In the present paper, we discuss the ethics of compassionate psychedelic psychotherapy and argue that it can be morally permissible. When talking about psychedelics, we mean specifically two substances: psilocybin and MDMA. When administered under supportive conditions and in conjunction with psychotherapy, therapies assisted by these substances show promising results. However, given the publicly controversial nature of psychedelics, compassionate psychedelic psychotherapy calls for ethical justification. We thus review the safety and efficacy of psilocybin- and MDMA-assisted therapies and claim that it can be rational for some patients to try psychedelic therapy. We think it can be rational despite the uncertainty of outcomes associated with compassionate use as an unproven treatment regime, as the expected value of psychedelic psychotherapy can be assessed and can outweigh the expected value of routine care, palliative care, or no care at all. Furthermore, we respond to the objection that psychedelic psychotherapy is morally impermissible because it is epistemically harmful. We argue that given the current level of understanding of psychedelics, this objection is unsubstantiated for a number of reasons, but mainly because there is no experimental evidence to suggest that epistemic harm actually takes place.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
In this paper, we will use “compassionate use” and “unproven treatment”, as well as “compassionate” and “unproven” interchangeably.
By “physicalism” we mean the view that everything is physical. “Naturalism” is a notoriously ambiguous term, but at minimum, it refers to the view that supernatural entities like gods, spirits, and magical spells do not exist.
We thank an anonymous reviewer of this journal for their clarifying remarks on this point.
Abrahart, D. 1998. A Critical Review of Theories and Research Concerning Lysergic Acid Diethylamide (LSD) and Mental Health [Unpublished master's thesis]. University of Portsmouth. Accessed 28 November 2019, from https://maps.org/research-archive/html_bak/abrahart.html.
Agrawal, M., C. Grady, D.L. Fairclough, N.J. Meropol, K. Maynard, and E.J. Emanuel. 2006. Patients’ Decision-Making Process Regarding Participation in Phase I Oncology Research. Journal of Clinical Oncology 24 (27): 4479–4484. https://doi.org/10.1200/JCO.2006.06.0269.
Borysowski, J., H. Ehni, and A. Górski. 2017. Ethics Review in Compassionate Use. BMC Medicine. https://doi.org/10.1186/s12916-017-0910-9.
Borysowski, J., and A. Górski. 2019. Compassionate Use of Unauthorized Drugs: Legal Regulations and Ethical Challenges. European Journal of Internal Medicine 65: 12–16. https://doi.org/10.1016/j.ejim.2019.04.008.
Bouso, J.C., R.G. dos Santos, M.Á. Alcázar-Córcoles, and J.E.C. Hallak. 2018. Serotonergic Psychedelics and Personality: A Systematic Review of Contemporary Research. Neuroscience & Biobehavioral Reviews 87: 118–132. https://doi.org/10.1016/j.neubiorev.2018.02.004.
Byock, I. 2018. Taking Psychedelics Seriously. Journal of Palliative Medicine 21 (4): 417–421. https://doi.org/10.1089/jpm.2017.0684.
Carhart-Harris, R.L., M. Bolstridge, J. Ruckner, C.M.J. Day, D. Erritzoe, M. Kaelen, M. Bloomfield, J.A. Rickard, B. Forbes, A. Feilding, D. Taylor, S. Pilling, V.H. Curran, and D. Nutt. 2016a. Psilocybin with Psychological Support for Treatment-Resistant Depression: An Open-Label Feasibility Study. Lancet Psychiatry 3 (7): 619–627. https://doi.org/10.1016/S2215-0366(16)30065-7.
Carhart-Harris, R.L., S. Muthukumaraswamy, L. Roseman, M. Kaelen, W. Droog, K. Murphy, E. Tagliazucchi, E.E. Schenberg, T. Nest, C. Orban, R. Leech, L.T. Williams, T.M. Williams, M. Bolstridge, B. Sessa, J. McGonigle, M.I. Sereno, D. Nichols, P.J. Hellyer, P. Hobden, J. Evans, K.D. Singh, R.G. Wise, H.V. Curran, A. Feilding, and D.J. Nutt. 2016b. Neural Correlates of the LSD Experience Revealed by Multimodal Neuroimaging. Proceedings of the National Academy of Sciences 113 (117): 4853–4858. https://doi.org/10.1073/pnas.1518377113.
Carhart-Harris, R.L., and G.M. Goodwin. 2017. The Therapeutic Potential of Psychedelic Drugs: Past, Present, and Future. Neuropsychopharmacology 42 (11): 2105–2113. https://doi.org/10.1038/npp.2017.84.
Cohen, S. 1960. Lysergic Acid Diethylamide: Side-Effects and Complications. Journal of Nervous and Mental Disease 130 (1): 33–40. https://doi.org/10.1097/00005053-196001000-00005.
COMPASS. 2018. COMPASS Pathways Receives FDA Breakthrough Therapy Designation for Psilocybin Therapy for Treatment-Resistant Depression [Blog Post]. October 23 Accessed 28 November 2019, from https://compasspathways.com/compass-pathways-receives-fda-breakthrough-therapy-designation-for-psilocybin-therapy-for-treatment-resistant-depression/.
Darrow, J.J., A. Sarpatwari, J. Avorn, and A.S. Kesselheim. 2015. Practical, Legal, and Ethical Issues in Expanded Access to Investigational Drugs. New England Journal of Medicine 372: 279–286. https://doi.org/10.1056/NEJMhle1409465.
DiMasi, J.A. 2001. Risks in New Drug Development: Approval Success Rates for Investigational Drugs. Clinical Pharmacology and Therapeutics 69 (5): 297–307. https://doi.org/10.1067/mcp.2001.115446.
DiMasi, J.A., H.G. Grabowski, and R.W. Hansen. 2016. Innovation in the Pharmaceutical Industry: New Estimates of R&D Costs. Journal of Health Economics 47: 20–33. https://doi.org/10.1016/j.jhealeco.2016.01.012.
Doblin, R., and M. Mithoefer. 2015. Study Protocol, a Randomized, Double-Blind, Placebo-Controlled Phase 2 Pilot Study of MDMA-Assisted Psychotherapy for Anxiety Associated with a Life-Threatening Illness [Protocol MDA-1IND #63,384]. Accessed 28 November 2019, from https://maps.org/research-archive/mdma/MDA-1_FINAL_Protocol_Amend%201_29Apr15_web.pdf.
Edwards, S.J.L. 2006. Restricted Treatments, Inducements, and Research Participation. Bioethics 20 (2): 77–91. https://doi.org/10.1111/j.1467-8519.2006.00479.x.
Erritzoe, D., L. Roseman, M. M. Nour, K. MacLean, M. Kaelen, D. J. Nutt, and R. L. Carhart-Harris. 2018. Effects of Psilocybin Therapy on Personality Structure. Acta Psychiatrica Scandinavica 138 (5): 368–378. https://doi.org/10.1111/acps.12904.
Flanagan, O., and G. Graham. 2017. Truth and Sanity: Positive Illusions, Spiritual Delusions, and Metaphysical Hallucinations. In Extraordinary science and psychiatry: Responses to the crisis in mental health research, ed. J. Poland and S. Temkin, 293–313. Cambridge: MIT Press.
Garcia-Romeu, A., R.R. Griffiths, and M.W. Johnson. 2014. Psilocybin-Occasioned Mystical Experiences in the Treatment of Tobacco Addiction. Current Drug Abuse Reviews 7 (3): 157–164. https://doi.org/10.2174/1874473708666150107121331.
Gasser, P., K. Kirchner, and T. Passie. 2014. LSD-Assisted Psychotherapy for Anxiety Associated with a Life-Threatening Disease: A Qualitative Study of Acute and Sustained Subjective Effects. Journal of Psychopharmacology 29 (1): 57–68. https://doi.org/10.1177/0269881114555249.
Greenfield, S., R. Kravitz, N. Duan, and S.H. Kaplan. 2007. Heterogeneity of Treatment Effects: Implications for Guidelines, Payment, and Quality Assessment. The American Journal of Medicine 120 (4A): S3–S9. https://doi.org/10.1016/j.amjmed.2007.02.002.
Griffiths, R.R., W.A. Richards, U. McCann, and R. Jesse. 2006. Psilocybin Can Occasion Mystical-Type Experiences Having Substantial and Sustained Personal Meaning and Spiritual Significance. Psychopharmacology (Berl) 187 (3): 268–283. https://doi.org/10.1007/s00213-006-0457-5.
Griffiths, R.R., M.W. Johnson, M.A. Carducci, A. Umbricht, W.A. Richards, B.D. Richards, M.P. Cosimano, and M.A. Klinedinst. 2016. Psilocybin Produces Substantial and Sustained Decreases in Depression and Anxiety in Patients with Life-Threatening Cancer: A Randomized Double-Blind Trial. Journal of Psychopharmacology 30 (12): 1181–1197. https://doi.org/10.1177/0269881116675513.
Griffiths, R.R., M.W. Johnson, W.A. Richards, B.D. Richards, R. Jesse, K.A. MacLean, F.S. Barrett, M.P. Cosimano, and M.A. Klinedinst. 2018. Psilocybin-Occasioned Mystical-Type Experience in Combination with Meditation and other Spiritual Practices Produces Enduring Positive Changes in Psychological Functioning and in Trait Measures of Prosocial Attitudes and Behaviors. Journal of Psychopharmacology 32 (1): 49–69. https://doi.org/10.1177/0269881117731279.
Griffiths, R. R., E. S. Hurwitz, A. K. Davis, M. W. Johnson, and R. Jesse. 2019. Survey of Subjective “God Encounter Experiences”: Comparisons among Naturally Occurring Experiences and those Occasioned by the Classic Psychedelics Psilocybin, LSD, Ayahuasca, or DMT. PLoS ONE. https://doi.org/10.1371/journal.pone.0214377.
Grob, C.S., A.L. Danforth, A.L. Chopra, A.M. Hagerty, C.R. McKay, A.L. Halberstadt, and andG. G. Greer. 2011. Pilot Study of Psilocybin Treatment for Anxiety in Patients with Advanced-Stage Cancer. Archives of General Psychiatry 68 (1): 71–78. https://doi.org/10.1001/archgenpsychiatry.2010.116.
Haijen, E. C. H. M., M. Kaelen, L. Roseman, C. Timmermann, H. Kettner, S. Russ, D. Nutt, R. E. Daws, A. D. G. Hampshire, R. Lorenz, and R. L. Carhart-Harris. 2018. Predicting Responses to Psychedelics: A Prospective Study. Frontiers in Pharmacology. https://doi.org/10.3389/fphar.2018.00897.
Hwang, T.J., D. Carpenter, J.C. Lauffenburger, B. Wang, J.M. Franklin, and A.S. Kesselheim. 2016. Failure of Investigational Drugs in Late-Stage Clinical Development and Publication of Trial Results. JAMA Internal Medicine 176 (12): 1826–1833. https://doi.org/10.1001/jamainternmed.2016.6008.
Johnson, M.W., W. Richards, and R.R. Griffiths. 2008. Human Hallucinogen Research: Guidelines for Safety. Journal of Psychopharmacology 22 (6): 603–620. https://doi.org/10.1177/0269881108093587.
Johnson, M.W., and R.R. Griffiths. 2017. Potential Therapeutic Effects of Psilocybin. Neurotherapeutics 14 (3): 734–740. https://doi.org/10.1007/s13311-017-0542-y.
Johnson, M.W., P.S. Hendricks, F.S. Barrett, and R.R. Griffiths. 2019. Classic Psychedelics: An Integrative Review of Epidemiology, Therapeutics, Mystical Experience, and Brain Network Function. Pharmacology & Therapeutics 197: 83–102. https://doi.org/10.1016/j.pharmthera.2018.11.010.
Jerome, L. 2007. Psilocybin: Investigator's Brochure [Unpublished]. Retrieved November 28, 2019 from https://maps.org/research-archive/psilo/psilo_ib.pdf.
Jesse, R. 2001. On Nomenclature for the Class of Mescaline-Like Substances and Why It Matters. In Psychoactive sacramentals, essays on entheogens and religion, ed. T. B. Robert, 225–231. San Francisco: Council on Spiritual Practices. Accessed 28 November 2019, from https://csp.org/docs/on-nomenclature.
Kaelen, M., B. Garibaldi, J. Raine, L. Evans, C. Timmermann, N. Rodriguez, L. Roseman, A. Feilding, D. Nutt, and R. Carhart-Harris. 2018. The Hidden Therapist: Evidence for a Central Role of Music in Psychedelic Therapy. Psychopharmacology (Berl) 235 (2): 505–519. https://doi.org/10.1007/s00213-017-4820-5.
Lebedev, A.V., M. Lovden, G. Rosenthal, A. Feilding, D.J. Nutt, and R.L. Carhart-Harris. 2015. Finding the Self by Losing the Self: Neural Correlates of Ego-Dissolution under Psilocybin. Human Brain Mapping 36 (8): 3137–3153. https://doi.org/10.1002/hbm.22833.
Letheby, C. 2015. The Philosophy of Psychedelic Transformation. Journal of Consciousness Studies 22 (9–10): 170–193.
Letheby, C. 2016. The Epistemic Innocence of Psychedelic States. Consciousness and Cognition 39: 28–37. https://doi.org/10.1016/j.concog.2015.11.012.
Letheby, C. 2017. Naturalizing Psychedelic Spirituality. Zygon 52 (3): 623–642. https://doi.org/10.1111/zygo.12353.
Lovering, R. 2015. A Moral Defense of Recreational Drug Use. New York: Palgrave Macmillan. https://doi.org/10.1057/9781137528681
Lyvers, M., and M.M. Honours. 2012. Illicit Use of LSD or Psilocybin, but not MDMA or Nonpsychedelic Drugs, is Associated with Mystical Experiences in a Dose-Dependent Manner. Journal of Psychoactive Drugs 44 (5): 410–417. https://doi.org/10.1080/02791072.2012.736842.
Lyons, T., and R.L. Carhart-Harris. 2018. Increased nature relatedness and decreased authoritarian political views after psilocybin for treatment-resistant depression. Journal of Psychopharmacology 32 (7): 811–819. https://doi.org/10.1177/0269881117748902.
MacLean, K., M.W. Johnson, and R.R. Griffiths. 2011. Mystical Experiences Occasioned by the Hallucinogen Psilocybin Lead to Increases in the Personality Domain of Openness. J Psychopharmacol 25 (11): 1453–1461. https://doi.org/10.1177/0269881111420188.
Malleson, N. 1971. Acute Adverse Reactions to LSD in Clinical and Experimental Use in the United Kingdom. British Journal of Psychiatry 118 (543): 229–230. https://doi.org/10.1192/bjp.118.543.229.
Matefy, R., and R. Krall. 1974. An Initial Investigation of the Psychedelic Drug Flashback Phenomena. Journal of Consulting and Clinical Psychology 42 (6): 854–860. https://doi.org/10.1037/h0037523.
Matefy, R., and R. Krall. 1975. Psychedelic Drug Flashbacks: Psychotic Manifestations or Imaginative Role Playing? Journal of Consulting and Clinical Psychology 43 (3): 434. https://doi.org/10.1037/h0076876.
Metzner, R. 2005. Sacred Mushroom of Visions: Teonanácatl: A Sourcebook on thePsilocybin Mushroom. Rochester: Park Street Press.
Mithoefer, C.M., C.S. Grob, and T.D. Brewerton. 2016. Novel Psychopharmacological Therapies for Psychiatric Disorders: Psilocybin and MDMA. Lancet Psychiatry 3 (5): 481–488. https://doi.org/10.1016/S2215-0366(15)00576-3.
Mithoefer, C.M., S. Feduccia, L. Jerome, and A. Mithoefer. 2019. MDMA-AssistedPsychotherapy for Treatment of PTSD: Study Design and Rationale for Phase 3 Trials Based on Pooled Analysis of Six Phase 2 Randomized Controlled Trials. Psychopharmacology (Berlin) 236 (9): 2735–2745. https://doi.org/10.1007/s00213-019-05249-5.
Multidisciplinary Association for Psychedelic Studies. 2017. Press Release: FDA Grants Breakthrough Therapy Designation for MDMA-Assisted Psychotherapy for PTSD, Agrees on Special Protocol Assessment for Phase 3 Trials [Blog Post]. August 26. Accessed 28 November 2019, from https://maps.org/news/media/6786-press-release-fda-grants-breakthrough-therapy-designation-for-mdma-assisted-psychotherapy-for-ptsd,-agrees-on-special-protocol-assessment-for-phase-3-trials.
Multidisciplinary Association for Psychedelic Studies. 2019. Statement: Public Announcement of Ethical Violation by Former Maps-Sponsored Investigators [Blog Post]. Accessed 25 November 2019, from https://maps.org/news/posts/7749-statement-public-announcement-of-ethica-violation-by-former-maps-sponsored-investigators.
Multidisciplinary Association for Psychedelic Studies. 2020. FDA Agrees to Expanded Access Program for MDMA-Assisted Psychotherapy for PTSD [Press Release]. Accessed 21 April 2020, from https://maps.org/news/media/8008-press-release-fda-agrees-to-expanded-access-program-for-mdma-assisted-psychotherapy-for-ptsd.
Nichols, D.E. 2016. Psychedelics. Pharmacological Reviews 68: 264–355. https://doi.org/10.1124/pr.115.011478.
Nour, M.M., L. Evans, and R.L. Carhart-Harris. 2017. Psychedelics, Personality and Political Perspectives. Journal of Psychoactive Drugs 49 (3): 182–191. https://doi.org/10.1080/02791072.2017.1312643.
Pace, J., N. Ghinea, I. Kerridge, and W. Lipworth. 2018. An Ethical Framework for the Creation, Governance and Evaluation of Accelerated Access Programs. Health Policy 122 (9): 984–990. https://doi.org/10.1016/j.healthpol.2018.07.014.
Passie, T. 1997. Psycholytic and Psychedelic Therapy 1931–1995: A Complete International Bibliography. Hannover: Laurentius Publishers.
Passie T., and P. Gasser 2016. Erfahrungen von Lebensbedrohlich Erkrankten in einer LSD-Unterstützten Psychotherapie. Existenzanalyse 33 (2): 79–86. Retrieved Accessed 18 November 2019, from https://www.existenzanalyse.net/wp-content/uploads/EA_2016_02.pdf.
Passie, T., J. Seifert, U. Schneider, and H. Emrich. 2002. The Pharmacology of Psilocybin. Addiction Biology 7 (4): 357–364. https://doi.org/10.1080/1355621021000005937.
Pollan, M. 2015. The Trip Treatment. The New Yorker, February 9. Accessed 18 November 2019, from https://www.newyorker.com/magazine/2015/02/09/trip-treatment.
Raus, K. 2016. An Analysis of Common Ethical Justifications for Compassionate Use Programs for Experimental Drugs. BMC Medical Ethics 17 (60). https://doi.org/10.1186/s12910-016-0145-x.
Roberts, B.W., J. Luo, D.A. Briley, P.I. Chow, R. Su, and P.L. Hill. 2017. A Systematic Review of Personality Trait Change Through Intervention. Psychological Bulletin 143 (2): 117–141. https://doi.org/10.1037/bul0000088.
Roseman, L., D. Nutt, and R. Carhart-Harris. 2018. Quality of Acute Psychedelic Experience Predicts Therapeutic Efficacy of Psilocybin for Treatment-Resistant Depression. Frontiers in Pharmacology. https://doi.org/10.3389/fphar.2017.00974.
