occupational or professional licensing board or bureau,

§  for assisting a qualifying patient

§  to whom he or she is connected

§  through the department's registration process

§  with the medical use of marihuana

§  in accordance with this act

Amount Allowed

The primary caregiver possesses an amount that does not exceed:

§  2.5 ounces of usable marihuana for each qualifying patient to whom he or she is connected through the department's registration process [NO MORE THAN 5 PATIENTS/caregiver] and

§  12 marihuana plants kept in an enclosed, locked facility for each registered qualifying patient who has specified that the primary caregiver will be allowed under state law to cultivate marihuana for the qualifying patient

§  Kept in an enclosed, locked facility. "Enclosed, locked facility" means a closet, room, or other enclosed area equipped with locks or other security devices that permit access only   by a registered primary caregiver or registered qualifying patient.

§  Any incidental amount of seeds, stalks, and unusable roots shall also be allowed under state law and shall not be included in this amount.

 

Primary Caregiver Compensation but cannot serve more than 5 patients

§   A registered primary caregiver may receive compensation for costs associated with assisting a registered qualifying patient in the medical use of marijuana. Any such compensation shall not constitute the sale of controlled substances.

§  This aspect of the law might be argued to be in conflict with Federal Law.

§  May not serve more than 5 Patients.

 

Protections and Responsibilities of Physicians: [Section 4(f)]

Nothing prevents a professional licensing board from sanctioning a physician for

§  Failing to properly evaluate a patient's medical condition, or

§  Otherwise violating the standard of care for evaluating medical conditions.

A physician (as defined by the act)

§  Shall not be subject to arrest, prosecution, or penalty in any manner, or denied any right or privilege, including but not limited to civil penalty or disciplinary action

§  By the Michigan board of medicine, the Michigan board of osteopathic medicine and      surgery,

§  Or any other business or occupational or professional licensing board or bureau,

§  Solely for providing written certifications, in the course of a bona fide physician-patient relationship and after the physician has completed a full assessment of the qualifying patient's medical history,

§  Or for otherwise stating that, in the physician's professional opinion, a patient is likely to receive   therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's serious or debilitating medical condition or symptoms associated with the serious or debilitating medical condition

 

Bystander or assistant [Section 4(i)]

A person shall not be subject to

§  arrest,

§  prosecution, or

§  penalty in any manner, or

§  denied any right or privilege, including but not limited to

§  civil penalty or

§  disciplinary action

§  by a business or occupational or

§  professional licensing board or bureau,

§  solely for being in the presence or vicinity of the medical use of marihuana in  accordance with this act, or for assisting a registered qualifying patient with using or administering marihuana.

 


 

Provider of marihuana paraphernalia [Section 4(g)]

A person shall not be subject to arrest, prosecution, or penalty in any manner, or denied any right or privilege, including but not limited to

§  civil penalty or

§  disciplinary action

§  by a business or

§  occupational or professional licensing board or bureau,

§  for providing

§  a registered qualifying patient or

§  a registered primary caregiver

§  with marihuana paraphernalia

§  for purposes of a qualifying patient's medical use of marihuana.

 

Specific Affirmative Defense Protections for Patient and Primary Caregiver

§  Any prosecution involving marihuana [Section 8(a)]

§  Any disciplinary action by a business or occupational or professional licensing board or bureau [Section 8(c)1]; or

§  Forfeiture of any interest in or right to property. [Section 8(c)2]

Note: Any marihuana, marihuana paraphernalia, or licit property that is possessed, owned, or used in connection with the medical use of marihuana, as allowed under this act, or acts incidental to such use, shall not be seized or forfeited. [Section 4(h)]  


 

Medical Purpose Affirmative Defense

Statutory authority to assert defense and presumption

Section 8(a) authorizes assertion of the affirmative defense, and crates a presumption of validity of the defense where a showing is made as to its elements. "Patient and a patient's primary caregiver, if any, may assert the medical purpose for using marihuana as a defense to any prosecution involving marihuana, and this defense shall be presumed valid where the evidence shows the elements of the defense." Generally, in asserting affirmative defenses, defendant has the burden of going forward, with proof by a preponderance of the evidence. At trial, where the defense has been asserted, and the threshold showing has been made by defendant, the prosecutor must show, beyond a reasonable doubt, that the legally excusing elements of the defense do not exist.

