Julia Neubauer · Mind Medicine Australia
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Psychedelic Hedonism — The Ethics Of Psychedelic Therapy

Psychedelic trip

INTRODUCTION

Psychedelic-assisted psychotherapy is a novel approach to treating mental illness which has recently been (re)gaining significant public and scientific attention. Current clinical trials are demonstrating promising results which suggest that not only might these medicines be effective at treating a wide array of mental illnesses[1], but in some instances they might be more effective than currently available treatments[2]. However, despite the growing body of empirical work regarding the efficacy of psychedelic-assisted psychotherapy, the socio-cultural history of these compounds along with their unique psychological effects raises a host of normative ethical questions which need to be addressed to ensure that the return of psychedelics to western psychiatry is done in a responsible and ethically sound manner. “Prescribing Meaning: Hedonistic Perspectives on the Therapeutic Use of Psychedelic-Assisted Meaning Enhancement”[3] is a paper which aims to begin the task of addressing the ethics of psychedelic-assisted psychotherapy. The paper does so by applying the moral theory of Hedonism to analyse the ethical justifiability of psychedelic-assisted psychotherapy.

 

HEDONISM

Hedonism is a well-known type of consequentialist moral theory. In other words, Hedonism is a moral theory which places moral value in the outcomes of actions[4]. This means that for an act to be considered moral, said act must produce outcomes which are of moral value. So then, according to Hedonism, what outcomes are of moral value?

Hedonism or Hedonist moral theories are moral theories which place moral value in the outcomes of pain and pleasure[5]. That is to say that according to Hedonism, an act is morally good if it produces more pleasure than pain, or morally bad if it produces more pain than pleasure. There are some nuances of Hedonism which are explored further in the paper, and which subdivide Hedonist moral theory further into Qualitative Hedonism, Quantitative Hedonism, Hedonistic Utilitarianism, and Hedonistic Egoism.

 

PSYCHEDELICS AS MEANING ENHANCERS

It has been suggested that psychedelics exert their effects via a phenomenon known as the meaning-response[6]. The meaning-response refers to the body’s ability to respond physiologically to perceived meaning or symbols in the environment. For example, when someone takes a pill believing it will heal them — even if it has no pharmacologically active component (e.g. a sugar pill) — the body responds in such a manner which is in turn conducive for healing, as the very act of taking a pill is symbolically active[7]. That is to say that even though there are no chemically active ingredients in the pill, the very action of taking a pill carries certain symbolic connotations which lead to physiological changes in the body that change the body in ways which lead to health. This ability of the body to heal itself via mere symbols of healing might initially sound far-fetched, however it is a very well recognised phenomenon, so much so that the scientific community controls for this effect in its research designs — where it is perhaps better known as the placebo effect.

An important thing to note here is that the proposed mechanism of psychedelics as meaning enhancers is not saying that the effects of psychedelic-assisted psychotherapy are merely due to placebo. But rather the same mechanism which gives rise to the placebo effect also underlies the therapeutic effects of psychedelic-assisted psychotherapy. So how is this possible? It is proposed that during psychedelic states of consciousness the perception of meaning is enhanced. That is to say that psychedelics alter the world such that there is a general increase of ‘meaningfulness’ in the things which are experienced. This extra meaningfulness, when experienced in a therapeutic set and setting, results in an increased perception of therapeutic meaning (i.e. symbolically active meaning which is conducive for healing). This enhanced perception of therapeutic meaning leads to a stronger meaning-response, such that the body/mind of the person undergoing psychedelic-assisted psychotherapy will respond with a host of physiological/psychological sequalae conducive for healing. In other words, psychedelic-assisted psychotherapy heals by increasing the ‘meaningfulness’ of experience in such a way that leads to a dramatically increased meaning-response.

