This paper is part of a book symposium for L. A. Paul (2014) Transformative Experience (OUP).

In this paper, we examine the case of psychedelic medicine for Alzheimer’s disease and related dementias (AD/ADRD). These “mind-altering” drugs are not currently offered as treatments to persons with AD/ADRD, though there is growing interest in their use to treat underlying causes and associated psychiatric symptoms. We present a research agenda for examining the ethics of psychedelic medicine and research involving persons living with AD/ADRD, and offer preliminary analyses of six ethical issues: the impact of psychedelics on autonomy and consent; (...) the impact of “ego dissolution” on persons experiencing a pathology of self; how psychedelics might impact caregiving; the potential exploitation of patient desperation; institutional review boards’ orientation to psychedelic research; and methods to mitigate inequity. These ethical issues are magnified for AD/ADRD but bear broader relevance to psychedelic medicine and research in other clinical populations. (shrink)

It is often said that ‘what it is like’-knowledge cannot be acquired by consulting testimony or reading books [Lewis 1998; Paul 2014; 2015a]. However, people also routinely consult books like What It Is Like to Go to War [Marlantes 2014], and countless ‘what it is like’ articles and youtube videos, in the apparent hope of gaining knowledge about what it is like to have experiences they have not had themselves. This article examines this puzzle and tries to solve it by (...) appealing to recent work on knowing-wh ascriptions. In closing I indicate the wider significance of these ideas by showing how they can help us to evaluate prominent arguments by Paul [2014; 2015a] concerning transformative experiences. (shrink)

Despite the fact that psychedelics were proscribed from medical research half a century ago, recent, early-phase trials on psychedelics have suggested that they bring novel benefits to patients in the treatment of several mental and substance use disorders. When beneficial, the psychedelic experience is characterized by features unlike those of other psychiatric and medical treatments. These include senses of losing self-importance, ineffable knowledge, feelings of unity and connection with others and encountering ‘deep’ reality or God. In addition to symptom relief, (...) psychedelic experiences often lead to significant changes in a patient’s personality and worldview. Focusing on the case of psilocybin, we argue that the peculiar features of psychedelics pose certain novel risks, which warrant an enhanced informed consent process–one that is more comprehensive than what may be typical for other psychiatric medications. We highlight key issues that should be focused on during the consent process and suggest discussion prompts for enhanced consent in psychedelic psychiatry. Finally, we respond to potential objections before concluding with a discussion of ethical considerations that will arise as psychedelics proceed from highly controlled research environments into mainstream clinical psychiatry. (shrink)

We develop a broader, more fine-grained taxonomy of forms of ‘transformative experience’ inspired by the work of L.A. Paul. Our vulnerability to such experiences arises, we argue, due to the vulnerability, dependence, and affliction intrinsic to the human condition. We use this trio to distinguish a variety of positively, negatively, and ambivalently valenced forms of epistemically and/or personally transformative experiences. Moreover, we argue that many transformative experiences can arise gradually and cumulatively, unfolding over the course of longer periods of time.

What happens when we consider transformative experiences from the perspective of gender transitions? In this paper I suggest that at least two insights emerge. First, trans* persons’ experiences of gender transitions show some limitations to L.A. Paul’s (forthcoming) decision theoretic account of transformative decisions. This will involve exploring some of the phenomenology of coming to know that one is trans, and in coming to decide to transition. Second, what epistemological effects are there to undergoing a transformative experience? By connecting some (...) experiences of gender transitions to feminist standpoint epistemology, I argue that radical changes in one’s identity and social location also radically affects one’s access to knowledge in ways not widely appreciated in contemporary epistemology. (shrink)

Summary of Transformative Experience by L.A. Paul and replies to symposiasts. Discussion of undefined values, preference change, authenticity, experiential value, collective minds, mind control.

