Are Psychedelic Experiences Transformative? Can We Consent to Them?

Psychedelic substances have great promise for the treatment of many conditions, and they are the subject of intensive research. As with other medical treatments, both research and clinical use of psychedelics depend on our ability to ensure informed consent by patients and research participants. However, some have argued that informed consent for psychedelic use may be impossible, because psychedelic experiences can be transformative in the sense articulated by L. A. Paul (2014). For Paul, transformative experiences involve either the acquisition of knowledge that cannot be obtained in any other way or changes in the self. Either of these characteristics may appear to undermine informed consent. This article argues, however, that there is limited evidence that psychedelic experiences are transformative in Paul's sense, and that they may not differ in their transformative features from other common medical experiences for which informed consent is clearly possible. Further, even if psychedelic experiences can be transformative, informed consent is still possible. Because psychedelic experiences are importantly different in several respects from other medical experiences, this article closes with recommendations for how these differences should be reflected in informed consent processes.

Is Suffering a Useless Concept?

"Suffering" is a central concept within bioethics and often a crucial consideration in medical decision making. As used in practice, however, the concept risks being uninformative, ambiguous, or even misleading. In this paper, we consider a series of cases in which "suffering" is invoked and analyze them in light of prominent theories of suffering. We then outline ethical hazards that arise as a result of imprecise usage of the concept and offer practical recommendations for avoiding them. Appeals to suffering are often getting at something ethically important. But this is where the work of ethics begins, not where it ends.

Epistemic injustice and the psychiatrist.

BACKGROUND: Psychiatrists depend on their patients for clinical information and are obligated to regard them as trustworthy, except in special circumstances. Nevertheless, some critics of psychiatry have argued that psychiatrists frequently perpetrate epistemic injustice against patients. Epistemic injustice is a moral wrong that involves unfairly discriminating against a person with respect to their ability to know things because of personal characteristics like gender or psychiatric diagnosis. METHODS: We review the concept of epistemic injustice and several claims that psychiatric practice is epistemically unjust. RESULTS: While acknowledging the risk of epistemic injustice in psychiatry and other medical fields, we argue that most concerns that psychiatric practice is epistemically unjust are unfounded. CONCLUSIONS: The concept of epistemic injustice does not add significantly to existing standards of good clinical practice, and that it could produce changes in practice that would be deleterious. Psychiatrists should resist calls for changes to clinical practice based on this type of criticism.

Hard Choices: How Does Injustice Affect the Ethics of Medical Aid in Dying?

Critics of medical aid in dying (MAID) often argue that it is impermissible because background social conditions are insufficiently good for some persons who would utilize it. I provide a critical evaluation of this view. I suggest that receiving MAID is a sort of "hard choice," in that death is prima facie bad for the individual and only promotes that person's interests in special circumstances. Those raising this objection to MAID are, I argue, concerned primarily about the effects of injustice on hard choices. I show, however, that MAID and other hard choices are not always invalidated by injustice and that what matters is whether the injustice can be remediated given certain constraints. Injustice invalidates a hard choice when it can, reasonably, be remedied in a way that makes a person's life go better. I consider the implications of this view for law and policy regarding MAID.

Three kinds of suffering and their relative moral significance.

Suffering is widely assumed to have particular moral significance, and is of special relevance in medicine. There are, however, many theories about the nature of suffering that seem mutually incompatible. I suggest that there are three overall kinds of view about what suffering is: value-based theories, including the theory famously expounded by Eric Cassell, which as a group suggest that suffering is something like a state of distress related to threats to things that a person cares about; feeling-based theories, which equate suffering with aversive feelings or sensations like pain; and objective theories, which suggest that suffering is the absence of objective flourishing. Rather than argue that one or another of these kinds of theory most accurately captures the nature of suffering, I allow that the term is ambiguous and thus that it may have at least three different kinds. I further argue, however, that when we think about suffering as potentially justifying end-of-life interventions, especially for cognitively typical adults, we are interested mainly in value-based suffering. This is because the moral significance of value-based suffering for persons with decision-making capacity generally outweighs that of the other types; those other types of suffering achieve overriding moral significance only if they also constitute, or contribute to, value-based suffering.

Moral Distress and Involuntary COVID-19 Vaccination of a Mature Minor Receiving Inpatient Psychiatric Treatment.