 

Statutory authority to bring a motion to dismiss, and mandatory dismissal

Section 8(b) establishes the statutory authority for a motion to dismiss. "A person may assert the medical purpose for using marihuana in a motion to dismiss, and the charges shall be dismissed following an evidentiary hearing where the person shows the specified elements of the defense." The showing must prove the elements by a preponderance of the evidence, and where this showing is made the dismissal is mandatory.

 

Standing and Scope of the Affirmative defense

The affirmative defense is available to the following people:

§  Any "patient" who demonstrates the patient's medical purpose for using marihuana pursuant to this section; or

§  Any patient's "primary caregiver" who demonstrates the patient's medical purpose for using marihuana pursuant to this section.

§  The defense applies to the acquisition, possession, cultivation, manufacture, use, delivery, transfer, or transportation of marihuana or paraphernalia, in these proceedings

§  Any prosecution involving marihuana [Section 8(a)]

§  Any disciplinary action by a business or occupational or professional licensing board or bureau [Section 8(c)1]; or

§  Forfeiture of any interest in or right to property. [Section 8(c)2]

 

No Seizure or Forfeiture of Marijuana Supply

Any marihuana, marihuana paraphernalia, or licit property that is possessed, owned, or used in connection with the medical use of marihuana, as allowed under this act, or acts incidental to such use, shall not be seized or forfeited. [Section 4(h)]

 

Disqualifications

Section 8(a) provides that the defendant cannot assert the affirmative defense if possessing or engaging in the use of marijuana was in violation of Section 7(b) of the Act. Section 7(b) lists certain disqualifying criteria that apply to the Section 8 affirmative defense and to the Act's other more prophylactic immunities for registry participants. The defense may not be asserted for any of the following:

§  Smoking marijuana "in any public place";

§  Smoking marijuana on any form of public transportation;

§  Any use by a person who has no serious or debilitating medical condition;

§  Any conduct where being under the influence would constitute negligence or professional malpractice per se;

§  Operating, navigating, or being in actual physical control of any motor vehicle, aircraft, or motorboat while under the influence of marihuana.

§  Any use or possession in a school bus;

§  Any use or possession on the grounds of any preschool, primary, or secondary school;

§  Any use or possession in any correctional facility.

Elements of the Affirmative Defense

The Gatekeeper's Statement [Section 8(a)1]:

§  A physician (Licensed MD or Osteopath)

§  has stated that

§  in the physician's professional opinion

§  after having completed a full assessment of

§  the patient's medical history and

§  patient's current medical condition

§  which assessment was made in the course of a bona fide physician-patient relationship

§  that the patient is likely to receive therapeutic or palliative benefit

§  from the medical use of marihuana

§  to treat or alleviate

§  the patient's serious or debilitating medical condition or symptoms of the patient's serious or debilitating medical condition

The Reasonably Necessary Quantity [Section 8(a)2]:

§  The patient and the patient's primary caregiver, if any, were collectively

§  in possession of a quantity of marihuana that was

§  not more than was reasonably necessary

§  to ensure the uninterrupted availability of marihuana

§  for the purpose of treating or alleviating

§  the patient's serious or debilitating medical condition or symptoms of the patient's serious or debilitating medical condition

The Medical Purpose [Section 8(a)3]:

§  The patient and the patient's primary caregiver, if any,

§  were engaged in the

§  acquisition, possession, cultivation, manufacture, use, delivery, transfer, or transportation of marihuana or paraphernalia relating to the use of marihuana

§  to treat or alleviate

§  the patient's serious or debilitating medical condition or symptoms of the patient's serious or debilitating medical condition.

 

Medical Use of Marijuana

"Medical use" means the acquisition, possession, cultivation, manufacture, use, internal possession, delivery, transfer, or transportation of marihuana or paraphernalia relating to the administration of marihuana to treat or alleviate a registered qualifying patient's debilitating medical condition or symptoms associated with the debilitating medical condition.

