Psychedelic injustice: should bioethics tune in to the voices of psychedelic-using communities?

Mcmillan frames the paper around a renewed scientific and public interest in psychedelic compounds and the contentious nature of their therapeutic use. Earlier bioethics literature is emerging but, according to the author, has largely omitted direct consultation with psychedelic-using communities despite lively normative discussions occurring in public forums run by those communities. This omission raises concerns about epistemic harms and the legitimacy of normative decisions that shape psychedelic medicalisation. The study sets out to argue that psychedelic-using communities ought to be included in bioethical deliberations that guide the medicalisation of psychedelics. Mcmillan advances two main claims: first, that these communities possess a form of epistemic expertise derived from lived experience; and second, that they are uniquely and heavily affected by medicalisation and therefore have a legitimate stake in normative decisions. The paper also presents and responds to a key counterargument—that affected groups may be epistemically limited in deliberative reasoning—and concludes that consultation is owed to these communities in order to redress testimonial injustice and inform fair policy-making.

This paper is a conceptual, normative analysis rather than an empirical study. Mcmillan develops a philosophical argument by synthesising work from epistemology, bioethics, and literature on public consultation. The approach involves (a) explicating types of knowledge from epistemology ('knowledge that', 'knowledge how', and 'knowledge by acquaintance') and applying these distinctions to psychedelic experiences, and (b) deploying the concept of being "affected" from public consultation literature to argue for inclusion of those with embodied experience. The author also draws on empirical studies about public consultation and the epistemology of affected groups to present a counterargument concerning decreased deliberative reasoning among those directly affected. Additionally, testimonial injustice—especially testimonial prejudice arising from the historical and social stigma attached to psychedelic use—is used as a normative lens to argue for reparative consultation. The extracted text does not report any original data collection, systematic search strategy, inclusion criteria, or formal methods typical of empirical or systematic-review papers; it instead relies on conceptual analysis and selective citation of existing scholarship and public debates.

Mcmillan presents two interconnected lines of argument as the paper's principal findings. First, psychedelic-using communities possess epistemic expertise stemming from lived psychedelic experience. Applying the epistemological categories, the author argues that psychedelic experiences can generate propositional insights ('knowledge that' about unconscious mental states), practical skills ('knowledge how' to navigate altered states, for example by managing set and setting), and direct experiential knowledge ('knowledge by acquaintance' such as insights about the constructed nature of self). Clinical research practices that attend to ritualistic factors like set and setting are cited as partial recognition of this expertise. Second, the paper contends that psychedelic-using communities qualify as groups that are "being affected" by medicalisation: their embodied practices and institutions are likely to be substantially transformed by regulatory and clinical changes. Mcmillan lists public concerns already raised in community forums—ecological impacts, colonisation of indigenous knowledge, shifts in authority over administration and meaning, and reductive scientific explanations of experiences—and argues these concerns matter for both ethical evaluation and pragmatic policy implementation. As a counterpoint, the author summarises empirical work suggesting that affected groups can be epistemically constrained: they may rely more on personal testimony and be less likely to engage in wide-ranging deliberative reasoning than lay publics. Mcmillan acknowledges this limitation but proposes that methodological safeguards (for example, mixed consultation designs or deliberative techniques) can mitigate it. Importantly, even if such mitigation were impossible, the author argues that psychedelic-using communities are owed consultation because they have suffered testimonial injustice—historical and ongoing devaluation of their testimony owing to associations with psychosis, counterculture, illicit drug use and indigenous practices—which has contributed to their marginalisation despite their central role in prompting renewed research.

Mcmillan interprets the foregoing arguments to mean that inclusion of psychedelic-using communities in bioethical deliberation is both epistemically valuable and morally required. The author positions this claim against the current state of bioethics literature, which rarely incorporates these communities' voices despite abundant community-led normative debate in public fora. By highlighting the kinds of knowledge that experiential users can offer, the paper suggests that academic and regulatory processes risk overlooking salient normative issues if they exclude embodied expertise. The paper situates its argument relative to earlier research on public consultation: while acknowledging empirical concerns about decreased deliberative reasoning among affected groups, Mcmillan argues these are methodological challenges rather than decisive objections. Proposed responses include combining lay and affected perspectives in consultative exercises and using deliberative methods that encourage consideration of multiple viewpoints. The author further contends that testimonial injustice provides a separate, weighty reason for consultation: because psychedelic-using communities have been historically discredited, institutions now engaging in medicalisation owe these communities avenues to express and legitimise their knowledge. Limitations and uncertainties are explicitly discussed. Mcmillan recognises the epistemic shortcomings attributed to affected groups and does not claim they are absent; instead, the author suggests these shortcomings can be addressed methodologically and should be weighed against the harms of exclusion. The extracted text does not report empirical testing of consultative methods or concrete implementation strategies; rather, it advances a normative claim and identifies areas where practical work—such as designing fair consultation processes—remains necessary. Finally, the author highlights implications for practice and policy: bioethicists, researchers and regulators should tune in to psychedelic-using communities, restore credibility to their testimonies, and ensure that policies account for the communities' expertise and interests as medicalisation proceeds.

Mcmillan concludes that psychedelic-using communities should play a substantive role in guiding normative aspects of psychedelic medicalisation. The author reiterates the two central reasons: these communities possess unique epistemic resources because of their lived experiences, and they are disproportionately affected by the regulatory, clinical and cultural changes that medicalisation will bring. Even acknowledging potential epistemic limitations in deliberation, the paper affirms that consultation is owed as a remedy for testimonial injustice and because many institutions now benefiting from these communities' knowledge are responsible for past marginalisation. The conclusion calls for the restoration of testimonial privilege to psychedelic-using communities and for their voices to be incorporated into ethical and policy deliberations as medicalisation advances.