![Sample our Humanities journals, sign in here to start your FREE access for 14 days]({"type":"image" , "src" : "/sda/5939/TOC-Subject-Sample-2021-Humanities.jpg"})
ABSTRACT
This paper attempts to integrate ongoing conversations about the nature and ethics of psychedelic-assisted psychotherapy (PAP) in order to clarify some outstanding ethical questions. First, I address a debate about whether informed consent is possible for “transformative” therapies like PAP, and I conclude that reasonable approaches to informed consent should not be considered especially difficult for PAP. Next, I argue that a focus on potential barriers to information about PAP has obscured a more central risk for the therapy – that posed by a PAP patient’s radical susceptibility to environmental influence, or what I call epistemic vulnerability. After expanding on this concept, I conclude that warnings about epistemic vulnerability should be a part of informed consent to PAP in all cases. Finally, I discuss more broadly the complexities of informed consent in PAP, drawing on analogous concerns for regular psychotherapy that may be addressed by a “process view” of consent. I propose that a “nondirective” approach to PAP may be more ethically supportable than other approaches, in part because of the theoretical benefit to patients from managing their own experience, prioritizing the potential for autonomous transformation.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes
1. Throughout this paper, I will use “patient” to describe the person taking psychedelics and “practitioner” to describe the person attending to them. This may not be the preferred terminology for clinical trials, in which “patients” might be more accurately described as “participants.” Also, under the broader Oregon regime of “psilocybin services” (discussed below), “practitioners” are “facilitators” who serve “clients.” While all of these distinctions are important, I will default to “patient” and “practitioner” for clarity here.
2. For a well-edited anthology of psychedelic experiences that run the gamut from profound to trivial, see Charles Hayes’s Tripping: An Anthology of True-Life Psychedelic Adventures (Hayes, Citation2000).
3. A similar dynamic inheres with regard to Paul’s central example of having a child. It is perfectly possible to have a child without becoming a parent (Kochevar, Citation2023).
4. 45 C.F.R. § 46.116(a)(4): “The prospective subject or the legally authorized representative must be provided with the information that a reasonable person would want to have in order to make an informed decision about whether to participate, and an opportunity to discuss that information”
5. Amia Srinivasan covers similar arguments in an earlier review of Paul’s book. “Paul insists that, just as I have no idea what it would be like to have a child, I have no idea how having a child would change what it’s like to be me. But surely this is wrong. I have watched many friends and family members become parents. I can see how they’ve changed. And unless I’m special (the odds are that I’m not), I, too, would change in similar ways” (Srinivasan, Citation2016).
6. To this point, Kious and colleagues also note that “[t]he reasonable person might conclude that she does not need to know about all aspects of a medical intervention for consent, but that her understanding could be informed by other sources, like the testimony of others, or statistics about adverse events. All of this information is still available even if the experience remains transformative and mysterious” (Kious et al., Citation2024). Similarly, Daniel Villiger observes that the possibility of transformation as such could be a rationally compelling benefit from within Paul’s model, including when considering PAP, depending on the patient’s status quo (Villiger, Citation2021, Citation2024).
7. Note that LSD and psilocybin are both active as 5-HT2A receptor agonists, and both are being tested for similar therapeutic applications.
8. Given that this influence plays out in affective, perceptual, and cognitive ways, “epistemic vulnerability” could be a misnomer. I stick with it here to distinguish it from physical vulnerabilities that impact perception without immediate cognitive ramifications (e.g., sensory impairments), and emotional vulnerabilities as “disorders” that might impact perception and cognition in discrete ways (e.g., sensitivity to triggers) without making someone broadly prone to belief change. In any case, the potential for changed beliefs is at the heart of the endeavor to explain how psychedelics can be therapeutic (Carhart-Harris et al., Citation2019).
9. Whether this “new knowledge” must relate specifically to the self is something of an open question, especially since experiences of “boundlessness,” “connectedness,” or “ego dissolution” would tend to deemphasize the self as a discrete entity (Ko et al., Citation2022). This is a general tension in accounting for the therapeutic effect of psychedelics. We go to therapy as a “self,” but perhaps leave with new understandings of where that self ends and other influences begin. New beliefs about environmental conditions – relationships, traumatic triggers, material situations – can change our experience of selfhood as much as new beliefs about our motivations, capabilities, preoccupations, etc.
10. Jacobs notes that “[c]onsent, as autonomous authorization, remains important, since the wrongdoing of administering PAP to an unwilling patient clearly dwarfs the challenge that comes from the epistemic inaccessibility of transformative experiences, as does the exploitation of a patient in the heightened state of vulnerability and suggestibility during acute drug effects” (Jacobs, Citation2023). To me, this is precisely the point, and his extended discussion of epistemic inaccessibility tends to foreclose discussion of this “heightened state of vulnerability,” which he admits “dwarfs” the problems he discusses.
11. A response from Paul Applebaum, published on the same day, notes an absence of “any systematic data about the predictors and extent of vulnerability and the duration of effects beyond short-term administration of the drug” (Appelbaum, Citation2024).
12. For instance, “too much emphasis on the pitfalls of psychotherapy could be negatively suggestive, or experienced by the patient as discouraging” (Beahrs & Gutheil, Citation2001).
13. Christopher Poppe applies L.A. Paul’s framework again to argue that this process view is problematic. However, he covers similar ground as Saks and Golshan and comes to a similar conclusion: that ex ante warnings about the possibility of transformation are appropriate (Poppe, Citation2019).
14. “By experiencing radically different forms of self-modelling, we come to see vividly that the previously unquestioned sense of who I am is just a story, and can be told otherwise … . There are other ways I can be, other ways I can see, and other ways I can parse experience” (Letheby, Citation2021, p. 183).
15. For instance, Riccardo Miceli McMillan offers that psychedelic phenomenology itself does the work of “inducing and consolidating a state of broadened pre-intentional possibility” as a kind of antidote to depressive states (Miceli McMillan & Jordens, Citation2022).
16. An anonymous reviewer helpfully noted that “advice,” or practical recommendations about how a patient should live, is generally already outside the purview of psychotherapy. While this line may be blurry at times, this is another place where the language in the Oregon materials could be tightened.
17. While MDMA is an amphetamine derivative and not a classic psychedelic, it is being studied for similar applications in therapeutic settings and presents similar risks for suggestion and manipulation.
18. “[T]here are occasions when failure to offer direction in a sensitive way would be problematic, just as being overly directive is problematic” (Mithoefer, Citation2017).
19. Marks and colleagues discuss the possibility of a “color-coding” system in order to “establish norms for quickly deescalating reassuring touch during psychedelic sessions. For example, patients might agree to say, ‘red,’ to quickly convey that they no longer wish to be touched” (Marks et al., Citation2024).
20. A dramatic psychedelic experience may raise questions about patient capacity for consent in the moment. While beyond the scope of this paper, the concept of “assent” may be useful, considered as an “opportunity to choose to the extent that [one is] able,” and as supporting the development and maintenance of future autonomy (Spriggs, Citation2023).
21. As Kious and colleagues note, there is risk both from practitioners under-promising and over-promising, and from speculation on either end (Kious et al., Citation2024).