 

Disqualifications for Protections under Act

Section 8(a) provides that the defendant cannot assert the affirmative defense if possessing or engaging in the use of marijuana was in violation of Section 7(b) of the Act. Section 7(b) lists certain disqualifying criteria that apply to the Section 8 affirmative defense and to the Act's other more prophylactic immunities for registry participants. The defense may not be asserted for any of the following:

§  Smoking marijuana "in any public place";

§  Smoking marijuana on any form of public transportation;

§  Any use by a person who has no serious or debilitating medical condition;

§  Any conduct where being under the influence would constitute negligence or professional malpractice per se;

§  Operating, navigating, or being in actual physical control of any motor vehicle, aircraft, or motorboat while under the influence of marihuana.

§  Any use or possession in a school bus;

§  Any use or possession on the grounds of any preschool, primary, or secondary school;

§  Any use or possession in any correctional facility;

 

Issuing Registry ID Cards

The Department Shall issue a Registry ID Card to Qulalifying Patient [Section 6]

Shall issue registry identification cards to qualifying patients who submit the following:

(1)  A written certification;

(2)  Application or renewal fee;

(3)  Name, address, and date of birth of the qualifying patient, ( homeless need no address)

(4)  Name, address, and telephone number of the qualifying patient's physician;

(5)  Name, address, and date of birth of the qualifying patient's primary caregiver, if any; and

(6)  If the qualifying patient designates a primary caregiver, a designation as to whether the qualifying patient or primary caregiver will be allowed under state law to possess marihuana plants for the qualifying patient's medical use.

 

Special Considerations for Minors

The department shall not issue a registry identification card to a qualifying patient who is under the age of 18 unless:

§  The qualifying patient's physician has explained the potential risks and benefits of the medical use of marihuana to the qualifying patient and to his or her parent or legal guardian

§  The qualifying patient's parent or legal guardian submits a written certification from 2 physicians

§  The qualifying patient's parent or legal guardian consents in writing to:

      Allow the qualifying patient's medical use of marihuana

      Serve as the qualifying patient's primary caregiver; and

      Control the acquisition of the marihuana, the dosage, and the frequency of the medical use of marihuana by the qualifying patient.

Parental Rights: A person shall not be denied custody or visitation of a minor for acting in accordance with this act, unless the person's behavior is such that it creates an unreasonable danger to the minor that can be clearly articulated and substantiated.

 

Primary Caregiver to be Issued a Registry Identification Card

Department Shall issue a registry identification card to the primary caregiver, if any, who is named in a qualifying patient's approved application; [Section 6]

§  each qualifying patient can have no more than 1 primary caregiver, and

§  a primary caregiver may assist no more than 5 qualifying patients with their medical use of marihuana.

 


 

Department must Approve or deny an application or renewal within 15 days of receipt [Section 6]

§  Deny an application or renewal only if the applicant did not provide the information required pursuant to this section, or if the department determines that the information provided was falsified.

§  Subject to judicial review in the circuit court for the county of Ingham.

 

Shall issue registry identification cards within 5 days of approval [Section 6]

§  Expires 1 year after the date of issuance.

§  Contains all the following information:

                (1) Name, address, and date of birth of the qualifying patient.

                (2) Name, address, and date of birth of the primary caregiver, if any, of the qualifying patient.

                (3) The date of issuance and expiration date of the registry identification card.

                (4) A random identification number.

                (5) A photograph, if the department requires 1 by rule.

                (6) A clear designation showing whether the primary caregiver or the qualifying patient will be allowed under state law to possess the marihuana plants (determined based solely on the               qualifying patient's preference)

Card deemed granted [Section 9(b)]

If the department fails to issue a valid registry identification card in response to a valid application or renewal submitted pursuant to this act within 20 days of its submission, the registry identification card shall be deemed granted, and a copy of the registry identification application or renewal shall be deemed a valid registry identification card.

 

Affidavit in lieu of Registry ID Card [Section 9(c)] If at any time after the 140 days following the effective date of this act the department is not accepting applications, including if it has not created rules allowing qualifying patients to submit applications, a notarized statement by a qualifying patient containing the information required in an application, pursuant to section 6(a)(3)-(6) together with a written certification, shall be deemed a valid registry identification card.