Evidence suggests that psychedelics bring about their therapeutic outcomes in part through the subjective or qualitative effects they engender and how the individual interprets the resulting experiences. However, psychedelics are contraindicated for individuals who have been diagnosed with certain mental illnesses, on the grounds that these subjective effects may be disturbing or otherwise counter-therapeutic. Substantial resources are therefore currently being devoted to creating psychedelic substances that produce many of the same biological changes as psychedelics, but without their characteristic subjective effects. (...) In this article, we consider ethical issues arising from the prospect of such potential “nonsubjective” psychedelics. We are broadly supportive of efforts to produce such substances for both scientific and clinical reasons. However, we argue that such nonsubjective psychedelics should be reserved for those special cases in which the subjective effects of psychedelics are specifically contraindicated, whereas classic psychedelics that affect subjective experience should be considered the default and standard of care. After reviewing evidence regarding the subjective effects of psychedelics, we raise a number of ethical concerns around the prospect of withholding such typically positive, meaningful, and therapeutic experiences from most patients. (shrink)

In “What you can’t expect when you’re expecting,” I argue that, if you don’t know what it’s like to be a parent, you cannot make this decision rationally—at least, not if your decision is based on what you think it would be like for you to become a parent. My argument hinges on the idea that becoming a parent is a transformative experience. This unique type of experience often transforms people in a deep and personal sense, and in the process, (...) changes their preferences. In section 1, I will explain transformative experience in terms of radical first-personal epistemic and self change. In section 2, I’ll explain the notion of subjective value that I use to develop the decision problem. In section 3, I will discuss the way we ordinarily combine our introspective assessments with testimony and evidence. In section 4, I will discuss the problems for rational decision-making. In section 5, I will explore the problem of first-personally transformed future selves. In section 6, I will engage with the main themes and arguments and ideas of the authors of the papers contributed to this volume. (shrink)

Psychedelics are experiencing a renaissance in mental healthcare. In recent years, more and more early phase trials on psychedelic-assisted therapy have been conducted, with promising results overall. However, ethical analyses of this rediscovered form of treatment remain rare. The present paper contributes to the ethical inquiry of psychedelic-assisted therapy by analysing the ethical implications of its therapeutic mechanisms proposed by the relaxed beliefs under psychedelics (REBUS) hypothesis. In short, the REBUS hypothesis states that psychedelics make rigid beliefs revisable by increasing (...) the influence of bottom-up input. Put differently, patients become highly suggestible and sensitive to context during a psychedelic session, amplifying therapeutic influence and effects. Due to that, patients are more vulnerable in psychedelic-assisted therapy than in other therapeutic interventions; they lose control during a psychedelic session and become dependent on the therapeutic setting (including the therapist). This enhanced vulnerability is ethically relevant and has been exploited by some therapists in the past. Therefore, patients in current research settings and starting mainstream medical settings need to be well informed about psychedelics’ mechanisms and their implications to give valid informed consent to treatment. Furthermore, other security measures are warranted to protect patients from the vulnerability coming with psychedelic-assisted therapy. (shrink)

Aims: The experience of a compromised sense of ‘self’, termed ego-dissolution, is a key feature of the psychedelic experience and acute psychosis. This study aimed to validate the Ego-Dissolution Inventory (EDI), a new 8-item self-report scale designed to measure ego-dissolution. Additionally, we aimed to investigate the specificity of the relationship between psychedelics and ego-dissolution. Method: Sixteen items relating to altered ego-consciousness were included in an internet questionnaire; 8 relating to the experience of ego-dissolution (comprising the EDI), and 8 relating to (...) the antithetical experience of increased self-assuredness. Items were rated using a visual analogue scale. Participants answered the questionnaire for experiences with classical psychedelic drugs, cocaine or alcohol. They also answered the 7 questions from the Mystical Experiences Questionnaire (MEQ) relating to the experience of unity with one’s surroundings. Results: 691 participants completed the questionnaire, providing data for 1828 drug experiences (1043 psychedelics. 377 cocaine. 408 alcohol). Exploratory factor analysis demonstrated that the 8 EDI items loaded exclusively onto a single common factor, which was orthogonal to a second factor comprised of the items relating to increased self-assuredness (rho= -.110), demonstrating discriminant validity. The EDI correlated strongly with our measure of unitive experience (rho =.735), demonstrating convergent validity. EDI internal consistency was excellent (Cronbach’s alpha 0.93). Three analyses confirmed the specificity of ego-dissolution for experiences occasioned by psychedelic drugs. Firstly, EDI score correlated with drug-dose for psychedelic drugs (rho=.371), but not for cocaine (rho=.115) or alcohol (rho=-0.055). Secondly, the linear regression line relating the subjective intensity of the experience to EDI was significantly steeper for psychedelics (unstandardized B coefficient= 0.701) compared with cocaine (0.135) or alcohol (0.144). Finally, a binary support vector machine classifier identified experiences occasioned by psychedelic drugs vs. cocaine or alcohol with over 85% accuracy using ratings of ego-dissolution and ego-inflation alone. Conclusions: Our results demonstrate the psychometric structure, internal consistency and construct validity of the EDI. Moreover, we demonstrate the close relationship between ego-dissolution and the psychedelic experience. The EDI will facilitate the study of the neuronal correlates of ego-dissolution, which is relevant for psychedelic-assisted psychotherapy and our understanding of psychosis. (shrink)