 

ETHICS

This is all very academically interesting, but how does this relate to the ethics of psychedelic-assisted psychotherapy? Well, the proposed mechanism of psychedelics as meaning enhancers raises the following ethical question: is it ethically justifiable to pharmacologically enhance the perception of meaning in order to heal patients?[6]. As was explored above, Hedonism would justify pharmacologically increasing the perception of meaning in order to heal patients so long as doing so led to more pleasure than pain. As is explored in greater deal in “Prescribing Meaning: Hedonistic Perspectives on the Therapeutic Use of Psychedelic-Assisted Meaning Enhancement”[3] the current literature on the effectiveness of psychedelic-assisted psychotherapy, its relative safety, as well as the epidemiology and morbidity of mental illness, would suggest that the introduction of psychedelic-assisted psychotherapy to psychiatry would produce more pleasure than pain.

But what if there is more to morality than pain and pleasure? This is the question that Robert Nozick asks people to consider when he presents his famous anti-Hedonist thought experiment: The Experience Machine[8]. To put his thought experiment simply, Nozick invites readers to imagine a machine which creates a completely realistic simulated reality. Before entering the Experience Machine people are allowed to select to kinds of experiences they want to have. Once inside, people become unaware that they have been wired up to the Experience Machine. According to Nozick, if pain and pleasure were the only relevant moral consequences, people would be morally obliged to enter the Experience Machine forever and live a life full of simulated pleasures. Nozick assumes that most readers would find this conclusion unappealing. Hence, Nozick argues that there is more to morality than just pain and pleasure. Nozick suggests that what also matters in determining morality is contact with an actual reality[8].

It has been suggested that psychedelic states of consciousness are analogous to the Experience Machine in Nozick’s thought experiment, and therefore represent a false reality. This analogy of psychedelic states representing a simulated false reality poses a further ethical challenge: are the effects of psychedelic-assisted psychotherapy ethically justifiable if they are produced by contact with a false reality? Two responses are suggested to such a question. Firstly, emerging research on the neuroscience of psychedelic states of consciousness could suggest that psychedelic states do not represent a false reality, but rather a different way of experiencing actual reality. Secondly, even if psychedelic states do represent a false reality, the use of psychedelic-assisted psychotherapy can still be justified in cases of extreme suffering, where concerns about contact with an actual reality are outweighed by extreme reductions in pain — e.g. treatment resistant patients.

 

CONCLUSION

The psychedelic renaissance is providing hope for many who have not responded to currently available psychiatric treatments. However, along with this hope comes a significant burden of responsibility for those researching and advocating for the medicalisation of psychedelics. Those living with mental illness are among some of the most vulnerable patient populations in society. Therefore, it is of utmost importance that the field of psychedelic science proceed with critical reflection to ensure that the work being done is ethically sound and not detrimental to those it is trying to serve. It is hoped that by beginning the process of applying moral theories to the experience of psychedelic-assisted psychotherapy, more discussion will ensue regarding some of the ethical challenges that this promising new paradigm presents.

 

REFERENCES

1. Reiff CM, Richman EE, Nemeroff CB, Carpenter LL, Widge AS, Rodriguez CI, Kalin NH, McDonald WM, Work Group on Biomarkers and Novel Treatments, a Division of the American Psychiatric Association Council of Research. Psychedelics and psychedelic-assisted psychotherapy. American Journal of Psychiatry. 2020 May 1;177(5):391–410.

2. Davis AK, Barrett FS, May DG, Cosimano MP, Sepeda ND, Johnson MW, Finan PH, Griffiths RR. Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial. JAMA psychiatry. 2020 Nov 4.

3. Miceli McMillan R. Prescribing meaning: hedonistic perspectives on the therapeutic use of psychedelic-assisted meaning enhancement. Journal of Medical Ethics Published Online First: 04 November 2020. doi: 10.1136/medethics-2020–106619

4. Sinnott-Armstrong W. The Stanford encyclopedia of philosophy: Consequentialism. Available: https://plato.stanford.edu/entries/consequentialism/

5. Moore A. The Stanford encyclopedia of philosophy: Hedonism, 2019. Available: https://plato.stanford.edu/entries/hedonism/

6. Hartogsohn I. The meaning-enhancing properties of psychedelics and their mediator role in psychedelic therapy, spirituality, and creativity. Front Neurosci 2018;12:129.

