Patch and Smith’s recent critique of set and setting in psychedelic research argues that the concept is too vague to support rigorous science or ethical clinical practice, and proposes a more narrowly operationalized, mechanism-first alternative. This paper argues that this critique, while valuable in its call for conceptual clarity, rests in part on a mischaracterization of prior scholarship and risks reintroducing the reductive assumptions that the set and setting model was developed to challenge. In response to Patch and Smith, we defend a non-reductive, interactional account of psychedelic action in which pharmacological and extra-pharmacological factors are dynamically entangled rather than cleanly separable. We argue, first, that the opposition between broad contextual mapping and causal explanation is overstated, since the former is often a necessary stage in the development of the latter. Second, we reject the attribution to our earlier work of a “Placebo View,” according to which psychedelics function merely or predominantly as placebo enhancers, clarifying instead that our position emphasizes the synergistic interaction of drug effects, suggestibility, meaning, and context. Finally, we argue that set and setting retains distinctive explanatory value because it captures the recursive relation between altered states of consciousness and their experiential surround. Psychedelic science should refine this framework, not abandon it.
Idiopathic normal pressure hydrocephalus (iNPH) is one of the few reversible causes of dementia, yet the experience of living with a programmable shunt—and the identity oscillations it produces—has received little attention in the neuroethics literature. This reflective essay draws on the author’s first-person experience as both a physician and a patient with iNPH to explore the ethical and philosophical dimensions of device-dependent selfhood. In my experience, changes from the prescribed valve setting have accompanied recurrent transitions between cognitive clarity and dementia-like impairment, raising fundamental questions about personal identity, informed consent across fluctuating cognitive states, and the existential burden of reversible neurological decline. After providing a clinical primer on iNPH and programmable cerebrospinal fluid shunts, the essay situates the shunt-dependent experience within existing scholarship on deep brain stimulation and identity, compares this experience of device-dependent oscillation with other fluctuating conditions such as bipolar disorder and delirium, offers working definitions of person, self, and identity, and engages the “then self/now self” debate in dementia ethics. I argue that oscillating between functional states is a distinct and undertheorized form of neurological suffering—one that challenges linear models of disease progression, scrambles the temporal assumptions built into our consent doctrines, and demands new ethical frameworks for device-dependent patient populations.
The academic debate on the governance of neurotechnology has progressively shifted from proposals to create new lists of so-called neurorights toward the reinterpretation of existing human rights, with freedom of thought attracting particular attention, among a broader set of candidate rights. This article examines whether freedom of thought can currently perform that anchoring role in Latin American jurisdictions. Drawing on a comparative analysis of constitutional texts, jurisprudence, and the Inter-American human rights system, the article argues that freedom of thought does not yet possess a clear, strong, and autonomous normative content in Latin American domestic law and in its regional human rights system. As a complementary and, in the region, more operative anchor, it argues that human dignity, which in several Latin American constitutional orders functions as an absolute autonomous fundamental right of direct application with extensive jurisprudential development, constitutes a more operationally effective legal basis for absolute prohibitions on the use of people as instruments or objects, and can protect them from coercive neurotechnological interventions. The article proposes that human dignity supplies the absolute floor against instrumentalization and coercion, while freedom of thought, as its doctrinal development advances, can complement that floor with the protection of the forum internum. It further contends that any rights-based strategy is structurally insufficient on its own, because rights depend on judicial interpretation that is inherently contextual and contingent, and therefore supports a multilevel governance approach combining the interpretation of existing rights, soft-law principles, and potential specific hard-law provisions.
A growing debate in psychedelic clinical research concerns whether facilitators (1) do administer psychotherapy (PT) or merely psychological support (PS) to trial participants, and (2) whether they should administer PT or PS. This controversy carries significant implications for scientific methodology, clinical regulation, professional training, and ethics. However, the field remains mired in definitional disagreement, as proposed criteria for distinguishing PT from PS consistently fail in liminal cases. I first analyze three leading definitional criteria grounded in facilitator intention, observable facilitator behaviors, and the argument that PS is a minimal form of PT, and demonstrate how each criteria encounters internal inconsistencies and unintuitive conclusions when applied to liminal scenarios. I argue that PT and PS are vague social constructs that resist precise empirical definition, and that continued debate over their “true” nature risks conceptual stalemate. In order to move out of a definitional impasse, the article draws upon Plunkett and Sundell’s framework of metalinguistic negotiation, and reframes this dispute as a pragmatic negotiation over the functional roles these concepts serve, including scientific, professional, regulatory, training, and safety functions. Rather than adjudicating what PS/PT really are, I invite disputants to articulate why they prefer one label over the other. This shift enables more productive, function-oriented dialogue aimed at resolving competing normative concerns. This framework of metalinguistic negotiation may help stakeholders in this debate to make meaningful progress on scientific, ethical, and regulatory objectives even amid persistent conceptual disagreement.
Adolescents sometimes express firm views about high-stakes medical decisions that conflict with those of their caregivers or clinicians, raising difficult questions about how much weight their wishes should carry. A recurring concern is whether such decisions will later be regretted, although the normative significance of future potential regret remains hotly debated. Recent work in adult bioethics has proposed using artificial intelligence–based Personalized Patient Preference Predictors (P4s) to estimate what current treatment incapacitated adults would have chosen based on their known or inferred preferences when last autonomous. This paper explores whether, and with what ethical significance, a parallel ‘Paediatric Personalized Patient Preference Predictor’ (P5) could be applied to children and young people. We analyse how predicted future preferences might bear on questions of substituted judgment or proxy consent, best-interests assessments, resistance to treatment, and adolescents’ own deliberation. We distinguish different groups of paediatric patients based on current and future decision-making capacity, and identify both where a P5 might have greatest promise and where it is least defensible. We identify challenges for a P5 including that of self-reinforcing or self-negating preferences as well as of deciding which future preferences are relevant to current decisions. We argue that, in paediatrics, predicted future preferences cannot ground substituted judgment in the adult sense, but may nonetheless play a supportive role in best-interests reasoning and shared decision-making, subject to significant epistemic and ethical constraints.
