Ethics and ego dissolution: the case of psilocybin
The paper argues that psilocybin’s characteristic effects—ego dissolution, feelings of unity and ineffability, and attendant lasting personality and worldview changes—create novel ethical risks that standard psychiatric consent procedures may not adequately address. It therefore proposes an enhanced informed consent process with specific discussion prompts, responds to likely objections, and outlines ethical issues for integrating psychedelics into mainstream clinical psychiatry.
Authors
- Smith, W. R.
- Sisti, D.
Published
Abstract
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.
Research Summary of 'Ethics and ego dissolution: the case of psilocybin'
Introduction
Recent early-phase clinical work has revived interest in classic serotonergic psychedelics, and in particular psilocybin, for psychiatric indications. Trials have reported sustained symptom reduction in treatment-resistant depression and cancer-related anxiety and depression, and promising findings have emerged for substance-use problems such as smoking and alcohol cessation. The therapeutic effects are commonly associated with distinctive subjective phenomena—so-called mystical experiences that include feelings of unity, ineffability, encounters with ‘deep’ reality or God, and a loss of self-importance often described as ‘‘ego dissolution’’. These experiences are also linked with longer-term changes in personality and worldview. Smith and colleagues identify a gap in medical-ethics literature: despite the growing clinical evidence and the potentially profound, rapid and sometimes ineffable effects of psilocybin, ethical analysis of its distinctive risks and consent implications has been limited. The paper therefore aims to analyse ethical issues raised by psilocybin-assisted psychotherapy, focusing on novel risks (for example, unexpected personality or value changes, trauma re‑exposure and rare psychotic outcomes) and on why these warrant an enhanced informed consent process. The authors limit discussion mainly to serotonergic psychedelics and use a broad, lay-oriented notion of personality to capture the ethically salient changes reported in clinical studies.
Expert Research Summaries
Go Pro to access AI-powered section-by-section summaries, editorial takes, and the full research toolkit.
Full Text PDF
Full Paper PDF
Create a free account to open full-text PDFs.
Study Details
- Study Typemeta
- Journal
- Compound
- Topics
- APA Citation
Smith, W. R., & Sisti, D. (2021). Ethics and ego dissolution: the case of psilocybin. Journal of Medical Ethics, 47(12), 807-814. https://doi.org/10.1136/medethics-2020-106070
References (33)
Papers cited by this study that are also in Blossom
Ross, S., Bossis, A. P., Guss, J. et al. · Journal of Psychopharmacology (2016)
Johnson, M. W., Griffiths, R. R. · Neurotherapeutics (2017)
Griffiths, R. R., Johnson, M. W. · Journal of Psychopharmacology (2016)
Carhart-Harris, R. L., Bolstridge, &. M., Day, C. M. J. et al. · Psychopharmacology (2017)
Carhart-Harris, R. L., Bolstridge, M., Rucker, J. et al. · Lancet Psychiatry (2016)
Johnson, M. W., Garcia-Romeu, A., Johnson, P. S. et al. · Journal of Psychopharmacology (2017)
Johnson, M. W., Garcia-Romeu, A., Griffiths, R. R. · The American Journal of Drug and Alcohol Abuse (2016)
Garcia-Romeu, A., Davis, A. K., Fire Erowid et al. · Journal of Psychopharmacology (2019)
Johnson, M. W., Richards, W. A., Griffiths, R. R. · Journal of Psychopharmacology (2008)
Danforth, A. L., Grob, C. S., Struble, C. et al. · Psychopharmacology (2018)
Show all 33 referencesShow fewer
Mithoefer, A. T., Mithoefer, M. C., Feduccia, A. A. et al. · Lancet Psychiatry (2018)
Ot'alora G, M., Grigsby, J., Poulter, B. et al. · Journal of Psychopharmacology (2018)
Gasser, P., Holstein, D., Michel, Y. et al. · Journal of Nervous and Mental Disease (2014)
Sanches, R. F., Osório, F. L., Dos Santos, R. G. et al. · Journal of Clinical Psychopharmacology (2016)
Griffiths, R. R. · Journal of Psychopharmacology (2008)
Nichols, C. D., Nichols, D. E., Johnson, M. W. · Clinical Pharmacology and Therapeutics (2016)
Carhart-Harris, R. L. · Neuropharmacology (2018)
Roseman, L., Nutt, D. J., Carhart-Harris, R. L. · Frontiers in Pharmacology (2018)
Belser, A. B., Agin-Liebes, G. I., Swift, T. C. et al. · Journal of Humanistic Psychology (2017)
Erritzoe, D., Roseman, L., Nour, M. R. et al. · Acta Psychiatrica Scandinavica (2018)
Maclean, K. A., Johnson, M. W., Griffiths, R. R. · Journal of Psychopharmacology (2011)
Watts, R., Day, C. M., Krzanowski, J. et al. · Journal of Humanistic Psychology (2017)
Carhart-Harris, R. L., Erritzoe, D., Haijen, E. C. H. M. et al. · Psychopharmacology (2017)
Carhart-Harris, R. L., Erritzoe, D., Williams, T. et al. · PNAS (2012)
Carhart-Harris, R. L., Leech, R., Shanahan, M. et al. · Frontiers in Human Neuroscience (2014)
Carhart-Harris, R. L., Roseman, L., Bolstridge, M. et al. · Scientific Reports (2017)
Kirchner, K. · Journal of Psychopharmacology (2014)
Murphy-Beiner, A., Soar, K. · Psychopharmacology (2020)
Soler, J., Elices, M., Franquesa, A. et al. · Psychopharmacology (2015)
Carbonaro, T. M., Bradstreet, M. P., Barrett, F. S. et al. · Journal of Psychopharmacology (2016)
Krebs, T. S., Johansen, P. ˚. Ø. · PLOS ONE (2013)
Johnson, M. W., Griffiths, R. R., Hendricks, P. S. et al. · Neuropharmacology (2018)
Rodríguez-Fornells, A., Ribeiro, S., Sanches, R. F. et al. · European Neuropsychopharmacology (2015)
Cited By (10)
Papers in Blossom that reference this study
Stellmacher, J., Schmidt, C., Aicher, H. D. et al. · Frontiers in Psychiatry (2026)
Evans, J., Aixalà, M., Anderson, B. T. et al. · Psychiatric Research & Clinical Practice (2025)
Kirlic, N., Lennard-Jones, M., Atli, M. et al. · American Journal of Psychiatry (2025)
Neitzke-Spruill, L., Beit, C., Robinson, J. et al. · Neuroethics (2024)
Nayak, S., Jackson, H., Griffiths, R. R. et al. · Journal of Psychoactive Drugs (2024)
Argyri, E. K., Evans, J., Luke, D. et al. · SSRN (2024)
Devenot, N., Seale-Feldman, A., Smith, E. et al. · Kennedy Institute of Ethics Journal (2022)
Johnson, S., Letheby, C. · Journal of Psychedelic Studies (2022)
Yaden, D. B., Earp, D., Graziosi, M. et al. · Frontiers in Psychology (2022)
Earp, B. D., Repantis, D., Langlitz, N. et al. · Frontiers in Psychiatry (2021)
Your Personal Research Library
Go Pro to save papers, add notes, rate studies, and organize your research into custom shelves.