5 Questions for Joseph Holcomb Adams

Joseph Holcomb Adams didn’t set out to become a bioethicist. At first, he applied to PhD programs in the philosophy of biology – but luckily, he says, he didn't get in. Instead, NYU suggested he might be a good fit for the bioethics masters program, and from there, he began to explore issues in psychedelics. His work focused on informed consent, and culminated in a thesis exploring the intimate connections people make with one another while using MDMA. He then turned that into a piece with actionable advice, which was published in DoubleBlind under the title “Should You Say ‘I Love You’ While On MDMA?” 

Now, Adams has been appointed to the City of Berkeley Community Health Commission, and has focused on protecting the rights of participants engaging in psychedelic-assisted therapy. The Microdose spoke with Adams about obtaining informed consent and other ethical responsibilities practitioners have to their patients. 

What are bioethics, and why might bioethics matter to the psychedelics world?

Bioethics is basically applied ethics in the domains of medicine, public health, and other areas of research that use human and animal subjects. It also includes environmental ethics, which is applied ethics to questions that involve living beings. It's so important for psychedelics — especially in this time of the “psychedelics renaissance” — because these drugs are tools that we can use to influence our minds and brains. Other cultures have been using them for centuries, but here in our culture, in this society, we don't have the background and framework to navigate our use of these tools yet.

There's a lot of interest out there in bringing these tools into widespread use, all this enthusiasm. But there are so many complex ethical questions about how we can use these tools while still respecting human rights, while rolling them out in ways that are equitable and safe. We need to recognize the power and the mystery of these drugs, and how much we do not know about them yet. There are so many under-researched risks and adverse effects, and they're getting left out of the conversation. We have a moral obligation to really understand these tools in order to use them ethically. We can't just rush out the gate with them without being very careful.

Practitioners and guides have been discussing the ethics of consent in psychedelic therapy. From a bioethics perspective, is giving consent for psychedelic therapy possible, and what might inform best practices in the field?

There are a lot of different issues involved here. First off, how do you get someone to understand consent in this situation? How do you describe the experiences they might have and prepare them for that? The problem is that in many cases, we might not be able to. You can't actually get someone to understand what egoless consciousness is like, or what it’s like to feel the presence of an invisible being. It's very out there, and these unfamiliar and transcendental experiences might be beyond what we can explain. 

What we need to do is develop language for talking about that, and to establish that there are limits to what we can actually convey beforehand with regard to mystical experiences. It's also important to focus on informing patients about ways that transcendent experiences could affect them. I call it the process of inner transformation: maybe your sense of self could be permanently changed, or your worldview. People need to understand what they're signing up for.

In bioethics, capacity is a really important concept: if someone's unconscious — if they’re in a coma or develop dementia — then they are incapacitated. When a person is under the influence of the psychedelic, they are incapacitated. They do not have the capacity to make medical decisions, or give or withdraw consent. Someone else, like a family member, needs to make decisions for them. I think we should operate under the assumption that during the administration sessions, participants simply are incapable of changing consent. 

This presents a huge problem, since there will be situations where patients may want to change their minds or give feedback so that their guide or clinician can better serve their needs during the treatment. If somebody is feeling extremely violated or having some terrible experience, we need to have exit routes; we need to work out how participants can communicate changing needs or desires.

There has never been a more exciting – or bewildering – time in the world of psychedelics. Don’t miss a beat.

What I’m hearing from you is that a big part of consent is helping people understand the risks, and to convey them clearly. Are there other aspects of psychedelic therapy you think potential patients need to understand to fully consent?

There are very real dangers that get written off as urban legends or propaganda for the war against drugs. People are too quick to dismiss those — like, for example, there was the whole people going blind after staring at the sun while on LSD thing. [Editor’s note: See this 1973 journal article as an example.] But the thing is, I personally know someone who did that. He was a teenager, and he stared at the sun while on mushrooms and injured his eyes. He's fine now, but he had to have treatment. 

There are underreporting issues with these risks, and people see absence of evidence as evidence of absence. Prohibition clearly would be a factor that would affect the reporting of risks or deaths over the decades. One concern I have is the most well-known, well-established contraindications for side-effects with the classical psychedelics: a family history for psychotic disorders. In clinical research, they exclude individuals who have a family history of psychosis. In clinical trials and regulated spaces like Oregon’s psilocybin rollout, people should ask about contraindications and exclude people who have them. But I’m concerned that in the alternative and unregulated guided scenarios, they might not. People might even understand psychosis differently altogether — some might see it as some kind of spiritual ailment that you can cure through your practice of psychedelics. But I think that any guide or therapist is obligated to not give psychedelics to someone who has a history of psychosis, given what we know. 

Guides, practitioners, researchers — whoever is leading a session — hold a lot of power. What issues do you hope those leaders are considering in their work?  

When we get into more alternative kinds of psychedelic guidance practices and scenarios, informed consent is even even more important — it needs extra weight. I don’t want to sound like I’m fearmongering, but there are opportunities for more dangerous dynamics of control. There are a lot of potential traps with that dynamic — people become isolated in these spaces, and if a guide or guru-type figure is giving people drugs, those people can become suggestible and vulnerable.  

Participants frequently have experiences that touch on the big questions, and have religious, spiritual, or existential themes. These experiences are extremely personally significant to people. And yet everybody has their own culture and worldview they bring to the experience that shapes and interprets it. When you're in a guided scenario, you are within a container that is largely managed and established and co-created. That guide has an outsized role: they have to be very careful not to influence this person's intimate, spiritual, existential experience. They need to be able to respect that person's right to freedom of thought, consciousness, and religion. Every single participant needs to understand that, too — there’s so much interpretation involved during and after a psychedelic experience. 

There's also a huge justice issue here. There are so many different cultures and worldviews, and the guide often invokes their own culture and worldview in their practices, even in things like the way they set up the room for a session. A lot of the clinicians and investigators in this space come from a culture that might be characterized as hippie, Buddhist, or New Age. That could work great for someone who shares that outlook, but guides have a responsibility to consider the individual needs of participants based on their culture, worldview, and religion. If you look at the huge number of people in this country, there are many — people of color, immigrants — who could be alienated by a guide who’s unintentionally imposing their own models onto them. That matters for the field of research as well; research and historical studies have shown that classical psychedelics increase acute suggestibility, so we need to see different models explored in that work, too.

How do you think a practitioner’s worldview might affect research?

All the factors that are involved in the participant and guide relationship and the set and setting have the power to accidentally influence participants and what we find. For instance, there's focus on what researchers call the mystical experience — it’s measured with a questionnaire and often is defined by experiencing a kind of oneness with the world, or ego dissolution. And mystical experiences are often seen as an indicator of therapeutic progress. Practitioners might talk to patients about it before they undergo treatment, and then people are like, “I'm going to have this experience and then I'll get better.” 

But there are people who, due to their personal worldview or psychology, just don't have that kind of experience. If you have these people focusing on one model of therapeutic progress — especially a model that relies on mystical oneness, which is contingent on a particular kind of religious worldview — then they might feel like, “Oh, no, something's wrong with me.” But there could be different ways of getting at the same idea with different people. Maybe for other people that mystical experience looks like dyadic encounters with other beings, or angels. 

And if people come to believe that psychedelics must be experienced in this or that way, then individual case studies also take that form, and as they get reported widely, that becomes even more of the dominant narrative. When it gets reported widely enough, you get this big cultural feedback loop. And if psychedelics are a way to understand ourselves and humanity, consciousness, and the cosmos, this kind of cultural feedback loop could squander a serious opportunity to really learn the truth.

This interview has been edited and condensed for clarity and length.