Robust conversations have been emerging in the psychedelic ecosystem related to accessibility. Many factors like race, gender, sexual orientation, and geography are central to these conversations, yet they are all (at least tangentially) related to the single largest accessibility issue: cost. As a naturopathic doctor I regularly wrestle with the difficulties of offering services outside the conventional healthcare system where sometimes the best care is not covered by insurance. As a professional in the psychedelic field I have been navigating various paradigms around the economics of these services, including an ends-justifies-the-means argument for regular old capitalism. This argument was once asserted to me as being analogous to Abraham Lincoln’s methods for ending slavery. Being something of a history nerd, I’ll break this historical argument down, because it fits, but maybe not in the way the psychedelic CEO who made it intended it to.
Psychedelic therapy is expensive; this is not unique, however. Mental health is among the most expensive health conditions treated in the United States, rivaling cancer, cardiology, and emergencies.1 The reason for this is myriad, but among them is the lack of (and complexity of) insurance coverage and the fact that many mental health providers opt out of the insurance system which often does not support them.2
I was drawn to naturopathic medicine because I saw it as a solution to a broken system. Naturopathic doctors are trained in holistic primary care, which means that we take more time with our patients to look for root causes, and balance modern, evidence based protocols with time tested traditional remedies. As a naive student, I blamed the foibles of the American healthcare system on the providers and figured if there were more holistic providers out there the system would improve. But it is not quite that simple.
In America, capitalism drives the healthcare system. Insurance companies make their money by collecting premiums while providing as little service as they can to consumers. While medical training institutions likely have the intention of training caring professionals, they also want them to be successful which means training them to the system that gets them paid, not one that challenges the status quo. Add to all of this the lobbying power of insurance, pharmaceutical, and medical technology companies that influence government policy and we have a beast of a problem to solve. Naturopathic doctors, if they can accept insurance at all, are often paid less than other professionals with less training for the same service. Insurance policies limit the time we can spend with patients and the types of treatments that get covered, forcing us to either act more like conventional providers or forego the insurance model, limiting our practices to cash payments that are financially inaccessible to many who need care.
As evidence for psychedelic therapies continues to mount and we move closer to legal pathways to provide them,3 the question looms large as to how we are going to pay for them? Although insurance coverage may come eventually, I'm not holding my breath that it will come soon enough or be delivered in holistic models, because insurance companies seemingly only care about short-term cost effectiveness. In part, this is because insurance in America is tied to employment impacting those with frequent job changes. No individual insurance company has the incentive to pay for expensive treatment even if it claims to be “ten years of therapy in a day.” It’s unlikely patients will be paying premiums long enough for insurance companies to recoup the cost; keeping patients on a cheap antidepressant until they change jobs and make it the next insurance company's problem is far more effective to maintain the insurance company's bottom line.
Despite the multitudes of people who would benefit from these treatments who cannot afford them, there is a market for people who can. This has created a “gold rush” of sorts. It was flattering at first, to have people reaching out to me as someone who knew something about psychedelics, which is why I entertained conversations, even from LinkedIn. Eventually, however, I noticed a pattern emerge. Johnny Q. was tired of years in corporate America, when his wife/friend/himself cured their malaise, depression, etc. with mushrooms or an ayahuasca retreat and now he wants to bring this amazing medicine to the world. The models they posed and the questions they asked assumed a clientele that looked like them and had money to spend. These exploratory conversations were always one directional in that I gave them answers to their questions and I got nothing in return. One of these cases, however, came via a personal connection and resulted in some paid work.
From the beginning I had reservations about the leadership of this company and their business model. The founder was charming, visionary, and genuine in his conviction that he was building his company to help people and while I never doubted his good intentions, his shadow motivations (more on this later) were firmly on my radar. Although challenging the person writing my checks was difficult, he was open to some degree of philosophical debate, so I engaged him on issues around ethics and the moral implications of capitalism, especially when it came to psychedelic healing work. At the time, the company was in the process of becoming publicly traded.
