Psychedelic Therapy and Ethical Design
Psychedelic plants, fungi and synthesised or extracted substances might not be considered technologies in and of themselves. But in the broader sense, if how and why they are used are considered as a whole, they are. This unequivocally applies to the development of psychedelic-assisted therapies and any commercialisation of psychedelics, whether the intended use is strictly medical or not. In this longer ‘deep dive’ piece, I’m going to look at commercial psychedelic therapy through this lens of the ethics of technological design. This is not as in-depth a treatment as I can possibly produce, but rather, is a pointer in the right direction and a simplified sample of the analysis I could produce if someone out there is willing to pay me appropriately for it. But before I can get to more specific analysis, there are some basic principles that are worth covering — especially for readers that are unfamiliar with either psychedelics or ethics.
Technology & ethics
Technology is not just the objects, artefacts or software we use and the science behind them — though it is all of those things. It is also the ways of thinking and maybe even behaviours that go with them. Values, attitudes, choices and actions can all be closely associated with what we normally consider technology to be.
Technologies can evolve. But generally, they are intentionally designed — at least initially. A person or group of people make decisions on how something operates, what it is made out of, how it will be manufactured, how it will be deployed or marketed, how much it will cost to purchase and much more. These design decisions carry with them ethical considerations, obligations and value judgments. While there can be a tendency to blame technological artefacts for any adverse outcomes that arise from their use, a great deal of responsibility rests with their designers and those who continue to control a technology over time.
Technologies change the architecture of our choices. People can make decisions, but the range of choices they have available is directly influenced by what technologies they have access to and are aware of. We can only troll each other to the point of suicide on social media if the system allows it, or avoid a repressive internet censorship regime with the use of a VPN. Similarly, someone suffering from treatment-resistant depression can only decide to have psilocybin-based therapy if it is in fact available. An individual might not even consider that option unless they know it is a possibility. Even though psychedelic therapies, with the possible exception of ketamine based interventions, are not widely available and psychedelics themselves are illegal in most countries, public interest in these treatments is evidence that this phenomena is already occurring. Even while in development, the technology of psychedelic-assisted therapy is out of the box and influencing the choices people make.
Engaging with ethics of technological design is to consider these ethical questions as part of the design process. It is also to revisit them over time as uses and contexts of use evolve. Whether as an original designer or subsequent vendor, there is always someone who can and should consider the ethical impact of a technology.
Why does ethics matter for psychedelic business?
One question that comes up in this context is essentially. “Why should designers/manufacturers/businesses care about any of this?”. Apart from just wanting to do the right thing, this predominantly comes down to one factor: ethical failure increases business risk.
Such failures, whether they occur during the design process or in execution of a project or business plan, do not always end with abstract rules being the only casualties. Engineering disasters and business collapses are very often preceded by partial or total neglect of ethical considerations. This is confirmed across many cases. The running aground of the Exxon Valdez, Challenger disaster, Deepwater Horizon oil spill, Enron collapse and thalidomide crisis are all examples where poor ethical choices led to profoundly adverse outcomes. And even though Facebook hasn’t folded, the damage to its brand by Cambridge Analytica is undeniable (and, in all likelihood, would have destroyed a smaller company).
This is not to say that unforeseeable events never occur, or that unethical behaviour always leads to disaster. But behind a great many of the bigger technological and business failures of the last 50 years, there were people who valued time above safety, profit over people, and expediency rather than diligence. There was often someone, if not multiple people, who knew about potential issues but did not act on this knowledge in an ethical way.
Not only can ethical failure lead to negative outcomes ranging from negative public relations to mass loss of life, it could impact on the ability to attract investment. Why? Because serious and institutional investors, lenders and risk assessors are aware of this connection between poor ethics and poor outcomes. Ethical behaviour does not guarantee commercial success — good people’s businesses fail too. But the last thing any project that is seeking funding needs at the moment is additional perceived risk.
Psychedelics and psychedelic therapy
Psychedelics are substances that produce non-ordinary or altered states of consciousness. This can include changes to perceptions or hallucinations that range from mild enhancement of colour or sound to otherworldly experiences of an all-encompassing nature. People may experience changes in how they perceive themselves in the context of their life or to their sense of self as being distinct from the wider world, manifesting as a feeling of being connected or as a dissolution of ego. These experiences may be mystical and difficult to capture in everyday language, and can carry a sense of profundity and importance.
The exact mechanism of how these experiences are produced by psychedelics is still under investigation, but is correlated with activation of the 5HT2A serotonin receptors in the brain for most ‘classic’ psychedelics, such as LSD, Psilocybin, DMT and Mescaline. A minority of known psychedelics interact with different receptors: Ketamine and Nitrous Oxide are active on NMDA receptors and Salvinorin A is a kappa-opioid antagonist. Arguably, these exceptions might be categorised as dissociatives, but they do seem to produce experiences that are at least similar to the serotonin-based psychedelics.
In the broadest sense, psychedelic therapy is any therapeutic or medical use of the aforementioned substances. Within this very general definition, there are distinct categories. The two most common are microdosing and psychedelic-assisted therapy.
Microdosing is a practice where doses of psychedelics below the level normally required to cause overt changes to perceptions, are used regularly to enhance mood, creativity or cognition. The period this use occurs over may vary, but it is not uncommon for people to adopt dosing regimes for weeks or months. While microdosing has attracted less attention from researchers and investors, it is increasingly widespread outside of the Silicon Valley milieu that popularised it. This has motivated research as well as a range of commercial enterprises that seek to monetise the practice in some way. Due to the ongoing illegality of psychedelics, most developments are around instruction or coaching associated with microdosing, rather than provision of the substances themselves.
The most common approach to psychedelic therapy is around psychedelic-assisted therapy, where talk-based interventions are combined with strong or acute psychedelic experiences. This is generally in a format where use of a psychedelic to bring about this experience is preceded by therapy to prepare the patient, and followed by further consultation after in order to integrate the experience. This integration usually requires a number of sessions in the weeks or even months following the psychedelic experience, and is a key step in many (if not most) psychedelic-assisted therapies. Considerable research has gone into psychedelic-assisted therapy, with it forming the core methodology of most investigations into the efficacy of psychedelics. There is strong clinical evidence, mainly from the past decade, that supports this approach across areas such as addiction, treatment-resistant depression and post-traumatic stress disorder.
The analysis that follows is not intended to be specific. And though it may be apparent to readers that I am referring to particular cases, companies, or therapies, I am not naming names. This is a general overview of how such an analysis could be conducted. More specific focus on a single company or therapy is possible, but is difficult when there has been less public interaction with commercially available psychedelic products. With access to the internal workings or documentation of a company or operation, an analyst could make much more precise judgments on specific therapies and associated actions, both commercial and otherwise.
There may also be methodological crossover between these two groups. Microdosing could be coupled with an approach that includes preparation and integration. Psychedelic-assisted therapy could conceivably be followed by a regime of microdosing (though such a practice is not yet supported by research). Other systems, both more or less clinical in nature may exist or be developed in the future. The approaches mentioned here are not intended to be exhaustive.
It is vital that these therapies be analysed in the context of how they are researched, promoted, and made available. This necessarily includes consideration of the commercial and social practices that are adjacent to or associated with a particular therapeutic approach or product. If a therapy were perfectly ethical in and of itself and it was marketed or deployed in an underhanded or unethical manner, failure to consider the whole picture would be both counterproductive and disingenuous.
The analysis that follows is not intended to be specific. And though it may be apparent to readers that I am referring to particular cases, companies, or therapies, I am not naming names. This is a general overview of how such an analysis could be conducted. More specific focus on a single company or therapy is possible, but is difficult when there has been less public interaction with commercially available psychedelic products. With access to the internal workings or documentation of a company or operation, an analyst could make much more precise judgments on specific therapies and associated actions, both commercial and otherwise.
The ethical design framework
The framework I am using is found in Ethical by Design, by Matt Beard and Simon Longstaff of the Ethics Centre. While there are more scholarly approaches, I think this has the right balance of being rigorous but still accessible to people who have not specifically studied ethics or philosophy. The framework consists of seven principles, which are listed here, though I will expand on each as I look at specifics. The principles are motivated by one key idea — a ‘rule zero’ that comes before all else.
0. OUGHT BEFORE CAN The fact that we can do something does not mean that we should.
1. NON-INSTRUMENTALISM Never design technology in which people are merely a part of the machine.
2. SELF-DETERMINATION Maximise the freedom of those affected by your design.
3. RESPONSIBILITY Anticipate and design for all possible uses.
4. NET BENEFIT Maximise good, minimise bad.
5. FAIRNESS Treat like cases in a like manner; different cases differently
6. ACCESSIBILITY Design to include the most vulnerable user.
7. PURPOSE Design with honesty, clarity and fitness of purpose.
In looking at how these principles might apply, it is possible to come to an at least preliminary judgement on whether or not psychedelic therapies are something that ought to be pursued, as well as indicating possible ethical issues before they actually happen. On the broad question of whether or not such therapies are a good thing, I know it seems obvious to many people that they are. But historically, something ‘being obviously true’ has not always been a good action-guiding principle. Being honest about not taking knowledge for granted means sometimes challenging things we are emotionally or ideologically attached to — an idea that people in the psychedelic community should be familiar with.
Non-instrumentalism
Psychedelic therapy is often thought of as being a break from contemporary psychiatry in that it centres on the person, rather than their diagnosis. So in this sense, it is an advance on the status quo, and should guard against a tendency to treat people as things or otherwise dehumanise them for the sake of profit. Nonetheless, there are some ways psychedelic therapy and associated businesses could fail to respect people as being inherently worthwhile. The most obvious would be to focus overly on outcomes to the extent that people, especially patients, are de-centred.
This principle entails that people, like anything else of inherent value, must always not solely be ‘things’ that serve a scientific or financial purpose. This is largely in line with Kant’s idea about not using people solely as means to an end. People have lives and experiences, and reducing them purely to sales targets, KPIs or a way to get research published diminishes this. That this potential exists anytime a health or wellness intervention is commercialised should not be sugar-coated. The danger for psychedelic therapy here is multifaceted. Not only would such an ethical breach ultimately endanger both patients and businesses, but it is actively self-contradictory. This contradiction could manifest as cognitive dissonance in staff and patients if they became aware of it (and they would), leading to workplace dissatisfaction, absenteeism, burnout and suboptimal therapeutic results. Nor would such a contradiction go unnoticed by the broader psychedelic community, with erosion of trust and support being a distinct possibility.
More subtle disrespect of people can occur through manipulation. This would include deceptive advertising of therapies, but also practices that manipulate potential investors into parting with their money where they might not otherwise do so. These might seem so obvious that it is not necessary to point them out, but in free-market economies it is inevitable that bad actors will attempt to use such strategies for personal gain. While anyone willing to do this is unlikely to be convinced to change their ways by this document, it is worth considering that individuals, companies and non-profit organisations in the psychedelic space have an obligation to call out or otherwise discourage such behaviour for the good of both the emerging psychedelic businesses sector and the inalienable interests of individual patients. Yes, buyers do have an obligation to beware. But a large enough incident at such an early stage in the development of the psychedelic business could reduce trust, and hence investment, in the entire sector.
Self-determination
In many ways, psychedelic therapies have the principle of self-determination at their core. While it might be both incorrect and unethical to conceive of people suffering from poor mental health as less free, it is certainly plausible to say that giving them an expanded range of choices over how to treat their conditions is freedom-enhancing.
But it is also the case that treatments which are hard to discontinue could be construed as freedom-limiting. The lack of habit-forming potential of substances such as LSD and psilocybin, as well as their modes of therapeutic use, bode well in this case, as it is extremely unlikely that patients could become addicted. The main consideration would be the possibility of deliberately structuring treatments so that patients had to continue treatment, where a different treatment regime would give them permanent or longer term relief from symptoms. A similar, but even less ethical strategy would be to manipulate patients/clients into erroneously believing that they need to continue treatment, when in fact they do not. Either strategy would be rightfully seen as deeply egregious, yet they would also be commercially appealing when compared to psychedelic treatments that give long-term results with limited or even a single session.
While it is considered at greater length below, any consideration of self-determination must at least touch on issues that could arise if psychedelics remain criminalised outside of clinical settings. Put simply, people who become aware of psychedelics due to their rise as legitimate treatments count as being ‘affected by your design’. If they were to face a custodial sentence for growing or possessing something that a company is commercially prescribing, then this is hardly freedom-maximising. There may be disagreement as to what the responsibility of a company is in this case, but what is certain is that they do have obligations and it would be a mistake to ignore them.
A final key issue around self-determination is that of who gets to administer psychedelics, and who gets to decide who administers psychedelics. The ability to control access to a therapy and the ability to confer legitimacy on providers is profoundly powerful. Having this control, apart from being an opportunity for regulatory capture and corruption, is to potentially interfere with the self-determination of a great many people. While it is not possible to consider all eventualities before they happen, a general sketch of the tension involved is illustrative nonetheless. On one hand there is the autonomy of people to seek out practitioners of their choice, as well as practitioners having the opportunity to make use of psychedelics. On the other is the safety of people as patients and consumers, as well as those who may be affected by their mental states and actions.
These factors, autonomy and safety, must be balanced in as transparent a way as possible. Diversity of vocation, viewpoint and ideology amongst those making decisions around legitimate access is essential. The temptation of particular groups to attempt to corner control over legitimate access to psychedelics and the ability to prescribe them is extremely serious. It is not hard to imagine professions such as clinical psychologists or psychiatrists attempting to engineer a situation where only they can make use of psychedelics, or a group of practitioners aiming to set themselves up as the peak licensing body for psychedelic therapies and the training required to provide them. In both cases it might be that this is the appropriate action to balance safety and autonomy. But it is also true in both cases that this control would deliver considerable financial reward and power to whichever group is ascendant. The extent of these benefits would interfere with people’s capacity to make judgments on the best course of action. This need not be conscious — people instinctively defend their self-interest on a regular basis, with little awareness they are doing so. For this reason, it is imperative that no one group control legitimate access to psychedelics and psychedelic therapies, or at least that such decisions be made by a group that includes a range of professions, as well as members of the psychedelic community and general public. Certainly, no single organisation, profession, company or other group should be allowed to designate themselves the sole gatekeepers of psychedelic legitimacy.
Responsibility
In considering the possible uses and flow-on effects from psychedelic therapies becoming more widespread, businesses are in a good position in that there is already a comprehensive model of what not to do, as typified by the opioid industry. More specifically, there are some fairly obvious areas of relevance, though this section is not exhaustive.
Manufacturers and businesses need to anticipate the diversion of medical psychedelics into recreational markets. While strict clinical practice models might reduce the incidence of this, it would be extremely optimistic to assume that this would not happen. Many psychedelics do not carry much danger of lethal overdose, though misadventure is always a possibility if a safe set and setting are not utilised. Diversion can and should be minimised, but education and harm-minimisation measures should be supported to help keep people informed and safe. This is, however, a minor consideration next to the broader ripples caused by the existence of psychedelic therapies and peoples’ awareness of them.
A key flow-on effect from psychedelic therapies will be interest in non-clinical, non-therapeutic, spiritual or recreational use of psychedelics. This is already occurring. As these therapies become more mainstream, so will demand for these substances outside of a clinical setting. It is vital to note that this demand would likely not exist had this mainstreaming of psychedelics not occurred (and in many cases been deliberately advanced). Psychedelic businesses who take part in this mainstreaming or profit from it have a responsibility to the people influenced by it.
Put simply, if you change the choice architecture of someone so that they think taking psychedelics is a good idea, it is deeply wrong to throw them to the wolves of prohibition by refusing to support calls for decriminalisation or legalisation of recreational use. Failure to do this not only limits the freedoms of individuals, but would allow the stigma attached to psychedelics to be perpetuated by law enforcement. So while condoning non-clinical prohibition might seem like a good way to maintain control of a psychedelic treatment, it will ultimately undermine the broader acceptance of it in the community.
A range of off-label and non-clinical uses potentially exist for any medicine, and psychedelics are no exception. Use as for cognitive enhancement or as concentration aids to increase productivity are already occurring and are likely to increase. Businesses may tolerate or condone this. They may even make it their business model. If they take this step though, the repercussions are always at least partially their responsibility and need to be considered. E.g.: does this lead to better or worse working conditions, and is it in the best interests of people to even be offering psychedelics for this purpose?
Net benefit
Obviously, psychedelic therapy providers should adopt best practice to minimise potential for adverse clinical outcomes that could directly occur — though the good safety profile of psychedelics greatly aids this. Pre-screening for pre-existing conditions or family histories should be considered where supported by research. Nor should providers skimp on preparation and integration. This goes as much for businesses associated with microdosing as anyone else.
As with the responsibility principle, considering net benefit should encourage reflection on broader impacts to society and individuals alike. This is not easy to do ahead of time, but can be clearer in retrospect. Did the medicalisation of ADHD and development of Ritalin provide a net benefit to the community? How about the development of antidepressants, or maybe Oxycodone or Fentanyl? Arguments about net benefit of these examples aside, they do illustrate that these considerations are iterative and ongoing. A psychedelic therapy could be rolled out with due diligence and in good faith, but some outcomes will never be apparent until it is deployed in a larger population.
Fairness
Application of concepts around fairness can sometimes be complex and controversial as ideas around justice are often influenced by political ideals. Even so, effort should be made to determine what the relevant moral similarities are in situations, even where surface differences seem incommensurate.
All psychedelic businesses should, in general, give proper credit to all individuals and groups whose work and life experience contribute to where they are now. A requisite for this is simply being aware of who meets this criteria. While failing to acknowledge formal scientific contributions is problematic, a more common omission is to gloss over the role that psychedelic users and underground amateur researchers have played in getting us to where we are today. While there is some disagreement on whether or not non-medical use has advanced or held back progress, it is plausible to suggest that much of what we know around areas such as set and setting, and microdosing, has come from the community. Nor would research that bolsters the evidence for psychedelics’ pro-social effects and excellent safety profiles be as strong without large numbers of people who have been willing to risk the legal consequences of their actions. Failure to acknowledge these facts would almost certainly lead to reduced community goodwill, but also to psychological hubris; do not mistake standing on the shoulders of giants for being one.
Other issues around fairness may connect to patient access. If two people have the same symptoms and level of need, to what extent is their difference in disposable income morally relevant? While offering psychedelic therapy as a for-profit endeavour necessarily means charging a fee for treatment, this should not prohibit taking steps to ensure that cases of similar urgency are treated, regardless of patient finances. What exactly these steps could be will vary according to the intersection of political contexts and healthcare systems that a psychedelic therapy business operates under. In some countries it may be appropriate to take steps to ensure coverage by private insurers or universal healthcare systems. Strategies such as sliding scales of fees according to income, or compassionate access schemes for urgent cases in low-income individuals or vulnerable groups could potentially be deployed across most jurisdictions. Again, undertaking these actions can do double-duty: important ethical obligations are met and goodwill is generated. Remember, the opposite is also true; failure to respect this principle entails both an ethical failure and a risk that the commercial operation is seen as elitist and overly focused on profit.
Accessibility
If the efficacy and safety of psychedelic therapies is proven, it would seem that, as already discussed, there is an obligation to minimise cost and maximise access, especially for people with urgent and serious need. That a people suffering from the worst illnesses should be considered as vulnerable potential users of the technology of psychedelic therapy should be fairly obvious.