Mandatory vaccination against COVID-19 is a highly controversial issue, and many members of the public oppose it on the grounds that they should be free to determine what happens to their own body. Opinion has generally favored parental authority with respect to vaccination of children, but less attention has been paid to the ethical complexities of how to respond when mature minors refuse vaccination that is requested by their parents. We present a case in which an mature minor, who was psychiatrically hospitalized, refused vaccination that had been requested by her parents, which lead to significant moral distress for her caregivers.

Ethical and public health implications of genetic testing for suicide risk: family and survivor perspectives.

PURPOSE: Death from suicide has an estimated heritability of ~50%. Research may soon allow calculation of polygenic risk scores (PRS) for suicide death, which could be marketed directly to consumers. This raises ethical concerns. Understanding how consumers will utilize this information is urgent. METHODS: We conducted three focus groups involving suicide attempt survivors ("survivors") and family members of suicide decedents ("family members") to gauge their reactions to this technology. Questions focused on positive and negative implications of PRS results. Qualitative research methods were used to summarize studio results. RESULTS: Eight survivors and 13 family members participated. Both groups postulated benefits of suicide PRS, including prevention and reduced stigma. Their concerns ranged from increased stigma to adverse psychological effects. They suggested that suicide PRS should be accompanied by extensive education and counseling. Participants experienced no adverse effects. CONCLUSION: Many ethical, legal, and social implications of genetic testing for suicide risk are highly salient to community stakeholders. Our participants hoped that suicide PRS could have significant individual and community-level benefits, but had concerns about effects in several domains, including stigma, access to insurance and employment, and increased anxiety and depression.

Risk of suicide after discharge from inpatient psychiatric care: a systematic review.

OBJECTIVE: The period following discharge from inpatient psychiatric care is recognised as an especially high-risk time for patient suicide. Astonishingly, there is a dearth of comprehensive studies examining risk and protective factors in this specific population. The aim of this study was to establish the protective and risk factors for suicide in the first year post-discharge (PD) from psychiatric facilities and their utility in categorising patients as high or low risk in a meaningful way to benefit clinical care and improve patient outcomes. METHODS: A methodical search of three databases (PubMed, EMBASE, and PsychINFO) was used to identify reports describing risk factors for suicide after psychiatric discharge. RESULTS: Predominantly, male sex, a history of self-harm, a history of suicide attempts, admission with suicidal ideation or suicidal behaviour, and hopelessness were identified as being associated with death by suicide after discharge. Lithium appeared to be protective against suicide in the studies reviewed. Other variables examined showed mixed results. CONCLUSIONS: The findings of this review suggest that significant suicide predictors both common and unique to those established for suicide in the general population exist and can be utilised in a clinically meaningful way, despite the difficulties inherent in studying this population.KEY POINTSThe risk of suicide after psychiatric hospitalisation is high.Factors that predict suicide after psychiatric hospitalisation overlap only partially with risk factors for suicide in general.Important risk factors for suicide in the post-discharge period include male sex, a history of self-harm, a history of suicide attempts, the presence of suicidal ideation during the admission, and hopelessness.The conclusions that can be drawn from the existing literature are limited by small study sizes, different study populations, and different follow-up periods; additional research in this domain is needed.

Ethical concerns relating to genetic risk scores for suicide.

Genome-wide association studies (GWAS) provide valuable information in research contexts regarding genomic changes that contribute to risks for complex psychiatric conditions like major depressive disorder. GWAS results can be used to calculate polygenic risk scores (PRS) for psychiatric conditions, such as bipolar disorder or schizophrenia, as well as for other traits, such as obesity or hypertension. Private companies that provide direct-to-consumer (DTC) genetic testing sometimes report PRS for a variety of traits. Recently, the first well-powered GWAS study for suicide death was published. PRS reports that claim to assess suicide risk are therefore likely to appear soon in the DTC setting. We describe ethical concerns regarding the commercial use of GWAS results related to suicide. We identify several issues that must be addressed before PRS for suicide risk is made available to the public through DTC: (a) the potential for misinterpretation of results, (b) consumers' perceptions about determinism and behavior change, (c) potential contributions to stigma, discrimination, and health disparities; and (d) ethical problems regarding the testing of children and vulnerable adults. Tests for genetic prediction of suicidality may eventually have clinical significance, but until then, the potential for individual and public harm significantly outweighs any potential benefit. Even if genetic prediction of suicidality improves significantly, information about genetic risk scores must be distributed cautiously, with genetic counseling, and with adequate safeguards.

Altitude and risk of depression and anxiety: findings from the intern health study.

