Ketamine-Induced Dissociation as an Ethical Signal, Not a Side Effect: Context as the Determinant of Clinical Duties Under Beneficence and Non-maleficence
Gun Moon, Jack Noto, Zachary Shuler, Bryan Pilkington
HEC Forum September 9, 2026 DOI: 10.1007/s10730-026-09611-x (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Theoretical or philosophical paper Peer reviewed |
|---|---|
| Intervention | Ketamine |
| Topics | Esketamine Ketamine |
| Key points | Argues that ketamine-induced dissociation is an ethically salient, context-dependent signal rather than a neutral side effect, and proposes a dual-trajectory model distinguishing a dysphoric trajectory, characterized by threat appraisal and foreseeable psychological harm, from an integrative trajectory, characterized by meaningful appraisal that may permit emotional reappraisal and meaning-making. The authors contend that clinical context shapes these outcomes and supports proportionate safeguards rather than categorical exclusion. |
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.
Comparable studies
Other theoretical and historical papers on ketamine, most cited first.
| Study | Year | Design | Participants |
|---|---|---|---|
| From PCP to MXE: a comprehensive review of the non-medical use of dissociative drugs. | 2014 | Historical analysis | |
| A Dendrite-Focused Framework for Understanding the Actions of Ketamine and Psychedelics | 2020 | Theoretical or philosophical paper | |
| Neuroscience and the Near-Death Experience: Roles for the NMSA-PCP receptor, the sigma receptor and the endopsychosins | 1990 | Theoretical or philosophical paper | |
| A unified model of ketamine's dissociative and psychedelic properties. | 2022 | Theoretical or philosophical paper | |
| An Integrative Approach to Ketamine Therapy May Enhance Multiple Dimensions of Efficacy: Improving Therapeutic Outcomes With Treatment Resistant Depression. | 2021 | Theoretical or philosophical paper |
Citations in the library
Cites 30
- Subanesthetic Effects of the Noncompetitive NMDA Antagonist, Ketamine, in Humans Archives of General Psychiatry March 1, 1994
- NMDAR inhibition-independent antidepressant actions of ketamine metabolites Nature April 24, 2016
- Measurement of dissociative states with the Clinician‐Administered Dissociative States Scale (CADSS) Journal of Traumatic Stress 1998
- The effect of a single dose of intravenous ketamine on suicidal ideation: a systematic review and individual participant data meta-analysis American Journal of Psychiatry October 3, 2017
- Side-effects associated with ketamine use in depression: a systematic review. The Lancet Psychiatry 2018
and 25 more in the library