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Towards a Broader Psychedelic Bioethics

Article · December 2023

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 1
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3 Towards a Broader Psychedelic Bioethics
4 Edward Jacobs1, David Yaden2, Brian D. Earp1
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This is the authors’ copy of an accepted manuscript. Please cite as:
6
Jacobs, E., Yaden, D., & Earp, B. D. (forthcoming). Towards a Broader Psychedelic Bioethics. AJOB
7
Neuroscience, in press.
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9 1University of Oxford

10 2Johns Hopkins University

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12 Peterson et al. (2023) present a range of ethical issues that arise when considering the use of
13 psychedelic substances within medicine. But psychedelics are, by their nature, boundary-
14 dissolving, and we suggest that progress in the Ethics of Psychedelic Medicine is best made within
15 a broader-ranging Psychedelic Bioethics, which encompasses not just medicine, but wider
16 society, including the breadth of cultural containers and settings in which these compounds are
17 used.
18
19 In part, this is because the boundaries between the clinical applications of psychedelics and
20 society at large are porous, and as such the developments within biomedical research and
21 practice do not happen in an ethical vacuum (Noorani, 2021). Consider the clinical trial
22 participants who experience symptom relief from psychedelic therapy which subsides after the
23 conclusion of the trial. In contrast to other investigational medicines, psychedelics can be
24 accessed illegally elsewhere. Participants with otherwise debilitating or treatment-resistant
25 symptoms, who have direct experience that psychedelics can benefit them, are placed in an
26 invidious position at least partly by virtue of their trial participation: to passively accept a
27 debilitating health condition which they know can be effectively treated, or to take on significant
28 risks in pursuit of symptom relief that they know is medically possible (Jacobs et al., under
29 review). We know that some of these participants do take those risks. While some may be able to
30 travel to other jurisdictions where psychedelics are not criminalised, note that this is an option
31 available only to the sufficiently wealthy, while, as seen in many drug policy issues (Earp et al.,
32 2021), here too racial disparities in wealth, coupled with those in drug policing and convictions,
33 can exacerbate inequalities.

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35 A broader-visioned Psychedelic Bioethics that takes into account the porous boundaries between
36 the different spheres in which psychedelics are used, can, as well as identifying otherwise unseen
37 challenges, identify potential solutions. By attending to the diversity of legitimate uses of
38 psychedelics, ethical impasses in one area of use can be informed by looking to the practices and
39 potential of the others.
40
41 For example, solutions to at least one classical medical ethics problem that arises in relation to
42 psychedelics - the treatment/enhancement distinction - can fruitfully be sought by attending to
43 their broader application than medicine alone. In Johns Hopkins’ first trial of psilocybin for
44 tobacco cessation, Noorani et al. (2018, p. 763) found that ‘[q]uitting smoking was often reported
45 as one of the least important effects of the study for participants in retrospect’, with non-smoking
46 related effects including improved relationships, newfound gratitude, tolerance, and aesthetic
47 appreciation, and shifts to self-understanding. That patients - motivated enough by their desire
48 to quit smoking that they would volunteer for experimental treatment - would nevertheless judge
49 other effects as more important, is a striking finding, and qualitative research that assessed
50 similar attitudes at other research centres and for other clinical indications would be welcome.
51 Regardless, multiple trials have reported a broad range of salutary if not symptom-related effects
52 following psychedelic therapy. We have argued elsewhere that because of the range of these
53 benefits, it may be preferable to offer psychedelic medicines that retain their characteristic
54 subjective experiences, and the benefits that seem to arise from them, even if equally effective
55 ‘tripless’ non-hallucinogenic psychedelics are proven more than a theoretical possibility (Yaden,
56 Earp & Griffiths, 2022; Yaden & Griffiths, 2020). Indeed, there is space for the broader effects of
57 psychedelics to invigorate discussion about what their use in psychiatry, or even psychiatry itself
58 is for - especially when self-reported benefit in generalised contentment, wellbeing, and
59 engagement with life exceeds that from the reduction of scores on validated psychopathology
60 symptom scales.
61
62 But until those issues are resolved, given the potential for psychedelic therapy to provide benefits
63 that are valued as much or more than treatment success, it is inappropriate for the medical
64 establishment to act as the sole gatekeepers over access to compounds with these effects. Lives
65 are enriched by a plurality of incommensurable goods that are not exhausted by ‘health’. An
66 otherwise healthy person who feels a sense of stuckness in their life, or notices a recurring pattern
67 of self-sabotage in relationships or at work, can benefit from a course of psychotherapy, just as a
68 person with depression or OCD might. The judicious use of psychedelics in similar circumstances,