Multiple studies suggest that the risks of depression and suicide increase with increasing altitude of residence, but no studies have assessed whether changing altitude changes these risks. To address this gap, this study used data from the Intern Health Study, which follows students from the end of medical school through the first year of residency, recording depression via the 9-item Patient Health Questionnaire (PHQ-9), anxiety via the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7), and multiple risk factors for these symptoms. Data from 3764 medical students representing 46 schools and 282 residencies were available. Odds ratios (OR) representing the effects of altitude on psychiatric symptoms were estimated using generalized linear models. After excluding participants with missing altitude data, 3731 medical students were analyzed. High altitude residence (> 900 m) was significantly associated with PHQ-9 total score (OR = 1.32, 95% CI = 1.001-1.75, p < 0.05), and PHQ-9 suicidal ideation (OR = 1.79, 95% CI = 1.08-0.02, p = 0.02). Moving from low to high altitude was significantly associated with PHQ-9 total score (OR = 1.47, 95% CI = 1.087-1.98, p = 0.01), GAD-7 total score (OR = 1.40, 95% CI = 1.0040-1.95, p < 0.05), and PHQ-9 suicidal ideation (OR = 1.10, 95% CI = 1.01-1.19, p = 0.02). The data suggest that moving from low to high altitude is associated with increasing symptoms of depression, anxiety, and suicidal ideation.

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons' mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge.

Boorse's Theory of Disease: (Why) Do Values Matter?

There has been much debate about whether the concept of disease articulated in Boorse's biostatistical theory is value-neutral or value-laden. Here, I want to examine whether this debate matters. I suggest that there are two basic respects in which value-ladenness might be important: it could threaten either scientific legitimacy or moral permissibility. I argue that value-ladenness does not threaten the scientific legitimacy of our disease-concept because the concept makes little difference to the formulation and testing of scientific hypotheses. Likewise, even if our disease-concept is value-laden, this does not show it is morally impermissible. To determine its permissibility, we must regard it as a tool to structure social institutions. Seen in that way, whether our disease-concept is morally permissible is a consequentialist matter and depends exquisitely on unanswered empirical questions.

An Open-Label Pilot Study of Combined Augmentation With Creatine Monohydrate and 5-Hydroxytryptophan for Selective Serotonin Reuptake Inhibitor- or Serotonin-Norepinephrine Reuptake Inhibitor-Resistant Depression in Adult Women.

PURPOSE: Many women with major depressive disorder (MDD) respond inadequately to standard treatments. Augmentation of conventional antidepressants with creatine monohydrate and 5-hydroxytryptophan (5-HTP) could correct deficits in serotonin production and brain bioenergetics associated with depression in women, yielding synergistic benefit. We describe an open-label study of 5-HTP and creatine augmentation in women with MDD who had failed selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) monotherapy. METHODS: Fifteen women who were adequately adherent to an SSRI or SNRI and currently experiencing MDD, with a 17-item Hamilton Depression Rating Scale (HAM-D) score of 16 or higher, were treated with 5 g of creatine monohydrate daily and 100 mg of 5-HTP twice daily for 8 weeks, with 4 weeks of posttreatment follow-up. The primary outcome was change in mean HAM-D scores. RESULTS: Mean HAM-D scores declined from 18.9 (SD, 2.5) at pretreatment visits to 7.5 (SD, 4.4) (P < 0.00001), a decrease of 60%. Participants did not experience any serious treatment-related adverse events. CONCLUSIONS: Combination treatment with creatine and 5-HTP may represent an effective augmentation strategy for women with SSRI- or SNRI-resistant depression. Given the limitations of this small, open-label trial, future study in randomized, placebo-controlled trials is warranted.

Respect for autonomy: deciding what is good for oneself.

Paternalistic interference in autonomous decisions is typically impermissible. This has several explanations, among which is a view I call the agent-constitution of the good: that the autonomous agent not only knows what is best for herself, but determines what is best for herself through her desires, goals and so on (her aims). For instance, it might seem that if an autonomous person does choose not to take insulin for her diabetes, then not only is it inappropriate to force treatment upon her, it is also not in her best interest to take insulin. Here I argue that agent-constitution, though appealing, is false. In fact, autonomous agents can be mistaken about their good, even when it seems to depend only upon their aims. Agent-constitution appears true only because we typically fail to notice constraints on a person's good in private, self-regarding decisions where paternalism might be considered.

A Focus Group Study of the Views of Persons with a History of Psychiatric Illness about Psychiatric Medical Aid in Dying.

BACKGROUND: Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with persons with lived experience of mental illness. METHODS: We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team. RESULTS: A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide. CONCLUSIONS: Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk.