Navigating New Terrain: Clinician Education at the Crossroads of Psychedelics and Medical Ethics

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COMMENTARY

The resurgence of psychedelics in public discourse and their therapeutic potential for a wide range of mental health conditions has sparked renewed interest among various populations.¹ This revival, accompanied by legislative movements towards decriminalization and the establishment of regulated programs for substances like psilocybin, highlights the increasing accessibility of these substances beyond traditional medical settings.² The societal and legal shifts towards acceptance of psychedelics require health care providers, especially psychiatrists, to integrate these changes with the steadfast principles of medical ethics.

Psychiatrists, who are more likely to encounter patients who are interested in or already using psychedelics,² may be involved in the prescribing of these substances if they gain regulatory approval.³ To responsibly navigate the ethical landscape presented by this novel form of treatment, psychiatrists must be well-informed about these substances. Though this discussion is rooted in the physician's oath and ethical medical practice, we must also acknowledge the significant roles of various practitioners in psychedelic medicine, such as therapists, facilitators, spiritual providers, and other types of practitioners. These roles are crucial and should be deeply respected.

However, the core focus of this article concerns the unique challenges confronting psychiatrists, who must adeptly maneuver between their foundational commitment to traditional medical ethics and the evolving perspectives on the therapeutic applications of psychedelics for certain patient groups. For clarity in this discussion, it is important to note that ketamine and MDMA are not classic psychedelics. However, they have been subsumed into the broader discussion around psychedelics due to their therapeutic potentials and mechanisms that are distinct yet relevant to psychedelic therapy. Therefore, this article uses the term "psychedelics" in an inclusive manner, incorporating discussions on ketamine, MDMA, and classic psychedelics such as psilocybin, to address their roles comprehensively in therapeutic contexts. Exploring the cardinal principles of medical ethics—autonomy, beneficence, nonmaleficence, and justice—can expand the discourse surrounding psychedelic treatment and provide a more nuanced understanding of the ethical considerations involved.

The Doctor-Patient Relationship and Trust

Clinicians have the privilege of being patient-facing, and therefore, can provide evidence-based education to their patients about psychedelics. Without guidance, patients may risk harm from medical or adverse interactions, and/or exploitation by others if the patient is in an unsafe setting when using them. Psychedelics are still federally illegal and considered Schedule I substances, despite the US Food and Drug Administration (FDA) breakthrough designation for certain ones (MDMA, psilocybin),⁴ mounting evidence of their efficacy, and decriminalization and legalization efforts.⁵ The federal penalties for a first-time offense include imprisonment for up to 1 year and a minimum fine of $1000.⁶ Penalties also vary in severity depending on the state. This can make some providers wary of discussing psychedelics with patients; however, open dialogues on risks and benefits are critical for patient safety.

When it comes to engaging patients in a clinical discussion about psychedelics, previous studies have advocated for the harm reduction approach, which has long been established as an ethical and legal means for working with individuals who use substances.⁷ Patients who seek professional guidance in relation to psychedelics often have little experience or knowledge with these substances and are unsure whether psychedelic use is a good idea for them. With a harm reduction approach, the psychiatrist maintains a neutral stance on the use of psychedelics, prioritizing instead the patient’s objectives and well-being.

Research

There is a paucity of data on psychiatrists’ awareness and attitudes towards psychedelics, but there exists a handful of studies from the patient perspective. Two recent studies underscore the need for providers to improve their knowledge base on psychedelics. One survey of 1221 individuals using psychedelics in nonclinical settings found less than 5% viewed medical providers as an information source, preferring personal experimentation, internet resources, and scientific literature.⁸ Another study found that 20% of participants discussed psychedelic use with primary care providers (PCPs). In contrast, among the participants who had psychiatric providers, 60% discussed their psychedelic use. Stigma was the most cited reason for nondisclosure (59%), followed by inadequate provider knowledge (49%), and privacy (40%). Notably, 23% reported taking their psychiatric medications on the same day they took psychedelics—including antidepressants, stimulants, and anxiolytics.⁹ It is vital to acknowledge that the participant demographics in both studies were not fully representative of the general population. Considering the underrepresentation of minorities in clinical research,¹⁰ the observed disparities could be even more significant.

These 2 studies underscore multiple concerns, emphasizing the necessity for improved education among psychiatrists regarding these emerging treatments. The small percentage of individuals citing medical providers as an information source, alongside the reported concurrent use of psychedelics and psychiatric medications, highlights a significant informational gap and potential safety risks. Furthermore, they highlight a disparity in these discussions between primary care providers and psychiatrists, suggesting a difference in comfort level or knowledge regarding these compounds. The reasons for nondisclosure—chiefly stigma and inadequate provider knowledge—echo the overarching narrative of enhancing education to ensure patient safety and informed consent.

Ethical Dilemmas in Psychedelic Medicine Autonomy

Patient autonomy is a cornerstone of ethical medical practice, and it encompasses the right of patients to make informed decisions about their own health care. The rise of citizen science and self-experimentation¹¹ presents an ethical conundrum: how can health care providers respect a patient's autonomy while also ensuring their safety? In the evolving field of psychedelic medicine, the principle of autonomy grounds agency and informed consent. There is also the notion of legalizing psychedelics for personal use, citing the inherent autonomy to explore one’s consciousness and personal growth.¹² This autonomy must be balanced with accurate, evidence-based information to ensure patients are making well-informed decisions. Psychiatrists are uniquely positioned to bridge this gap. By fostering open dialogues, psychiatrists can provide the necessary knowledge about the potential risks, benefits, and the legal status of psychedelics, thereby empowering patients with the information needed to make informed choices.

Beneficence

The principles of beneficence and nonmaleficence further structure the ethical landscape. Beneficence directs health care providers to act in the best interest of the patient by promoting well-being and ensuring the benefits of treatment outweigh the risks. An example of beneficence in the context of psychedelic therapy would be a psychiatrist's role in facilitating access to these treatments in medically supervised settings, such as in clinical studies, ketamine clinics, or Spravato (a form of ketamine FDA approved for depression). If approved for medical use, this would involve not just recommending therapy, but also ensuring comprehensive follow-up care to maximize therapeutic benefits and address any emergent psychological issues. Another example would be a psychiatrist actively participating in or promoting research studies on psychedelics. By contributing to the scientific understanding of these substances, they can help develop safer and more effective treatment protocols. Furthermore, consider cases of patients with escalating suicidal ideation. Ketamine is included in this discussion precisely because it has not been FDA approved for depression, and continues to be used off-label. That makes it just as relevant to these broader ethical concerns.

Nonmaleficence

On the other hand, nonmaleficence emphasizes the obligation to prevent and not inflict harm. The principles of harm reduction are especially relevant to psychedelics. Patients should be educated about safe usage, potential drug interactions, and the importance of set and setting when considering use in a nonclinical context.² Psychiatrists can also conduct thorough medical and psychiatric screenings to identify possible contraindications if a patient expresses intent to try psychedelics. Such screenings could reduce the risk of harm to patients with a history of psychotic disorders, those with medical comorbidity (eg, preexisting cardiac disease), or those on medications that would increase the risk of adverse interactions with psychedelics.¹³ A relevant example here is the psychedelic ayahuasca. If taken in conjunction with a selective serotonin reuptake inhibitor, this could precipitate a serious medical emergency known as serotonin syndrome.¹³ Similarly, consider MDMA and its impending FDA approval.¹⁴ Increased awareness of this development may give patients a false sense of safety and embolden them to seek it through illicit sources. Given the widespread issue of counterfeit pills and the risk of contamination with fentanyl and other hazardous substances, such a course of action could pose serious dangers. It is crucial, therefore, to guide patients towards reliable sources of information, including support networks, hotlines, and testing kits as a key component of harm reduction strategies.

Providers must be aware of providing evidence-based education to promote safety without endorsing use of the substance. This includes education on the limitations and potential adverse effects of psychedelic therapies, including exacerbation of mood disturbance and/or psychosis.¹³ For instance, a doctor might discuss the risks of psychological distress and provide strategies to patients on how to manage these risks, such as controlled settings, professional supervision, and proper mental preparation. For example, if a patient discloses intent to try a psychedelic in a nonclinical setting, the practitioner may recommend having a trusted personal contact to ensure safety and avoid trauma. Or the provider may advise starting with lower doses, even if they cannot condone psychedelic use overall. Most importantly, the provider must remind patients to call 911 immediately for any acute safety concerns or 988 for any mental health concerns, and remind patients that doctors cannot report or reveal their substance use to legal authorities.

A challenging nuance of the beneficence/nonmaleficence principles include issues surrounding self-disclosure. Ethical issues surrounding self-disclosure have been discussed elsewhere at length.¹⁵ There are several special issues that arise regarding self-disclosure and psychedelics (Table). The idea that providers should have personal experience in psychedelics reflects a complex layer of patient expectations. There are no easy answers, only nuanced ethical analysis, which is beyond the scope of this paper.

Table. Special Issues Regarding Self-Disclosure and Psychedelics

Justice

The ethical principle of justice is one of the most fundamental aspects of patient care, and among other issues, it addresses fair distribution of resources. In the context of psychedelics, it is essential to consider the accessibility of psychedelic therapies to diverse populations, particularly those who have historically been marginalized and impacted by the War on Drugs.⁸ A case in point is the proactive effort to inform and refer underrepresented groups to clinical trials on psychedelics.¹¹ An ongoing concern is that research studies predominantly involve participants from homogeneous demographics.¹¹ By advocating for and implementing inclusive research practices, providers and investigators can help advance psychedelic science that is applicable to a broader, more diverse patient population.

A focus on justice might also involve psychiatrists and health care institutions collaborating with community leaders and advocacy groups to create educational programs about psychedelic medicine. In this context, education is advocacy. Such collaborations, especially when tailored to address the specific concerns and contexts of various communities, can help demystify psychedelics and reduce stigma, paving the way for more equitable access to these innovative treatments. Consider also the broader consequences of inadequate patient education. This shortfall could restrict treatment access for eligible individuals or heighten the risk of patients turning to unauthorized sources for psychedelic therapies.

Self-Check

Part of medical ethics requires that physicians consider their own attitudes and bias about psychedelics. Consider the following questions to examine your attitudes, biases, and practices:

1. Knowledge and Education: How deep is your understanding of psychedelic medicine? Reflect on whether your knowledge is based on scientific evidence or influenced by popular media and societal opinions.
2. Personal Beliefs and Attitudes: How do your personal beliefs about psychedelics influence your clinical practice? Are you able to separate your personal opinions from professional advice when discussing psychedelics with patients?
3. Patient Selection: Do you find yourself discussing psychedelic therapies with certain types of patients compared to others? If so, what are the criteria influencing this selective communication? Consider whether subconscious biases are at play.
4. Cultural Competence: Are you considering the cultural and social backgrounds of your patients when discussing psychedelics? Do you understand the history and impact of the War of Drugs on marginalized communities?
5. Risk Communication: How do you balance the conversation between the potential benefits and risks of psychedelic therapy?
6. Regulatory/Legal: are familiar with the laws around possession/use in your state or locality?
7. Interdisciplinary Collaboration: How you engage with other health care professionals in discussions about psychedelics? Are you open to interdisciplinary insights?

Concluding Thoughts

Psychiatry’s future requires embracing opportunities presented by psychedelic therapies while upholding core values. These are urgent times, and the role of psychiatrists’ guidance in honoring and informing patient autonomy is critical as psychedelics reemerge in the popular and medical consciousness. The ethical quandaries presented by psychedelic medicine are nuanced and necessitate careful deliberation to achieve comprehensive and pragmatic solutions to ensure equal access to the transformative potential of psychedelic treatment. Empowering patients with comprehensive knowledge supports informed, ethical, and patient centered care. This psychedelic reemergence has transitioned psychedelics from the periphery to the forefront of medical discourse.

Health care providers have the power to inform policymakers about the risks and benefits of introducing psychedelics in the medical ecosystem. Evidence-based informed consent, psychiatrists can honor their patients’ choices while establishing a framework of safety and ethical integrity. By acknowledging and addressing these ethical concerns, this article highlights the crucial role of psychiatrists’ education in navigating the multifaceted realm of psychedelic medicine, ensuring not only the safety and well-being of patients but also the just and ethical deployment of these potent medicines into contemporary health care.

What ethical quandaries do you face in the field of mental health? Tell us about it at PTEditor@MMHGroup.com!

Dr Carrington is a psychiatrist, psychotherapist, and psychopharmacologist.

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