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 69 with guardrails appropriate for their risk profile, could be morally comparable (Earp & Savulescu,
70 2020).
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72 Turning to some of the issues outlined by Peterson et al., we likewise see that productive
73 expansion of possibilities can be achieved by cross-fertilisation of ideas from different contexts
74 of psychedelic use.
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76 The matter of appropriate consenting procedures for psychedelic therapy has rightly been a
77 concern of several bioethicists in recent years. This is in part because the potentially
78 transformative nature of psychedelic experiences butts against the idealised medical view of
79 informed consent processes (Paul, 2014). as a means not only to secure autonomous
80 authorisation for treatment from a prospective patient, but also to support values-aligned
81 decision-making on their part. Although patient understanding can be enhanced by measures
82 such as the provision of a range of patient testimonials, when an intervention may have the
83 potential to change personality, attitudes, and the very values upon which decisions are made,
84 there remains an epistemically inaccessible element to life after treatment that is qualitatively
85 different to the uncertainty that surrounds much medical decision-making (Jacobs, under review).
86
87 Smith and Sisti (2020, p.6) note that “we regularly accept consent to various [transformative
88 experiences]”. Life is replete with experiences that alter our core values and attitudes. But where
89 these experiences are centred around or initiated by a discrete event - e.g. getting married, joining
90 the military - they are frequently accompanied by a ritual that attends to the seriousness of the
91 choice that is being made. The heightened level of scrutiny that Peterson et al. recommend can be
92 buttressed by multiple means to draw attention to the gravity of the decision that is being made,
93 over and above reflection about one’s medical best interests. Given that clinically administered
94 psychedelic experiences have been reported as among the most significant events in a patient’s
95 life (Griffiths et al., 2016) , reflection of this kind is likely proportionate. Asking participants to
96 actively reflect on the impact of the most significant events of their life - including the birth of a
97 child or death of a parent - could attune them to the dimensions of what is being embarked upon.
98 Where psychedelics are used in indigenous cultures, it is not done casually, but in the context of
99 ritualised ceremony, which impresses upon those present the gravity of what is to follow. We are
100 not advocating clumsy attempts to transplant any particular indigenous ritual into medical
101 practice, and recognise that the intrusion of specific symbols or beliefs into clinical practice
102 introduces a range of risks: from being alienating and aversive to some patients (Johnson, 2020),
103 and thereby potentially compromising optimal clinical efficacy, to wrongful appropriation, to
104 being unwittingly impositional of a belief system.