ABSTRACT It is accepted that treatment of previously competent, now incompetent patients can be limited if that is what the patient would desire, if she were now competent. Expressed past preferences or an advance directive are often taken to constitute sufficient evidence of what a patient would now desire. I distinguish between desires and rational desires. I argue that for a desire to be an expression of a person's autonomy, it must be or satisfy that person's rational desires. A person (...) rationally desires a course of action if that person desires it while being in possession of all available relevant facts, without committing relevant error of logic, and “vividly imagining” what its consequences would be like for her. I argue that some competent, expressed desires obstruct autonomy. I show that several psychological mechanisms operate to prevent a person rationally evaluating what future life in a disabled state would be like. Rational evaluation is difficult. However, treatment limitation, if it is to respect autonomy, must be in accord with a patient's rational desires, and not merely her expressed desires. I illustrate the implications of these arguments for the use of advance directives and for the treatment of competent patients. (shrink)

According to L. A. Paul (2014), transformative experiences pose a challenge for decision theory, as their subjective value is not epistemically accessible. However, several authors propose that the subjective values of options are often irrelevant to their ranking; in many cases, all we need for rational transformative decision-making are the known non-subjective values. This stance is in conflict with Paul’s argument that the subjective value can always swamp the non-subjective value. The approach presented in this paper takes Paul’s argument into (...) account and shows how potential swamping can be controlled given that one desires the transformative outcome: If one knows from previous decisions that desired transformative outcomes are associated with positive subjective value and if, in addition, testimony confirms this association for the current decision situation, one can infer that a desired outcome’s expected subjective value has a positive valence. Accordingly, one can rationally choose the desired transformative option if its non-subjective value is no lower than the overall value of any other option. (shrink)

Disease radically changes the life of many people and satisfies formal criteria for being a transformative experience. According to the influential philosophy of Paul, transformative experiences undermine traditional criteria for rational decision-making. Thus, the transformative experience of disease can challenge basic principles and rules in medical ethics, such as patient autonomy and informed consent. This article applies Paul’s theory of transformative experience and its expansion by Carel and Kidd to investigate the implications for medical ethics. It leads to the very (...) uncomfortable conclusion that disease involves transformative experiences in ways that can reduce people’s rational decision-making ability and undermine the basic principle of respect for autonomy and the moral rule of informed consent. While such cases are limited, they are crucial for medical ethics and health policy and deserve more attention and further scrutiny. (shrink)

Some decisions we make—such as becoming a parent or moving to a different part of the world—are transformative. According to L. A. Paul, transformative decisions pose a major problem to us because they fall outside the realm of rationality. Her argument for that conclusion rests on the premise that subjective value is central in transformative decisions. This paper challenges that premise and hence the overall conclusion that transformative decisions usually are not rational. In the theoretical part of the paper, we (...) specify conditions under which transformative decisions are possibly rational and likely rational. The data we present in the empirical part of the paper reveal that subjective value often plays only a minor role in people’s decision-making process. Putting both parts together, we argue that people have a great chance of making rational transformative choices. (shrink)

