Katherine Cheung

Psychedelics are increasingly being studied and used in clinical and therapeutic contexts, prompting renewed ethical and regulatory debate. Claims of psychedelic exceptionalism—whether “negative,” portraying psychedelics as uniquely risky and thus requiring stricter oversight, or “positive,” portraying them as uniquely beneficial and thus exempt from ordinary ethical rules—have become common. In a recent article, we argued that while psychedelics may involve distinctive constellations of features, these do not justify fundamentally new ethical standards. In response, Daniel Villiger and, separately, Edward Jacobs, agreed that psychedelics should not be exempt from existing ethical standards (what Villiger calls Type A ethical exceptionalism) but suggested that their distinctive qualities may still warrant unique applications of those standards (Type B ethical exceptionalism). For example, Villiger argues that psychedelics possess certain features that do not, in his view, exist anywhere else in medicine, including the unpredictability and emotional intensity of the psychedelic experience, alongside a temporary lowering of psychological defences, leading to heightened suggestibility and sensitivity to context. He argues that such allegedly unique features call for exceptional policies around how existing ethical standards are to be applied—Type B exceptionalism. In this essay, we argue that the features Villiger identifies are only ethically significant insofar as they raise concerns about (inter alia) autonomy and vulnerability. But these concerns arise also in other medical settings. As such, policies addressing these issues would apply more broadly to other medical interventions raising similar concerns. Villiger thus fails to establish a genuine case for psychedelic ethical exceptionalism, even of the more modest, Type B variety.

Virtues commonly associated with physicians and other healthcare professionals include empathy, respect, kindness, compassion, trustworthiness, and many more. Building upon the work of Bortolloti, Murphy-Hollies, and others, I suggest that curiosity as a virtue has an integral role to play in healthcare, namely, in helping to make those who are invisible, visible. Practicing the virtue of curiosity enables one to engage with and explore the experiences of patients and contributes toward building a physician–patient relationship of trust. As the perspectives and experiences of patients can be too often dismissed or lost within medical settings, curiosity can allow physicians to deeply know their patients, and thus provide better care. However, caution must be exercised so as to not to venture into inappropriate curiosity, where questions are asked for improper reasons or to help satisfy the personal interest of physicians. Finally, I sketch out two cases—on chronic pain and on vaccine hesitancy—to illustrate where curiosity can play a valuable role.

Epigenetic research has brought several important technological achievements, including identifying epigenetic clocks and signatures, and developing epigenetic editing. The potential military applications of such technologies we discuss are stratifying soldiers’ health, exposure to trauma using epigenetic testing, information about biological clocks, confirming child soldiers’ minor status using epigenetic clocks, and inducing epigenetic modifications in soldiers. These uses could become a reality. This article presents a comprehensive literature review, and analysis by interdisciplinary experts of the scientific, legal, ethical, and societal issues surrounding epigenetics and the military. Notwithstanding the potential benefit from these applications, our findings indicate that the current lack of scientific validation for epigenetic technologies suggests a careful scientific review and the establishment of a robust governance framework before consideration for use in the military. In this article, we highlight general concerns about the application of epigenetic technologies in the military context, especially discrimination and data privacy issues if soldiers are used as research subjects. We also highlight the potential of epigenetic clocks to support child soldiers’ rights and ethical questions about using epigenetic engineering for soldiers’ enhancement and conclude with considerations for an ethical framework for epigenetic applications in the military, defense, and security contexts.

