Ethical Limbo and Enhanced Informed Consent in Psychedelic-Assisted Therapy : Identifying New Challenges and Ethical Dimensions

Abstract: Human cultures have used classic psychedelics for healing purposes for millennia, emphasizing their subjective effects. In the 21st century, research has been revived to investigate the therapeutic effects of these substances. These substances show promising results in the treatment of various mental-related disorders such as depression, post-traumatic stress disorder, and others, necessitating ethical considerations and guidelines for researchers, psychotherapists, and policymakers. The subjective effects of the psychedelic experience that these substances evoke, such as the feeling of oneness and interconnectedness, infallibility, the sense of reduced one's self-importance, the encounter with the "ultimate" reality or with God, radically distinguish them from typical psychiatric medications such as selective serotonin reuptake inhibitors (SSRIs). In their essay "Ethics and Ego Dissolution: the Case of Psilocybin", William R. Smith and Dominic Sisti argue that the special properties of psychedelics entail certain novel risks that warrant "enhanced" informed consent that is "one that is more comprehensive than what may be typical for other psychiatric medications". They emphasize the unique effects of these substances, including 1) the potential for significant personality changes, 2) the short duration of treatment, and 3) the potential for profound and transformative experiences. They highlight the importance of explicitly addressing these potential changes as part of the informed consent process to ensure patient understanding, autonomy, and well-being. This current paper substantially complements Smith and Sisti's work by discussing in more detail the differences between psychedelics and typical psychiatric medications with respect to informed consent. I first support their arguments and then further argue that there are three other critical reasons why psychedelics should not be treated like other psychiatric medications that should be considered when discussing the enhancement of informed consent and disclosure. 1) potential changes in ethical values, 2) set and setting, and 3) suggestibility. To clarify my argument, I propose a distinction between changes in worldview and ethical values induced by the psychedelic experience and emphasize their differential impact on individuals undergoing psychedelic therapy. I introduce the term "ethical limbo", characterized as a state of uncertainty or ambiguity regarding the ethical implications or consequences of a particular action, decision, or situation due to conflicting ethical values, to highlight a potential risk of the psychedelic experience that should be considered in informed consent. Finally, I address potential objections to my arguments before concluding the paper and addressing some limitations of the research.