7. Moerman, D. Meaning, Medicine and the “Placebo Effect”. Cambridge; New York, NY: Cambridge University Press, 2002.

8. Nozick R. Anarchy, state, and utopia. New York: Basic Books, 1974

Medically Assisted Psychotherapy in a Global Context

 

World from space

Written by Amelia French and Dr Alana Roy

Psychedelics and plant medicines have been used around the world since early humanity for spiritual, ritual, divination and recreational purposes.[1] Indigenous cultures used plants as medicines for millennia and many cultures carry on this tradition today.[2] Despite the growing evidence for use of psychedelics by humans as modern-day medicine for mental health disorders, they were abruptly made illegal to supply and possess by the United Nations convention in 1971 as a result of President Nixon’s War on Drugs.[3] Studies suggest psychedelics could be a breakthrough therapy for mental health issues including depression, anxiety, addiction, Obsessive Compulsive Disorder, and Post Traumatic Stress Disorder through their ability to work on a deep emotional as well as biological level. [4] Currently statistics of Mental Health in Australia is one in four people.[5] Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease.[6] There needs to be innovation and change for the treatment of mental illnesses. MMA are advocating for the therapeutic use of Psilocybin and MDMA to support people with treatment resistant depression and Post traumatic stress disorder, respectively.

Current pharmacotherapy treatments for depression and anxiety work in 20–40% of cases.[7] Psilocybin has been shown to alleviate depression in 67% of patients within one to two doses even where standard treatments have failed.[8] Current pharmacotherapy has even lower efficacy in the treatment of PTSD with success rates of around 20%, MDMA has been shown lead to remission from PTSD in 78% of cases where standard treatments have not worked.[9] Current treatments such as antidepressants must be taken every day for months, often years. With medicine-assisted psychotherapy, patients frequently experience long-lived reductions in symptoms within a few single dose sessions.

Around the globe we are seeing countries take the lead in medically assisted psychotherapy with the legalization or decriminalization of psychedelics with logical, research-based, and tolerant policies on psychoactive substances. There are currently no countries in which psychedelics are regulated and approved medicines. Also, psilocybin is legally available in the Netherlands and both psilocybin and MDMA are decriminalized for personal use in Portugal, Czech Republic and several countries in South America.[10] When we explore the research into countries with decriminalization of MDMA and Psilocybin from across Europe there is statistics to show the positive outcomes for mental health.

“When delivered safely and professionally, psychedelic therapy holds a great deal of promise for treating some very serious mental health conditions.” Dr Robin Carhart-Harris Head of the Centre for Psychedelic Research

Portugal allows the use of psychedelic drugs through the decriminalization of drugs since 2001 and opted for a harm minimization approach to drug use.[11] Portugal have found that removing criminal penalties for personal drug possession did not cause an increase in levels of drug use but rather drug use is dependent on social and cultural factors and trends.[12] Decriminalization allowed space for research into mental health, supporting those with addictions better access to services by reducing the taboo and shame around drug use.[13] The Dutch drug policy is also driven by the idea that each person should make informed decisions on matters of their own health and recognize that drug policy is also a social issue.

The Dutch are world-renowned for their more logical, research-based, and tolerant policies on psychoactive substances. However, this does not mean psychedelics are completely legal in the Netherlands. Just like many other countries, the Dutch government classifies some drugs, including certain psychedelics, as illegal substances however the use of psychedelics is regulated. Drug policy in the Netherlands is guided by the principle that suppressing drug use and having a blanket ban on all drugs does not make mental health illnesses associated with drug use disappear but quite the opposite, makes mental health outcomes worse.[14] This is reflected in literature that mental health issues become far more difficult to minimize and control without appropriate education and prevention of drug abuse disorders is one of the most effective ways to reduce the impact of mental health on individuals and wider society, this is done through education, effective treatments and reducing cultural stigma or shame around mental health. Mental health disorders are exacerbated through lack of recognition to research and suppression through drug policy.[15] Psychedelic assisted therapies can positively impact mental health outcome and has shown to be safe in therapeutic contexts.[16] The Netherlands are embracing medically assisted psychotherapies through clinics, which are leading a movement to transform the way people approach emotional, cognitive, and spiritual well-being, through safe and legal medically assisted psychotherapy backed by research.[17]