According to Paul (Transformative experience, 1st edn, Oxford University Press, 2014), transformative experiences pose a challenge to decision theory since their value cannot be anticipated. Building on Pettigrew’s (in: Lambert, Schwenkler (eds) Becoming someone new: essays on transformative experience, choice, and change, Oxford University Press, pp 100–121, 2020) redescription, this paper presents a new approach to how and when transformative decisions can nevertheless be made rationally. Thanks to fundamental higher-order facts that apply to any kind of experience, an agent always (...) at least knows the general shape of the utility space. This in combination with the knowledge about the non-transformative alternative in the choice set can enable rational decision-making despite the presence of a transformative experience. For example, this paper’s approach provides novel arguments for why gender transition (cf. McKinnon in Res Philosophica 92(2):419–440, 2015) or staying childfree (cf. Barnes in Philos Phenomenol Res 91(3):775–786, 2015) can be rational. (shrink)

This paper explores how transformative experience generates decision-making problems of particular seriousness in medical settings. Potentially transformative experiences are especially likely to be encountered in medicine, and the associated decisions are confronted jointly by patients and clinicians in the context of an imbalance of power and expertise. However in such scenarios the principle of informed consent, which plays a central role in guiding clinicians, is unequal to the task. We detail how the principle’s assumptions about autonomy, rationality and information handle (...) transformative experiences poorly, appealing to several difficult cases for medical decision-making to illustrate the resulting problem, and we consider how the existing literature on complications with consent fails to offer a resolution. We argue that recognition of the problem has a role to play in achieving a more effective response to transformative decisions. In Sect. 1 we introduce several representative cases of challenging patient decision-making that clinicians might face. In Sect. 2 we detail how transformative experience has been analysed in the recent literature, before outlining in Sect. 3 the theoretical basis of the principle of informed consent, which plays a central role in how clinicians are expected to support decision-making. In Sect. 4, having laid the groundwork for a clear description, we return to the cases given in Sect. 1 to confirm how their transformative nature presents a problem: either clinicians treat the decisions faced by these patients as ‘normal’, encouraging them to focus on information provision that patients may be unable to act on, or they treat them as transformative, in which case they lack the resources to recognise whether they are helping patients make (subjectively) good decisions. In Sect. 5 we argue that the existing literature does not offer any escape from this problem. We close in Sect. 6 by noting the significant impact that appreciating the problem of transformative experience could have on supporting transformative decisions in medicine and briefly suggesting how we might aim to develop new approaches to dealing with these. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ought We to Require Emotional Capacity as Part of Decisional Competence?Paul S. Appelbaum* (bio)AbstractThe preceding commentary by Louis Charland suggests that traditional cognitive views of decision-making competence err in not taking into account patients’ emotional capacities. Examined closely, however, Charland’s argument fails to escape the cognitive bias that he condemns. However, there may be stronger arguments for broadening the focus of competence assessment to include emotional capacities, centering on (...) the ways in which emotions aid humans in processing information. Before emotional capacities are added to the list of functions essential for decisional competence, though, the feasibility and utility of such a reorientation must be demonstrated.To what extent ought persons’ capacities to experience emotion be taken into account when determining whether they should be deemed competent to make their own decisions? In the previous article, Louis Charland (1998) argues that traditional models of decision-making competence—of which the MacArthur Competence Treatment Study is a typical example—are mistaken in focusing narrowly on persons’ cognitive abilities to the neglect of emotional factors. In contrast, he suggests, constructs of competence ought explicitly to require a capacity to experience emotions, which he believes is central to meaningful decision making, before deeming persons competent.Charland, as he acknowledges, is not the first to suggest that the presence of some degree of emotional capacity is a necessary element of competence, but his argument is among the most elaborate to date and is certainly worth closer examination. Looked at carefully, however, Charland’s argument does not make quite the case for the determination of emotional capacity in competence assessment that he claims for it. Indeed, as I demonstrate below, Charland may share the same “pernicious [End Page 377] cognitive bias” that he ascribes to more traditional approaches. However, despite what I identify as the problems in Charland’s argument, others have raised more disturbing questions about the lack of attention to emotional issues in competence assessment. Thus, I am not ready to reject entirely the possibility that determinations of decisional competence ought to consider emotional factors. I conclude by outlining the questions that remain to be answered to identify more clearly the potential benefits of such an approach.The Construct of Decision-Making CompetenceSome preliminary comments about the nature of the dominant construct of decision-making competence may provide a useful frame for my response to Charland’s paper. Contemporary ideas of competence are tied inextricably to the ideal of self-determination in modern Western societies. Such societies are committed to respect for individual choice, both as a good in its own right and on the grounds that each person knows best what choices will maximize his or her own welfare. In general, therefore, states will not intervene to prevent persons from acting on their decisions, even when the choices they make—like the decision to smoke or to refuse potentially life-saving medical care—may objectively be thought to be detrimental to them.In some cases, however, the presumption that people will act in their own interests, as well as the notion that there is something intrinsically valuable in respecting their choices, fails (Buchanan and Brock 1989). When people’s minds are so disordered that they cannot be said to be making meaningful choices, other values come into play. Such people are called “incompetent.” When persons reach that point, the state’s interest in protecting its citizens becomes primary and someone else must make decisions on their behalf. Note that the size of this group must be sharply limited, lest a liberal society’s commitment to self-determination be undermined: There is no more profound infringement of the rights of citizens than the determination that they are incompetent. Thus, the criteria for incompetence must be selected in a deliberately narrow fashion—alternately, one might say that the standards for competence are made intentionally broad—so that all but a tiny percentage of citizens will be permitted to make decisions on their own.In the Anglo-American world, the process of formulating criteria of competence by and large has been left to the common law courts. Over the course of centuries they have identified the capacities that are, in... (shrink)