Background Classic psychedelics, such as psilocybin and LSD, evoke certain kinds of altered states of consciousness. Specific features of the experience, such as its allegedly ineffable nature, have been discussed as posing challenges to the informed consent process. A growing call for tailored informed consent documents (ICDs) in the psychedelic bioethics literature raises the question of how closely ICDs used in contemporary psychedelic trials reflect the concrete suggestions and proposals offered by psychedelic bioethicists.Methods In this article, we review ICDs from psilocybin clinical trials in the United States. Using a content analysis approach, we provide a systematic qualitative description of the ICDs which comprise our final sample (N = 28; 28 clinical trials across 13 unique sites). Coders demonstrated good reliability (κ =.683).Results Qualitative analyses revealed that most of the coding aligned with expectations based upon the psychedelics bioethics literature, such as the emphasis on mental health risks and physical risks in ICDs. Notably, psychedelic-specific codes (e.g., ineffability, therapeutic touch) did not appear as frequently in ICDs.Conclusions Scholars in psychedelic bioethics have called for the inclusion of a variety of potential risks and benefits in ICDs. It will be important to continue debating which elements are worth including in ICDs such that potential research participants are presented with the most salient factors relevant to their decision about joining a study. We provide a table of best practices applied by our sample of ICDs.

ABSTRACT:Psychedelics, including psilocybin, and other consciousness-altering compounds such as 3,4-methylenedioxymethamphetamine (MDMA), currently are being scientifically investigated for their potential therapeutic uses, with a primary focus on measurable outcomes: for example, alleviation of symptoms or increases in self-reported well-being. Accordingly, much recent discussion about the possible value of these substances has turned on estimates of the magnitude and duration of persisting positive effects in comparison to harms. However, many have described the value of a psychedelic experience with little or no reference to such therapeutic benefits, instead seeming to find the experience valuable in its own right. How can we make sense of such testimony? Could a psychedelic experience be valuable even if there were no persisting beneficial effects? If so, how? Using the concept of psychological richness, combined with insights from the philosophy of aesthetics and the enhancement literature, this essay explores potential sources of value in the acute subjective experience, apart from the value derived from persisting beneficial effects.

In his paper ‘Ethical problems with kindness in healthcare’, Jesudason sets out an interesting examination of the concept of kindness, arguing that it poses significant ethical challenges due to its discretionary nature. I suggest that kindness, a concept difficult to define, may still have a role to play in healthcare. Different treatments of kindness show us that it need not be discretionary, and that kind care can be provided to all. Finally, curiosity may also have a role to play in medicine to help promote inclusiveness.

Psychedelics such as psilocybin reliably produce significantly altered states of consciousness with a variety of subjectively experienced effects. These include certain changes to perception, cognition, and affect,1 which we refer to here as the acute subjective effects of psychedelics. In recent years, psychedelics such as psilocybin have also shown considerable promise as therapeutic agents when combined with talk therapy, for example, in the treatment of major depression or substance use disorder.2 However, it is currently unclear whether the aforementioned acute subjective effects are necessary to bring about the observed therapeutic effects of psilocybin and other psychedelics. This uncertainty has sparked a lively—though still largely hypothetical—debate on whether psychedelics without subjective effects (“nonsubjective psychedelics” or “non-hallucinogenic psychedelics”) could still have the same therapeutic impact, or whether the acute subjective effects are in fact necessary for this impact to be fully realized.3,4,5.

A prominent critique of cognitive or athletic enhancement claims that certain performance‐improving drugs or technologies may ‘cheapen’ resulting achievements. Considerably less attention has been paid to the impact of enhancement on the value of moral achievements. Would the use of moral enhancement (bio)technologies, rather than (solely) ‘traditional’ means of moral development like schooling and socialization, cheapen the ‘achievement’ of morally improving oneself? We argue that, to the extent that the ‘cheapened achievement’ objection succeeds in the domains of cognitive or athletic enhancement, it could plausibly also succeed in the domain of moral enhancement—but only regarding certain forms. Specifically, although the value of moral self‐improvement may be diminished by some of the more speculative and impractical forms of moral enhancement proposed in the literature, this worry has less force when applied to more plausibly viable forms of moral enhancement: forms in which drugs or technologies play an adjunctive or facilitative, rather than a determinative, role in moral improvement. We illustrate this idea with three examples from recent literature: the possible use of psychedelic drugs in certain moral‐learning contexts, ‘Socratic Al’ (a proposed Al‐driven moral enhancer) and empathy enhancement through virtual reality (VR). We argue that if one assumes that these technologies work roughly as advertised (which is an open empirical question), the ‘cheapened achievement’ objection loses much of its bite. The takeaway lesson is that moral enhancement in its most promising and practical forms ultimately evades a leading critique of cognitive and athletic enhancement. We end by reflecting on the potential upshot of our analysis for enhancement debates more widely.