Switzerland have allowed the legal therapeutic use of LSD and MDMA for treatment of post-traumatic stress disorder and depression when used alongside non-drug psychotherapy sessions with an experienced practitioner.[18] In Switzerland, limited medical use of non-registered drugs, or compassionate use is available from psychiatrists to prescribe MDMA for therapeutic use in conjunction with talk therapy for the treatment of trauma disorders.[19] Subjects with chronic, treatment-resistant posttraumatic stress disorder experienced clinically meaningful improvements and no evidence of harm after participating in a Swiss study evaluating MDMA-assisted psychotherapy.[20] The field of medicine-assisted psychotherapy needs to be driven by evidence-based studies to inform policies and law. Through evidence-based research we can effectively improve the quality of people’s lives and to promote healthier societies through policy reform of medicine-assisted psychotherapy. Mind Medicine Australia are advocating for clinical changes to bring these new innovative mental health treatments to Australia. Law is socially constructed by the culture and social influence, and it is ever changing with new research and knowledge emerging. Psychedelics have been shown to have significant therapeutic potential which is seen to outweigh ill-informed anti-drug laws.[21]

There is significant evidence to support the safe use of medicine-assisted psychotherapy when used in a clinically controlled space and appropriate screening is conducted.[22] Research suggests that there is no link between the use of psychedelics and the development of mental illnesses.[23] Further to this, there has been no negative health outcomes associated with the use of psychedelic medicines.[24] However, psychedelic use is highly context dependent and we only advocate for clinical use of psychedelics.

Mind Medicine Australia is an Australian registered charity (with DGR-1 status) seeking to broaden the treatment paradigm available to medical practitioners and their patients and improve treatment effectiveness by establishing, safe, accessible and effective Medicine-Assisted Psychotherapy in Australia for major Mental Illnesses.

 

References

[1]. Nicola Bragazzi et al., ‘Ancient Shamanism and Modern Psychotherapy: From Anthropology to Evidence-Based Psychedelic Medicine,’ Cosmos and History: The Journal of Natural and Social Philosophy 4, no. 1 (2018): 142, https://cosmosandhistory.org/index.php/journal/article/view/688; David Smith, ‘The Role of the Journal of Psychedelic Drugs in the Evolution of Psychedelic Medicine,’ Journal of psychoactive drugs 51, no. 2 (December 2019): 98–101, https://doi.org/10.1080/02791072.2019.1589607

[2]. Richard Doblin, Merete Christiansen, Lisa Jerome, and Brad Burge, ‘The Past and Future of Psychedelic Science: An Introduction to This Issue,’ Journal of psychoactive drugs 51, no. 2 (April 2019):93–97, https://doi.org/10.1080/02791072.2019.1606472; Smith, ‘The Role of the Journal of Psychedelic Drugs,’ 98–101; Michael Winkelman, ‘Shamanic guidelines for psychedelic medicine,’ in Psychedelic medicine: New evidence for hallucinogenic substances as treatments, ed. Thomas Roberts (Connecticut: Praeger Publishers, 2007), 143–168, https://www.academia.edu/4165474/Shamanic_Guidelines_for_Psychedelic_Medicines

[3]. Doblin, Christiansen, Jerome, and Burge, ‘The Past and Future of Psychedelic Science,’ 93–97; Smith, ‘The Role of the Journal of Psychedelic Drugs,’ 98–101

[4]. Tanya Calvey and Fleur Howells, ‘An introduction to psychedelic neuroscience,’ Progress in Brain Research 242, no. 1 (2018): 1–23, https://doi.org/10.1016/bs.pbr.2018.09.013

[5]. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of Results. Canberra: ABS, 2008. https://www.abs.gov.au/statistics/health/mental-health/national-survey-mental-health-and-wellbeing-summary-results/latest-release

