Ketamine-Induced Dissociation as an Ethical Signal, Not a Side Effect: Context as the Determinant of Clinical Duties Under Beneficence and Non-maleficence

Abstract

Ketamine has emerged as an important intervention in contemporary psychiatry, yet its acute dissociative effects remain ethically under-theorized. Clinical approaches often frame dissociation as either a liability to minimize or a therapeutic feature to promote, but both views oversimplify a context-dependent phenomenon. We propose that ketamine-induced dissociation is better understood as an ethically salient signal whose significance is shaped by patient vulnerability, dosing, preparatory framing, interpersonal support, and post-session integration. Using a framework grounded in beneficence and non-maleficence, we conceptualize dissociation not as a neutral side effect but as a predictable alteration of subjectivity that may orient patients toward harm or therapeutic possibility. We distinguish two clinically meaningful trajectories: the dysphoric trajectory of dissociative experience, characterized by threat appraisal and foreseeable psychological harm, and the integrative trajectory of dissociative experience, characterized by meaningful or generative appraisal that may permit emotional reappraisal and meaning-making. We advance a dual-trajectory model in which clinical context shapes these outcomes, supporting proportionate safeguards rather than categorical exclusion and informing consent, risk assessment, and intervention design.