Ross, S., A. Bossis, J. Guss, G. Agin-Liebes, T. Malone, B. Cohen, S.E. Mennenga, A. Belser, K. Kalliontzi, J. Babb, Z. Su, P. Corby, and B.L. Schmidt. 2016. Rapid and Sustained Symptom Reduction Following Psilocybin Treatment for Anxiety and Depression in Patients with Life-Threatening Cancer: A Randomized Controlled Trial. Journal of Psychopharmacology 30 (12): 1165–1180. https://doi.org/10.1177/0269881116675512.
Rubin, R. 2015. Experts Critical of America’s Right-To-Try Drug Laws. The Lancet 383 (10001): 1325–1326. https://doi.org/10.1016/S0140-6736(15)00393-1.
Samorini, G. 2019. The Oldest Archeological Data Evidencing The Relationship of Homo Sapiens with Psychoactive Plants: A Worldwide Overview. Journal of Psychedelic Studies 3 (2): 63–80. https://doi.org/10.1556/2054.2019.008.
Scheidegger, M. 2018. Bewusstseinserweiternde Substanzen als neue Möglichkeiten der Therapie. InFo Neurologie & Psychiatrie 16 (1): 28–30.
Sessa, B. 2017a. Why Psychiatry Needs 3,4-Methylenedioxymethamphetamine: A Child Psychiatrist’s Perspective. Neurotherapeutics 14 (3): 741–749. https://doi.org/10.1007/s13311-017-0531-1.
Sessa, B. 2017b. Why MDMA Therapy for Alcohol Use Disorder? And Why Now? Neuropharmacology 142: 83–88. https://doi.org/10.1016/j.neuropharm.2017.11.004.
Sessa, B., L. Higbed, and D. Nutt. 2019. A Review of 3,4-methylenedioxymethamphetamine (MDMA)-Assisted Psychotherapy. Frontiers in Psychiatry. https://doi.org/10.3389/fpsyt.2019.00138.
Simianu, V. V., M. A. Grounds, S. L. Joslyn, J. E. LeClerc, A. P. Ehlers, N. Agrawal, R. Alfonso-Cristancho, A. D. Flaxman, and D. R. Flum. 2016. Understanding Clinical and Non-Clinical Decisions Under Uncertainty: A Scenarion-Based Survey. BMC Medical Informatics and Decision Making. https://doi.org/10.1186/s12911-016-0391-3
Sisti, D. 2018. Creating an Ethical Framework for Psychedelic Therapy Research. MAPS Bulletin 28 (3): 34–35. Accessed 28 November 2019, from https://maps.org/news/bulletin/articles/435-maps-bulletin-winter-2018-vol-28-no-3/7505-maps-bulletin-winter-2018-vol-28,-no-3.
Smith, P. 2008. Moral and Political Philosophy: Key Issues, Concepts, and Theories. New York: Palgrave Macmillan. https://doi.org/10.1007/978-0-230-59394-7
Walker, M.J., W.A. Rogers, and V. Entwistle. 2014. Ethical Justifications for Access to Unapproved Medical Interventions: An Argument for (Limited) Patient Obligations. The American Journal of Bioethics 14 (11): 3–15. https://doi.org/10.1080/15265161.2014.957416.
West, A.F., and R.R. West. 2002. Clinical Decision-Making: Coping with Uncertainty. Postgraduate Medical Journal 78: 319–321. https://doi.org/10.1136/pmj.78.920.319.
World Health Organization. 2018. International Classification of Diseases for Mortality and Morbidity Statistics (11th Revision). Accessed 28 November 2019, from https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/932028588.
World Medical Association. 2013. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA 310 (20): 2191–2194. https://doi.org/10.1001/jama.2013.281053.
Yazar-Klosinski, B., and M. Mithoefer. 2017. Potential Psychiatric Uses for MDMA. Clinical Pharmacology and Therapeutics 101 (2): 194–196. https://doi.org/10.1002/cpt.565.
This work was supported by the Slovak Research and Development Agency under the Contract no. APVV-18-0178.
Conflict of interest
The authors declare that they have no conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Greif, A., Šurkala, M. Compassionate use of psychedelics. Med Health Care and Philos 23, 485–496 (2020). https://doi.org/10.1007/s11019-020-09958-z
- Compassionate use
- Epistemic harm