According to L. A. Paul, the subjective value of an outcome is normally assessed by running a cognitive model of what it would be like if that outcome were to occur. However, cognitive models, along with the expectations in which they result, are unreliable for application to transformative experiences because we cannot know what it would be like for an outcome to occur if we have never experienced it before. This paper argues that despite their unreliability, expectations are still important (...) in the case of chosen and unchosen transformative experiences because expectations about an outcome can systematically influence the very experience of that outcome. More precisely, empirical research shows that affective experiences tend to assimilate to affective expectations. In turn, more positive affective experiences lead, ceteris paribus, to higher subjective value. Therefore, rational agents confronting transformative outcomes should form or cultivate positive/optimistic affective expectations since, all else being equal, that maximizes subjective value. (shrink)

There is a growing resurgence in the study of psychedelic medicines for the treatment of mental health and substance use disorders. However, certain early investigations are marred by questionable research methods, abuses against research participants, and covert Central Intelligence Agency financial involvement. The purpose of this study was to understand how and to what extent people of colour and other vulnerable populations, specifically, individuals who were incarcerated or incapacitated due to mental health issues, were exploited during the first wave of (...) psychedelic research in the USA. To do so, we reviewed available empirical publications according to current ethical standards. Variables of interest included race and ethnicity of participants, population vulnerability, drug administration conditions, informed consent and undue influence. Our findings draw attention to the history of research abuses against people of colour in Western psychedelic research. In light of these findings, we urge a call-to-action to current psychedelic researchers to prioritise culturally inclusive and socially responsible research methods in current and future studies. All data relevant to the study are included in the article. (shrink)

Book reviewed in this article: Beginning Lives, by Rosalind Hursthouse. On Moral Medicine:Theological Perspectives in Medical Ethics, edited by Stephen E. Lammers and Allen Verhey. Quantitative Risk Assessment, edited by James M. Humber and Robert F. A Theory of Value and Obligation, by Robin Attfield. Ethical Issues at the Outset of Life, edited by William B. Weil Jr. and Martin Benjamin. Legal Frontiers of Death and Dying by Norman L. Cantor Having Your Baby By Donor Insemination:A Complete Resource Guide, by (...) Elizabeth Noble. (shrink)