Agency, informed consent and transformative experiences: A proposed conceptual analysis of the ethical challenges of psychedelic-assisted psychotherapy

Recent discussions of psychedelic-assisted psychotherapy (PAP) have raised concerns about its potential to produce unpredictable and persistent personal transformations that patients cannot fully anticipate and may subsequently regret. These concerns pose challenges for informed consent and have contributed to arguments for psychedelic ethical exceptionalism. In this conceptual commentary, we propose a process-based, agency-sensitive account of personal transformation. Rather than treating psychedelic transformation as a ‘single’ event imposed upon a ‘passive’ subject, we distinguish between a potentially rapid transformative trigger, the subsequent process throughout which psychedelic experiences are interpreted and integrated, and its longitudinal outcomes. Patients' agency may vary across these phases, being particularly compromised during acute psychedelic experiences while playing a greater role during preparation, integration, and longer-term reflection. This account does not eliminate the informed-consent challenges associated with PAP, including the possibility of persistent and regretted personal change, but suggests that they do not by themselves require a fundamentally exceptional framework for informed consent. We argue instead for enhanced disclosure of transformative uncertainty, attention to patients' susceptibility during acute and interpretative phases, and follow-up practices that support patients' agency in responding to persistent personal changes.