Capitalism at its best has given us many good things. It fuels innovation and has generated extraordinary convenience and nearly immeasurable prosperity. However, at its worst, it embodies the colonizing spirit; the need to get there first, extract as much value as possible by whatever means, send the wealth back to investors, and move on with little to no regard for the consequences. While most businesses may be either good or neutral, the system allows the worst to flourish among us. I have always found it curious how we have allowed even something as fundamental to life as healthcare, (including psychedelics for healing), to be within the boundaries of profit seeking investors. How is it moral to see human suffering and think, ‘sure I’ll help, but only if I get more out of the suffering person than I put in’?
When I brought up these questions or suggested reading We Will Call It Pala,4 which without reading he called “socialist propaganda”, he defended capitalism with the following logic: By selling shares, as a publicly traded company, he would be “printing money” which would enable the company to fund psychedelic services to people. His unofficial motto was something like, ‘get the medicine to as many people as possible, right now’. He claimed to not care if the company was hugely profitable as long as it stayed in business to keep helping people.
One debate we had stands out in particular. I was waxing philosophical about the inherent nature of capitalism depending on extraction, and the risk, especially of a publicly traded company, of losing its way. This can happen when a well intentioned founder is forced by fiduciary duty to make decisions in the interest of profit driven investors rather than clients, workers, or anyone or anything else, not least of which is the spirit of the medicine itself, or he is replaced all together. His response is worth a careful breakdown because it fits in more ways than one, none of which is how he intended it.
He admitted that at its worst capitalism can and does cause harm, but the economic system as a whole is a lesser evil than alternatives. Then he pointed to the precedent of how Abraham Lincoln passed the 13th Amendment to end slavery. Amending the U.S. Constitution is a difficult task that requires tremendous support and he didn’t have the votes outright. So, he pulled strings to make deals, trade votes, offer positions, and indirectly bribed congressmen to vote for it. He did some shady political, and perhaps unethical things to get an ethical job done, ending slavery. The end justifies the means, my colleague argued.
If we zoom out on that piece of American history, however, another story can be told. The foundations of the colonial American economy was entirely dependent on imported African slave labor. Among the many tensions between the American colonies and the British Crown was their hinting toward ending slavery in America, which it had already done throughout most of the empire.5 This was a motivation for the southern colonies to join a union of states to fight for independence. Many of the founding fathers wanted to ban slavery from the outset, but they knew that to successfully fight off the mighty British empire, their only chance was to be united. This meant appeasing the southern states’ resolve to maintain slavery.
Following the successful war for independence, the founding fathers took another big risk: democratic rule. Though democracy had existed in the past, no Western nation had pulled it off in centuries. Would they succeed or fail only to be once again ruled by a European monarchy? The more urban and textile oriented economy of the northern states needed the agricultural states of the south to hope for a successful national economy. A united defense was going to be vital to protect any individual state from conquest. But the Southerners knew that in a democracy, the more populous North would vote to end slavery. So after a great deal of debate, compromises were reached in what became the U.S. Constitution. Each slave would count as 3/5ths of a person during a census to determine representation in the House of Representatives and each state would get two senators regardless of population. Both gave a disproportionate advantage to the slave states of the South and are forever memorialized in our founding document.
At the time, the divide between urban and rural was much smaller than it is today, so the senate compromise might have seemed more reasonable. It also seemed more reasonable at the time when the states had more autonomy and sense of identity, whereas today we think of ourselves as American before Virginian or Rhode Islander. Neither of these compromises, however, resolved the conflict around slavery. Decade after decade the issue persisted and many compromises were debated, implemented, and redacted. As more states joined the Union, and it appeared that we would expand across the continent, the issues of balancing the vote in the senate in favor or opposition to slavery became a constant concern. This tension reached a boiling point in the 1860 presidential election. It was immediately upon the announcement that Abraham Lincoln, who was known as a fierce abolitionist, had won the election that South Carolina seceded. Within a year the conflict turned to violence, and the American Civil War was underway, which to this day remains the bloodiest war in American history by deaths per capita. We were slaughtering each other to determine if we had a right to enslave one another or not.
