Dying, Addiction, and Psychedelics: Who Gets to Alter Consciousness?

Some state laws allow people with serious, life-threatening illnesses to choose when to die. But few jurisdictions allow people to choose how to experience their deaths.

This is not a minor inconsistency. It is a statement about authority, describing who gets to alter consciousness, and which forms of altered experience count as legitimate. It is centrally about freedom of thought, deftly addressed by Mason Marks and by Matthew Lawrence.

Consider “Aldous,” a patient with end-stage ALS who qualified for medical aid in dying under the New York Medical Aid in Dying Act. In the final week of his life, he wanted to take LSD, not to hasten death, but to have an experience through which he had hoped to encounter death differently. 

The law permitted his death, but prohibited him from having an experience that he thought would be therapeutic and transformative. 

To access LSD, Aldous had to rely on others willing to break the law. The state allowed the method of death but reasserted control at the level of consciousness and, in Marks’ language, thought moderation. It’s as if they said, “You may experience death, but only in ways we recognize.” 

That boundary is not accidental. In Gonzales v. Oregon, the Court allowed states to authorize medical aid in dying. In Washington v. Glucksberg, it made clear that no constitutional right to die exists. And in United States v. Oakland Cannabis Buyers’ Cooperative, it rejected the idea that medical necessity could justify access to prohibited drugs, even for the seriously ill. The result is a narrow, tightly governed autonomy: The state may permit death, but it will decide how consciousness can be altered on the way to death.

Now consider “Janice,” living with severe opioid use disorder, cycling through overdoses, hovering near death. Her family sought ibogaine, a psychedelic often described as an “addiction interrupter.” Access was illegal, so she could not obtain it. As Lawrence explains, “[addiction] treatments are unavailable to many patients because of legal restrictions that reflect longstanding stigma surrounding mental illness.” 

Here the logic shifts and is contradictory. Aldous is trusted to choose death. Janice is not trusted to choose a transformation that could allow her to live, that, in Lawrence’s language, denied her “fundamental constitutional right to freedom from addiction.”

This is not simply paternalism. Rather, as Mason Marks has argued, it is content-based thought moderation implicating the First Amendment. Governments recognize some altered states of consciousness as therapeutic and permissible. They dismiss others as dangerous, illegible, or illegitimate, regardless of context. As Marks and I. Glenn Cohen point out, the FDA frames the subjective effects of psychedelics — including alterations of sensation and perception — as adverse events, and the more pleasurable or interesting those effects, the greater the potential for abuse, and more heavily restricted the substance. 

Psychedelics expose this attempt to moderate thought/consciousness with unusual clarity. They do not behave like conventional medicines. Opioids dull pain and sedatives suppress awareness and have familiar, governable effects. Psychedelics do something else entirely: They intensify, reframe and sometimes destabilize experience. They do not just treat symptoms; they can alter one’s perspective, provide valuable insights, and disrupt the frameworks through which pain and addictive behaviors are understood.

Psychedelics defy conventional allopathic categories. They resist easy measurement and challenge the authority of clinical categories. And despite growing evidence of their efficacy in treating PTSD, addition, and depression, they remain largely prohibited. Most psychedelics — including psilocybin, LSD, DMT, and mescaline — are Schedule I controlled substances under federal law, meaning they are considered to have no accepted medical use and a high potential for abuse. Possession, manufacture, or distribution outside approved research is illegal. Some states and cities have begun to relax these restrictions: Oregon allows licensed use of psilocybin, and cities like Denver, Oakland, and Santa Cruz have decriminalized possession, though federal prohibitions remain in effect.

What the law regulates, then, is not only risk. It regulates intelligibility: It allows only forms of consciousness or experience that it can classify and control, a distinction with real consequences for autonomy and care. It privileges forms of care that render consciousness manageable, predictable, and contained. It is disturbing that sedation is acceptable but meaningful transformation is not.

Seen this way, the contrast between Aldous and Janice is not an anomaly; it is a pattern. Autonomy is granted where it can be stabilized and supervised, rendering it less autonomous than restricted. It is withdrawn where it threatens to exceed those boundaries, especially when it involves forms of consciousness that cannot be easily disciplined. 

The question is not simply whether psychedelics should be legal in these cases. Rather, it reveals a potential gap between the law’s respect for autonomy and the reality of human experience, especially in extreme or vulnerable states. It’s not just about legality; it’s about what autonomy really means when life is at its most intense or fragile. Does autonomy include the right to alter one’s own consciousness at the edge of death, or in the depths of addiction? Or is that precisely where the law draws the line?

You may end your life, but you may not transform your experience of it. 

You may be protected from yourself, even as you are permitted to die.

This is not just a legal contradiction. It is an ethical one.

It suggests that what is ultimately at stake is not safety alone. It is legitimacy: Which forms of consciousness the state is willing to recognize, and which does it reject, even when rejection deepens suffering, or leads to death.