When used clinically, psychedelics may appear unusual or even unique when compared to more familiar or long-standing medical interventions, prompting some to suggest that the ethical issues raised may likewise be exceptional. If that is correct, then perhaps psychedelics should be treated differently from other medical substances: for example, by being subjected to different ethical or evidentiary standards. Alternatively, it may be that psychedelics have more in common with various existing medical interventions than first meets the eye. We argue in favor of the latter position, drawing on parallels from earlier debates around genetic exceptionalism in bioethics. We suggest there are risks to adopting a stance of “psychedelic ethical exceptionalism,” and propose that consistent ethical rules and evidentiary standards should be applied across all relevant areas of clinical medicine. Importantly, this does not preclude the possibility that changes to existing standards should be made; but if so, this should not be justified by appealing to the alleged uniqueness of psychedelics.

Psychedelic treatment with psilocybin is receiving increased attention following clinical trials showing it may help treat end-of-life anxiety, depression, and several other conditions. Despite this, physicians may be reluctant to prescribe psilocybin and carry out psilocybin treatment because of the stigma surrounding psychedelics and the potential for medical malpractice liability. This paper explores whether psilocybin treatment gives rise to a risk of medical malpractice liability for physicians. Following an overview of psilocybin treatment and its regulatory regime in Canada, exploratory vignettes are used to highlight the relevance and limits of malpractice claims. This paper argues that the lack of established medical standards, standardized training, and credentialing contribute to liability risks surrounding psilocybin treatment. More clinical trials, meta-studies of research analyses, and knowledge sharing will help to develop training programs and medical standards of practice to better realize psilocybin’s potential.

The current revival of interest in classic psychedelics and other psychoactives such as ketamine and MDMA, coupled with changes to their regulatory status in many jurisdictions, necessitates rigorous ethical guidelines both within and beyond clinical and scientific contexts. This paper examines crucial ethical, philosophical, and policy considerations needed to ensure psychedelic use across various settings remains equitable, beneficial, consensual, and safe, with appropriate accountability mechanisms for addressing potential harms. We seek to broaden the lens beyond the medical model of psychedelics to include potentially valuable non-medical applications that could benefit individuals, communities, and society. With popular interest in psychedelics growing outside of therapeutic and research settings, there is a need to determine which aspects of any proffered guidelines, or underlying principles, should be applied similarly across contexts and in what ways there should be flexibility and/or context-sensitivity in their interpretation or application. In developing such guidelines, we suggest the “treatment versus enhancement” distinction – and associated debates familiar from bioethics and philosophy of medicine – requires renewed attention. We argue that neglecting non-medical and broad scientific use cases for psychedelics may have important implications for a range of ethical issues surrounding psychedelic use and research, including concerns about psychedelic hype and exceptionalism (both positive and negative), therapeutic touch, informed consent, data-gathering, and balancing access and safety. We conclude with suggestions for future directions in research and policy in the burgeoning area of psychedelic bioethics, stressing the importance of incorporating the perspectives of a diversity of stakeholders and fostering cross-sector collaboration.

Randomized controlled trials (RCTs) are considered the gold standard for demonstrating the efficacy of a treatment or intervention; however, the RCT study design alone is insufficient to prevent all forms of bias. In this paper, we review conflicts of interest and other biases that pose challenges to the methodological rigor of psychedelic RCTs, and explore recommended bias mitigation measures. We focus on biases of special relevance to psychedelic RCTs and methods of mitigating bias that we believe are actionable and urgent practices to implement in psychedelic research: (1) independent data assessment, (2) multisite trials, (3) quantitative bias analysis, and (4) open science practices. Although we advocate for the adoption of these practices in psychedelic research, they are not psychedelic specific. We suggest that the challenges posed by psychedelic research offer an opportunity for researchers to creatively find and implement solutions across the study lifecycle to reduce bias in other fields of clinical research.