So why the history lesson, you ask? Because the psychedelic “industry”, like Lincoln, has a choice to make. Will we try to operate within a broken system, try to fix it, or build something new? Lest one be too quick to point out the silliness of comparing capitalism to slavery, lets briefly examine their parallels. The most obvious point is that slavery is a capitalist practice. It degrades a human being to an asset to be bought, sold, and used for the benefit of an owner. The American manifestation of slavery was designed around racial distinctions, but it didn’t invent racism, that unfortunately, lives within every human. We are born with survival instincts which include fear of the unknown, people who don’t look like us, and scarcity. This fear of scarcity can, and often does, persist in the context of abundance; we call this greed, and it is what drives capitalism. The way to overcome racism and greed is to uproot the fear from which they grow in each of us. But this is neither simple nor easy work. Before discussing how we might get there, we need to return to Lincoln and what he did versus what he could have done for context.
Today the state of Wyoming has a population of 577,000 people, the least of any state, yet has two senators who are Republicans, who have the same amount of power to pass laws, confirm supreme court justices, and fulfill other senatorial duties as the two Democratic senators from our most populous state of California with its 39,186,000 people. That equates to a Wyoming resident having 68 times more voting power than a Californian when it comes to representation in the Senate. Not only is it still an urban and rural divide, but for the most part it is still a coalition of the same Southern states impeding progress on a number of cultural issues, including especially policies with racial implications. The system we have gives disproportionate power to rural states. The not-so-funny thing about power is that once someone has it they tend to justify having it and are reluctant to give it up. So how do we change our broken system of representation? It would seem we have to change the constitution or come up with a new one.
If ever there was a time in American history that we had an opportunity for a do-over in designing the modern world’s first democracy, it was during the American Civil War. Lincoln doesn’t appear to have ever considered the idea of convening a new constitutional convention, nor was there a political will to do so.6 He was staunchly committed to the law we had and holding our fragile new nation together. He believed that there was no legal path for a state to secede and was deeply committed to upholding the constitution, though during the war he had to justify bending a few rules and exercising powers he did not.7 This duty to the written law runs deep in the American tradition. I still vividly remember the day I enlisted in the Army by raising my right hand and swearing an oath to uphold the Constitution. I did not pledge my allegiance to a flag, president, piece of land, or a group of people, but a document. To this day it is not uncommon to hear people talk about the Constitution like it is a sacred scripture.
Having grown up in a conservative Christian home that took the Bible to be the perfect and literal word of God, the mindset of revering old documents with good intentions is familiar. The problem with rigid allegiance to a written doctrine is that it carries the risk of becoming outdated, open to interpretation, and creating power dynamics that have led to organized religions which define who God is and what “He” wants. These power dynamics create hierarchies of leaders, some of whom abuse that power. Certainly there is a lot more that could be said, but I will leave the subject by saying that perhaps a more holistic and genuine spirituality would be based on direct personal experience rather than the authority of others.
Returning to the subject of law, it is relevant to point out that they are constructs that exist only so far as we permit. Laws are made, enforced, and upheld by human beings who accept them however legitimate or dubious their justification. While the law’s underlying purpose is often safety, history provides innumerable cases of laws creating safety for some at the expense of others. Few understood this point better than Martin Luther King, Jr. who said, “One has not only a legal, but a moral responsibility to obey just laws. Conversely, one has a moral responsibility to disobey unjust laws.” In short, we have an obligation to change oppressive systems.