[6]. World Health Organization. Prevention of Mental Disorders Effective Interventions and Policy Options. France: WHO, 2004. https://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf?ua=

[7]. Courtney Hutchison and Sara Bressi, ‘Social Work and Psychedelic‑Assisted Therapies: Practice Considerations for Breakthrough Treatments,’ Clinical Social Work Journal (January 2020), https://doi.org/10.1007/s10615-019-00743-x

[8]. Mind Medicine Australia. A new paradigm for mental health. Australia: MMA, 2020. https://mindmedicineaustralia.org/wp-content/uploads/2020/10/Mind-Medicine-Australia-EBook-09102020-small.pdf

[9]. Smith, “The Role of the Journal of Psychedelic Drugs,” 98–101

[10]. Jeff Lebowe, ‘A Global Guide to Where Magic Mushrooms and Psilocybin Are Legal or Decriminalized,’ Mary Jane, May 29, 2020, https://merryjane.com/culture/a-global-guide-to-where-magic-mushrooms-and-psilocybin-are-legal-or-decriminalized

[11]. David Bronner, ‘The Unified Field Theory of Psychedelic Integration and Portugal Style Decriminalization,’ Multidisciplinary Association for Psychedelic Studies 30, no. 1 (2020): 14–19, https://maps.org/news/bulletin/articles/439-bulletin-spring-2020/8126-the-unified-field-theory-of-psyhedelic-integration-and-portugal-style-decriminalization

[12]. Linnae Ponté, ‘Decriminalization and Harm Reduction in Portugal: An Interview with Dr. João Goulão,’ Multidisciplinary Association for Psychedelic Studies 25, no. 1 (2015): 18–21, https://maps.org/news/bulletin/articles/387-bulletin-spring-2015/5671-decriminalization-and-harm-reduction-in-portugal-an-interview-with-dr-jo%C3%A3o-goul%C3%A3o

[13]. Scott Bernstein, Emily Amirkhani, Dan Werb, and Donald MacPherson, ‘The regulation project: Tools for engaging the public in the legal regulation of drugs,’ International Journal of Drug Policy 86, no. 1 (December 2020):102949, https://doi.org/10.1016/j.drugpo.2020.102949

[14]. Bronner, ‘Unified Field Theory’

[15]. Bernstein, Amirkhani, Werb, and MacPherson, ‘The regulation project,’ 102949; WHO, Prevention of Mental Disorders

[16]. Calvey, and Howells, ‘Intro to psychedelic neuroscience,’ 1–23.

[17]. Bernstein, Amirkhani, Werb, and MacPherson, ‘The regulation project,’ 102949

[18]. Peter Gasser, ‘Psychedelic Group Therapy in Switzerland,’ Multidisciplinary Association for Psychedelic Studies 27, no. 1 (2017): 28–29, https://maps.org/news/bulletin/articles/420-bulletin-spring-2017/6622-research-update-psychedelic-group-therapy-in-switzerland

[19]. WHO, Prevention of Mental Disorders

[20]. WHO, Prevention of Mental Disorders

[21]. David Nichols, ‘Psychedelics,’ Pharmacological Reviews 68, no. 2 (April 2006):264–355, https://doi.org/10.1124/pr.115.011478; Tingying Chi and Jessica Gold, A review of emerging therapeutic potential of psychedelic drugs in the treatment of psychiatric illnesses,’ Journal of the Neurological Sciences 411, no. 1 (Jan 2020): 116715, https://doi.org/10.1016/j.jns.2020.116715

[22]. Jacob Aday et al., ‘Long-term effects of psychedelic drugs: A systematic review,’ Neuroscience and Biobehavioral Reviews 113, no. 1 (June 2020): 179–189, https://doi.org/10.1016/j.neubiorev.2020.03.017

[23]. Teri Krebs and Pål-Ørjan Johansen, ‘Psychedelics and Mental Health: A Population Study,’ PLoS ONE 8, no. 8 (August 2013): 1–9, https://doi.org/10.1371/journal.pone.0063972

[24]. Krebs and Johansen, ‘Psychedelics and Mental Health,’ 1–9

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