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106 Rather, the initiation of psychedelic therapy may be a place for heightening a sense of ritual to
107 foster recognition that what is to be embarked upon, in both its acute and long-term effects, is
108 outside of the usual expectations of medical practice. Undoubtedly this is already practised in
109 some forms and will continue to develop organically. Rather than prescribing particulars, we
110 suggest that, so long as they do not impute a broader belief system that may not be shared by the
111 patient, the development of elements of rituality may add to the ethical structure supporting good
112 practice.
113
114 We endorse Peterson et al.’s call for intentional, proactive steps toward addressing inequities in
115 psychedelic medicine. As well as forming a small part of a much larger social conversation,
116 attention to inequity is a priority in psychedelic research (George et al., 2020). Adding to the
117 recognition that minority populations are underrepresented in clinical trials to date is the recent
118 finding - amidst a surge in population studies suggesting myriad benefits to psychedelic use in
119 uncontrolled settings - that these benefits are moderated by race and ethnicity (Jones, 2023).
120 Determining the extent to which these disparities are driven by similar mechanisms to those
121 leading to inequities across health outcomes, and the extent to which there are psychedelic-
122 specific causes (such as the impacts of discriminatory drug policing on ‘set and setting’) would
123 be one appropriate early avenue for research (Fogg et al., 2021).
124
125 As well as the measures Peterson et al. propose, federal agencies can be informed by efforts
126 embedded within Oregon’s Psilocybin Services Act. In their licence application, prospective
127 Oregon Psilocybin Services licensees are required to submit a social equity plan, outlining specific
128 commitments to addressing inequity. Many of the concrete suggestions compiled by Herzberg et
129 al. (2019) are directly implementable by future providers of psychedelic therapy. Perhaps of chief
130 interest are the use of scholarships for training to help develop a future pool of psychedelic
131 therapists that is culturally competent and demographically representative of the communities it
132 serves, as well as the provision of resources to support some pro-bono treatment, which, if
133 politically infeasible to mandate, could be encouraged by the development of tax relief incentives.
134
135 We are heartened by the recent expansion of ethical analysis of psychedelic medicine to which
136 Peterson et al. have made a valuable contribution. Just as biomedical research into psychedelics
137 has been informed, and continues to be informed, by practices from other users, including
138 indigenous communities and underground therapists, an Ethics of Psychedelic Medicine would
139 do well to look further afield to advance.
140

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141 References
142 Earp, B. D.,Lewis,, J. Hart., C. L. Hart, and with Bioethicists and Allied Professionals for Drug Policy
143 Reform. "Racial justice requires ending the war on drugs." The American Journal of Bioethics 21, no.
144 4 (2021): 4-19.
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146 Earp, B. D., and Savulescu, J.. "Love is the drug: The chemical future of our relationships." In Love is
147 the Drug. Manchester University Press, 2020.
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149 Fogg, C., Michaels, T. I., Salle, S., Jahn, Z. W., and Williams, M.T. . "Ethnoracial health disparities
150 and the ethnopsychopharmacology of psychedelic-assisted psychotherapies." Experimental and
151 Clinical Psychopharmacology 29, no. 5 (2021): 539.
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154 inclusion." Journal of Psychedelic Studies 4, no. 1 (2020): 4-15.
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156 Jacobs., E., Murphy-Beiner, A., Roullier, I., Nutt, D. and Spriggs, M. (unpublished). “When the Trial
157 Ends: The Ethical and Pragmatic Case for Post-Trial Provisions in Clinical Psychedelic Research
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159 Jacobs, E. (unpublished). “Transformative Experience and Informed Consent to Psychedelic-assisted
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162 Johnson, Matthew W. "Consciousness, religion, and gurus: pitfalls of psychedelic medicine." ACS
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165 Herzberg, G., Conour, K., Butler, J., Emerson, A., Gillooly, L. S., Gold, V., Hayes, M., Mix, L., and
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176 Noorani, T., Garcia-Romeu, A., Swift, T. C., Griffiths, R. R., & Johnson, M. W. (2018). Psychedelic
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182 Peterson, A., Largent, E. A., Lynch, H. F., Karlawish, J. and Sisi, D. “Journeying to Ixtlan: Ethics of
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186 Smith, W. R., and Sisti, D. "Ethics and ego dissolution: the case of psilocybin." Journal of medical
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189 Yaden, D. B.,. Earp, B.D., and Griffiths, R. R.. "Ethical Issues Regarding Nonsubjective Psychedelics
190 as Standard of Care." Cambridge Quarterly of Healthcare Ethics 31, no. 4 (2022): 464-471.
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