Change is not only needed, it is possible. This former political conservative, Christian, soldier turned liberal, Buddhist, healer is living proof of that. Change, however, is not easy. Fortunately, we have something that helps. Most psychedelics work, at least in part, by temporarily inhibiting the function of the default mode network (DMN).8 The DMN consists of several distinct areas of the brain that are responsible for our sense of self. Many mental health conditions are associated with increased activity in the DMN. It appears that suspending our sense of self enables us to see things from a new perspective and perhaps recognize our interconnection with the universe which may result in a release of our suffering. Furthermore, psychedelics have a neuroplastic effect, helping us rewire our nervous system and allowing new connections or narratives about what it means to be who we are.
In other words, psychedelics have the power to disrupt rigid systems. This is why their use has been historically repressed. The Christians sacked Eleusis and burned witches to consolidate their religious authority. The Nixon administration started the War on Drugs to oppress minorities and liberals who opposed their capitalist agenda.9 Despite evidence from the resurgence of psychedelic research examining their healing potential, they remain illegal today, though this doesn’t prevent everyone from doing them anyway. Psychedelics’ disrupting nature causes many to ask ‘Why take someone else’s word for what is sacred when you can have a direct experience yourself?’ ‘Why settle for marginal improvement when you can have a breakthrough?’ We have already established that unjust laws ought to be changed. But how we enact change matters.
A common psychedelic phenomena is increased feelings of interconnectedness to all things. While this is often a very beautiful experience it can also be a dark one. Light always casts a shadow; we all have some darkness within us. To be whole we must accept all our parts and reject none of them. Where there is incongruency, we move toward integrity. This is how we create peace within ourselves. To reject some part of ourselves or live in contradiction to our own values is to invite turmoil. How do we accept the scared, greedy, racist, and selfish parts of ourselves? Acknowledging their existence is a good place to start. We all have the survival instincts from which these negative attributes originate. By accepting them as part of our human nature, we can learn to control their impulses rather than allowing them to control us.
So how do we examine our need for financial security while working in the psychedelic healing space? There is no doubt an exchange of value when providing healthcare, be it psychedelic facilitation, talking with a psychotherapist, or getting an herbal medicine consultation. I believe few would argue that providers deserve to make a fair living. To run a practice that is capable of financially supporting providers, one must engage with business services such as marketing, scheduling, real estate, etc. These are aspects of running a practice that few providers enjoy and where businesses can provide real value. What I find dubious is why CEOs and investors are suddenly interested in healing all the suffering in the world. Psychedelics have enjoyed a quick rise in the awareness of the public in recent years. Many see this as a beacon of hope for mending mental, emotional, or spiritual distress; others see the potential of psychedelics to shift global consciousness in ways that may save us from climate change and extinction. Some, it seems, smell opportunity.
Start ups abound claiming to be the “first” company doing something special in the field that is going to help countless people. When I see these claims I find myself questioning the intentions of the individuals behind these companies. I wonder how much of their focus remains on the bottom line while they operate and promote themselves under the guise of altruism. When they cite the number of diagnosed cases of mental illness, do they think in terms of real humans and their suffering, or sales opportunities? Regardless of intentions, these companies are still operating under capitalistic frameworks. The trendy new treatment is just the next market to exploit until they get a return on their investment and move on to the next thing. To be fair, practitioners are not immune to the trappings of capitalism either. There is money to be made not only in providing services, but creating training programs, and consulting. Possibilities for conflicts of interest abound. So what do we do about it?
Lincoln and his contemporaries chose the path of compromise. Of course it’s much easier to criticize history than it is to make it and the context of the political situation of Lincoln’s time was more complex than I am able to articulate in this article. In short, Lincoln may have produced the best possible outcome given the circumstances. That being said, Lincoln took a fundamentally flawed system, born from compromise with slave owners, and fixed it just enough to keep it going. As a result we are stuck with the same dysfunctional, polarizing system to this day.