 

The Department of Community Health

 

Department to Promulgate Rules by March 2009 [Section 5]

§  Not later than 120 days after the effective date of this act. [effective date is 10 days after election certified]

§  Govern the manner in which the department shall consider the addition of medical conditions or treatments

§  Shall allow for petition by the public to include additional medical conditions and treatments.

§  Provide notice of, and an opportunity to comment in a public hearing upon, such petitions.

§  After hearing, approve or deny such petitions within 180 days of the submission of the petition.

§  The approval or denial subject to judicial review in the circuit court for the county of Ingham.

§  Promulgate rules govern the manner in which it shall consider applications for and renewals of

§  Registry identification cards for qualifying patients and primary caregivers.

§  Establish application/renewal fees that generate revenues sufficient to offset all expenses of implementing and administering this act.

§  May establish a sliding scale of application and renewal fees based upon a qualifying patient's family income.

§  May accept gifts, grants, and other donations from private sources to reduce the application and renewal fees.

Annual Program Report to Legislature

§  submit to the legislature an annual report that does not disclose any identifying information about qualifying patients, primary caregivers, or physicians, but does contain, at a minimum, all of the following information:

                (1) The number of applications

                (2) The number approved in each county.

                (3) The nature of the debilitating medical conditions.

                (4) The number cards revoked.

                (5) The number of physicians providing written certifications for qualifying patients.

 

The Certificate

Physicians are unquestioned Gatekeepers. They determine whether a person is a Qualified Patient. "Written certification" means a document signed by a physician, stating the patient's debilitating medical condition and stating that, in the physician's professional opinion, the patient is likely to receive therapeutic or palliative benefit from the medical use of marihuana to treat or alleviate the patient's debilitating medical condition or symptoms associated with the debilitating medical condition.

Revocation of Registry ID Cards

Physician Notice to Department-Card Revoked: If a registered qualifying patient's certifying physician notifies the department in writing that the patient has ceased to suffer from a debilitating medical condition, the card shall become null and void upon notification by the department to the patient. [Section 6(f)]

Revocation of Registry Identification Card and Felony for Abuse: [Section 4(k)]

Any

§  Registered qualifying patient or

§  Registered primary caregiver

§  Who sells marihuana

§  To someone who is not allowed to use marihuana for medical purposes under this act

§  Shall have his or her registry identification card revoked and

§  Is guilty of a felony punishable by imprisonment for not more than 2 years or a fine of not more than $2,000.00, or both, in addition to any other penalties for the distribution of marihuana.

 

Penalties for False Pretenses and Abuse of Program

Penalty for Fraudulent representation [Section 7(d)]

§  To a law enforcement official

§  Of any fact or circumstance

§  Relating to the medical use of marihuana

§  To avoid arrest or prosecution

§  Shall be punishable by a fine of $500.00, which shall be in addition to any other penalties that may apply for making a false statement or for the use of marihuana other than use undertaken pursuant to this act.

 

Revocation of Registry Identification Card and Felony for Abuse [Section 4(k)]

Any registered

§  Qualifying patient or

§  Registered primary caregiver

§  Who sells marihuana

§  To someone who is not allowed to use marihuana for medical purposes under this act

§  Shall have his or her registry identification card revoked and

§  Is guilty of a felony punishable by imprisonment for not more than 2 years or a fine of not more than $2,000.00, or both, in addition to any other penalties for the distribution of marihuana.

 

Confidentiality Rules

[Section 6(h)] Applications and supporting information submitted by qualifying patients, including information regarding their primary caregivers and physicians, are confidential.

§   Maintain a confidential list of the persons to whom the department has issued registry identification cards.

§   Individual names and other identifying information on the list is confidential and is exempt from disclosure under the freedom of information act, 1976 PA 442, MCL 15.231 to 15.246.

§   Shall verify to law enforcement personnel whether a registry identification card is valid, without disclosing more information than is reasonably necessary to verify the authenticity of the registry identification card.