But perhaps there are other senses in which people are vulnerable. This principle is about designing with the most likely actual client/patient in mind, as opposed to the theoretically ideal client or patient. Ideally, psychedelic-assisted therapy would be going to the people who actually need it most. But in reality, perhaps many patients, at least initially, will be those who feel they need the treatment, but would experience more limited benefit. What would a provider’s obligation to these people be? Should they take their money and provide a treatment regardless? One mitigating approach would be to emphasise the educational aspect as part of pre-screening and preparation. A potential client may well hope that their life will be transformed, but providers should ensure that they have a realistic expectation based on both overall research outcomes and the client’s personal circumstances. This protects patients, but also providers, as unmet expectations are a quick route to bad reviews or even litigation.
Similar mitigating factors should be considered in microdosing contexts too. The ideal client will have no potentially complicating psychological problems, but in reality many will. The ideal client will pay close attention to recommendations around dose, dosing regimes, mindful reflection on effects. They will source their psychedelics safely and/or test them appropriately. And they will not get into legal difficulties in jurisdictions where psychedelics are still illegal. Non-ideal clients of a microdosing business, on the other hand, may well be psychologically unsuited to psychedelic use, and do nothing that is recommended. They might even get into legal difficulties. This does not cover all eventualities, but does illustrate how important it is for messages around safety to be at the core of microdosing coaching and education. It also hints (again) that such businesses have an obligation to assist with law-reform efforts. Supporting legalisation should be obvious for those who provide microdosing-related services as it meets ethical obligations and enhances profit potential.
Purpose
Psychedelic businesses should avoid therapeutic and pharmaceutical design decisions that are intended to maximise profit by gaming systems around patents or illegality. Creating an isomer or formulation that is pharmacologically similar to an existing psychedelic compound, for the sole purpose of creating a more expensive treatment, or to avoid engaging in law-reform efforts is understandable. But ultimately, such actions convey the message that the company is unwilling to take responsibility for its broader actions and is not serious about reciprocating support from the psychedelic community.
Psychedelic therapy providers should strive to align their marketing with the best available evidence on patient outcomes. While this is less likely to be an issue for psychedelic-assisted therapy in a mainstream regulated context, this depends heavily on specifics around advertising that vary by jurisdiction. Companies that do not directly provide an activity but profit from people undertaking it, e.g.: psychedelic integration services or microdosing education & coaching, should be similarly cautious in their claims.
Conclusion
Some potential ethical issues only arise in relation to one principle, but others seem to touch on multiple areas. This can indicate heightened risk, relative seriousness of the potential ethical failure and existence of a profound moral hazard. For example, deliberate manipulation of treatments to make them less efficacious, especially for the sake of profit, would contravene every principle considered above. In this specific case, the risk to the entire sector could not be overstated and would absolutely deserve both moral condemnation and legal action in order to prevent the practice becoming widespread.
While arguably less serious, failing to consider and take responsibility for the possible flow-on effects that psychedelic therapies could have on broader community attitudes to psychedelic use is not just a failure of responsibility. Such a breach would disrespect self-determination and neglect giving suitable weight to principles of net benefit, fairness and accessibility. Even though the remedy might not be the same as for manipulation of therapeutic outcomes, some action will still be required. It is inevitable that the advent of therapeutic psychedelics will increase awareness of and interest in off-label or non-therapeutic uses. Taking responsibility for this and acting to safeguard the interests of people involved is going to mean supporting both honest education and drug law reform.
Nonetheless, the analysis above does show that the business of psychedelic therapy has the potential to be ethical. If businesses, researchers and therapy providers treat all people, including patients, as having inherent value, respect them enough to value their freedom while acknowledging their diversity and vulnerability, keep an eye on the greater good and the broader effects that ripple out from their actions and approach these issues with honesty and in good faith, then perhaps the “psychedelic renaissance” and revolution will live up to the hype. Though it is limited in scope, I am optimistic that this analysis can help highlight potential problems before they happen, and contribute to a future where psychedelic businesses are world leaders in ethical behaviour.
A version of this work was first published on my now-idle Patreon page.