I acknowledge there is a heavy dose of idealism that I’m prescribing here and none of the changes I’m proposing will happen overnight. Nonetheless, if we passively accept that capitalism is the vehicle available for us to deliver psychedelic healing, surely some good will come from it, but just as ending slavery with the 13th Amendment did not end or prevent centuries of systemic oppression and political dysfunction that continues to this day, capitalism will fail to deliver this medicine to the people who need it the most. Capitalism has no incentive to do any differently. A better system starts with universal healthcare that includes accessible psychedelic therapy from trained professionals when that is most indicated. It also ends the prohibition of these substances and protects them as a religious right, so that communities can provide them in their own way to those who need or want them for the exploration of their consciousness, cultivation of spiritual practice, or healing in whatever way they see fit.
The political battle for universal healthcare has been raging for decades and resolution is unlikely any time soon. While psychedelic advocates ramp up their efforts to decriminalize and reschedule these substances and protect their practice as a 1st Amendment right, those who raise the accessibility and cost issue should recognize that it is no different than the need to make basic healthcare, if not high quality holistic healthcare, accessible through a single payer system. Furthermore, I would argue that all healthcare should be non-profit in principle, and providers should receive pay reflective of their value. However, I am not suggesting that all organizations should become non-profits under the currently available regulations governing non-profits. The 501(c)3 IRS tax-exempt organization rules are cumbersome and designed mostly for charities. Most of the regulations are to prevent wealthy people from exploiting the system in order to avoid taxes. What we need is a new type of non-profit organization that removes capitalist incentives from the healthcare industry, while making it possible for clinicians to run successful businesses.
Why not just run a business with integrity? Of course this is what we should do; it is possible and many are doing it. However, operating a business in a capitalist economy is not unlike resisting your favorite ice cream in the freezer. Some have the will power or accountability to resist the indulgence, others struggle; regardless, knowing it is there has subtle effects. We did not evolve in an environment that had anything near the sweetness of a tub of ice cream. Thus, to our paleolithic brains eating ice cream is somewhat equivalent to finding a bunch of berries full of vitamins, antioxidants, and environmentally-rare carbohydrates. It feels good but in actuality ice cream has no redeeming nutritional value. Today we have unparalleled access to junk food that activates our brain’s reward system leading to unhealthy habit formation. Capitalism not only feeds these bad habits, it is analogous to them. Just as we have become addicted and dependent on cheap, nutrient deficient food that is destroying our health, we are addicted and dependent on quick profits and propping up industries that are destroying the environment and our souls. We need an economic system that is not only more equitable, but one that nourishes us and the ecosystem of which we are a part.
Healers, as much as any other human beings, are susceptible to the prospect of making money, yet as stated before, making money is not the problem. The problem is the very human tendency to let our reward circuitry unconsciously (or consciously) influence how we do things. And while intentions are powerful, they are not enough. Fortunately, we can choose to create systems that naturally operate in integrity. This can look like clearly written mission statements to be held accountable to, published financial details, regular community gatherings of stakeholders, etc. that embody transparency, humility, and interconnection. The alternative is to keep your freezer stocked with ice cream and hope that you never have a bad day.
In my own entheogenic experiences, I often connect to something that feels numinous, which is to say true, ancient and infinite. These kinds of experiences go by many names, but “mine” is not one of them in the sense that they are unique to me or something to be owned or sold. In my clinical work with ketamine or the lectures I give on psychedelics, it would be absurd to claim that any of the ideas, techniques, or wisdom I use or share, are my own. While I spent years working hard to study and acquire these skills “there is nothing new under the sun,” and they are not mine to hold onto. I believe in holding to the maxim “there is no first owner, only a first thief”. That is why I feel it utterly incongruent to think of psychedelics as a resource to be mined for investors. I would encourage anyone with any level of interest in participating in the psychedelic ecosystem to be wary of capitalism’s invitation and requirement to hold a cognitive and spiritual dissonance within yourself. Instead, like a psychedelic journey, we ought to take the opportunity to be introspective about our form of government, our healthcare system, our religion, and ourselves, and take the courageous step toward death, so that they can be reborn into something new, more connected, and more whole.