§   A person, including an employee or official of the department or another state agency or local unit of government, who discloses confidential information in violation of this act is guilty of a misdemeanor

§   Department employees may notify law enforcement about falsified or fraudulent information submitted

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Stedman's Concise Medical Dictionary for health professionals v2 4th edition
patient - one who is suffering from disease, injury, abnormal state, or mental disorder.

relationship - the state of being related, associated, or connected.

symptom - any morbid phenomenon or departure from the normal in structure, function, or sensation, experienced by the patient and indicative of disease. See Also: phenomenon (1), reflex (1), syndrome, sign (1).

relieve - to free wholly or partly from pain or discomfort, either physical or mental.

chronic - 1. referring to a health-related state, lasting a long time. 2. referring to exposure, prolonged or long-term, sometimes meaning also low-intensity. 3. the U.S. National Center for Health Statistics defines a chronic condition as one of three months' duration or longer.

pain - 1. an unpleasant sensation associated with actual or potential tissue damage, and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors. 2. term used to denote a painful uterine contraction occurring in childbirth.

Chronic
1. referring to a health-related state, lasting a long time.
2. referring to exposure, prolonged or long-term, sometimes meaning also low-intensity.
3. the U.S. National Center for Health Statistics defines a chronic condition as one of three months' duration or longer.

symptom - any morbid phenomenon or departure from the normal in structure, function, or sensation, experienced by the patient and indicative of disease. See Also: phenomenon (1), reflex (1), syndrome, sign (1).

cachexia - a general weight loss and wasting occurring in the course of a chronic disease or emotional disturbance.

nausea - a feeling of being sick at the stomach; an inclination to vomit.

seizure - 1. an attack; the sudden onset of a disease or of certain symptoms.
2. an epileptic attack. Syn: convulsion (2).

epilepsy - a chronic disorder characterized by paroxysmal brain dysfunction due to excessive neuronal discharge, and usually associated with some alteration of consciousness. The clinical manifestations of the attack may vary from complex abnormalities of behavior including generalized or focal convulsions to momentary spells of impaired consciousness. These clinical states have been subjected to a variety of classifications, none universally accepted to date and, accordingly, the terminologies used to describe the different types of attacks remain purely descriptive and nonstandardized; they are variously based on 1) the clinical manifestations of the seizure (motor, sensory, reflex, psychic or vegetative), 2) the pathologic substrate (hereditary, inflammatory, degenerative, neoplastic, traumatic, or cryptogenic), 3) the location of the epileptogenic lesion (rolandic, temporal, diencephalic regions), and 4) the time period at which the attacks occur (nocturnal, diurnal, menstrual). Syn: fit (3), seizure disorder.


spasm - a sudden involuntary contraction of one or more muscle groups; includes cramps, contractures. Syn: spasmus, muscle spasm.


multiple sclerosis (MS) - common demyelinating disorder of the central nervous system, causing patches of sclerosis (plaques) in the brain and spinal cord; occurs primarily in young adults; clinical manifestations depend upon the location and size of the plaques; typical symptoms include visual loss, diplopia, nystagmus, dysarthria, weakness, paresthesias, bladder abnormalities, and mood alterations; characteristically, the symptoms show exacerbations and remissions.

patient - one who is suffering from disease, injury, abnormal state, or mental disorder.

relationship - the state of being related, associated, or connected.

relieve - to free wholly or partly from pain or discomfort, either physical or mental.

debilitating - denoting or characteristic of a morbid process that causes weakness.

medical - 1. relating to medicine or the practice of medicine. Syn: medicinal

cancer - general term for malignant neoplasms; carcinoma or sarcoma, especially the former.

neoplasm - an abnormal tissue that grows by cellular proliferation more rapidly than normal and continues to grow after the stimuli that initiated the new growth cease. Neoplasms show partial or complete lack of structural organization and functional coordination with the normal tissue, and usually form a distinct mass of tissue which may be either benign (benign tumor) or malignant (cancer). Syn: tumor (2).

carcinoma, pl. carcinomas, carcinomata (CA) - any of the various types of malignant neoplasm derived from epithelial tissue, occurring more frequently in the skin and large intestine in both sexes, the lung and prostate gland in men, and the lung and breast in women. Carcinomas are identified histologically on the basis of invasiveness and the changes that indicate anaplasia, i.e., loss of polarity of nuclei, loss of orderly maturation of cells (especially in squamous cell type), variation in the size and shape of cells, hyperchromatism of nuclei (with clumping of chromatin), and increase in the nuclear-cytoplasmic ratio. Carcinomas may be undifferentiated, or the neoplastic tissue may resemble (to varying degree) one of the types of normal epithelium.

sarcoma - a connective tissue neoplasm, usually highly malignant, formed by proliferation of mesodermal cells.

glaucoma - a disease of the eye characterized by increased intraocular pressure and excavation and atrophy of the optic nerve; produces defects in the visual field and may result in blindness.

human immunodeficiency virus (HIV) - human T-cell lymphotropic virus type III; a cytopathic retrovirus that is the etiologic agent of acquired immunodeficiency syndrome (AIDS). Syn: lymphadenopathy-associated virus.
MEDICINE denoting a response to a diagnostic maneuver or laboratory study that indicates the presence of the disease or condition tested for.

AIDS - a syndrome of the immune system characterized by opportunistic diseases, including candidiasis, Pneumocystis carinii pneumonia, oral hairy leukoplakia, herpes zoster, Kaposi sarcoma, toxoplasmosis, isosporiasis, cryptococcosis, non-Hodgkin lymphoma, and tuberculosis. The syndrome is caused by the human immunodeficiency virus (HIV-1, HIV-2), which is transmitted in body fluids (notably blood and semen) through sexual contact, sharing of contaminated needles (by IV drug abusers), accidental needle sticks, contact with contaminated blood, or transfusion of contaminated blood or blood products. Hallmark of the immunodeficiency is depletion of T4+ helper/inducer lymphocytes, primarily the result of selective tropism of the virus for the lymphocytes. Syn: acquired immunodeficiency syndrome.

hepatitis C - a viral hepatitis, usually mild but often progressing to a chronic stage; the most prevalent type of post-transfusion hepatitis, which is inflammation of the liver; usually from a viral infection, but sometimes from toxic agents.

amyotrophic lateral sclerosis (ALS) - a disease of the motor tracts of the lateral columns and anterior horns of the spinal cord, causing progressive muscular atrophy, increased reflexes, fibrillary twitching, and spastic irritability of muscles; associated with a defect in superoxide dismutase. Syn: Lou Gehrig disease, Aran-Duchenne disease, Duchenne-Aran disease, Charcot disease, progressive muscular atrophy, Cruveilhier disease.

regional enteritis chrohns disease - a chronic enteritis, of unknown cause, involving the terminal ileum and less frequently other parts of the gastrointestinal tract; characterized by patchy deep ulcers that may cause fistulas, and narrowing and thickening of the bowel by fibrosis and lymphocytic infiltration, with noncaseating tuberculoid granulomas that also may be found in regional lymph nodes; symptoms include fever, diarrhea, cramping abdominal pain, and weight loss. Syn: granulomatous enteritis, distal ileitis, Crohn disease, terminal ileitis, regional ileitis.

Alzheimer disease - progressive mental deterioration manifested by loss of memory, ability to calculate, and visual-spatial orientation; confusion; disorientation. Begins in late middle life and results in death in 5-10 years. The brain is atrophic; histologically, there is distortion of the intracellular neurofibrils (neurofibrillary tangles) and senile plaques composed of granular or filamentous argentophilic masses with an amyloid core; the most common degenerative brain disorder. Syn: primary senile dementia, presenile dementia


nail
1. one of the thin, horny, translucent plates covering the dorsal surface of the distal end of each terminal phalanx of fingers and toes. A nail consists of corpus or body, the visible part, and radix or root at the proximal end concealed under a fold of skin. The under part of the nail is formed from the stratum germinativum of the epidermis, the free surface from the stratum lucidum, the thin cuticular fold overlapping the lunula representing the stratum corneum.
2. a slender rod of metal, bone, or other solid substance, used in operations to fasten together the divided extremities of a broken bone.
 Syn: onyx, unguis [TA], nail plate.


patella - the large sesamoid bone that covers the anterior surface of the knee.  It is formed in the tendon of the quadriceps femoris muscle and is attached to the tibia by the patellar tendon.

treatment - medical or surgical management of a patient. See Also: therapeutics, therapy.