Soul Quest and Lightning in a Bottle: Liability Verdicts For Wrongful Deaths Involving Psychedelics
Ron McNutt, June 15, 2024
Ron studied religious use of psychedelics at Tufts, where he was a religion major. He has been a litigation attorney for most of his 41-year legal career. Ron is the steward of the Litigation and Advocacy Committee of the Psychedelic Bar Association. In October 2024, he will serve a one-year chaplain residency with the Veterans Administration hospitals in Nashville and Murfreesboro, Tennessee.
Some thoughts about my time with Soul Quest
Soul Quest Church of Mother Earth, Inc. was founded in 2015 in Orlando, Florida by Chris Young and Verena Young. It is formed as a neo-shamanic church with a hybrid retreat center model, like many plant medicine ceremonial centers in Peru and Latin America. Dr. Scott Irwin was a corporate director as well, but he resigned and left for Ecuador in July 2021. He is living with the Sacha Wasi, an indigenous village with medicine ceremonies.
My introduction to ayahuasca was at Soul Quest on March 9–10, 2018. I went back for ceremonies the weekends of August 14–15, 2020, December 4–5, 2020, March 26–27, 2021, August 26–27, 2021, January 28–29, 2022, and October 14–15, 2022. I have had 20 ayahuasca ceremonial weekends, 7 at Soul Quest, and I have never tried Kambo. Ayahuasca can cause blood sugar to drop, or blood pressure to increase, so it is necessary to stop eating after 3:00, to have a clear diet beforehand, and to avoid contraindicated medications. I did not eat enough the first time I went, although eating beforehand was recommended. Adequate nutrition is very important with ayahuasca consumption.
I was feeling very well when I left that Sunday from my first ceremony. Chris was encouraging people to have Kambo ceremonies. Two weeks later was the ceremony weekend that led to the death of Brandon Begley. He died of hyponatremia, low sodium levels, which can be caused by overhydration. There was evidence that the decedent consumed copious amounts of water after having Kambo that Sunday morning, despite directions to the contrary. Chris Young has emergency medical tech training, although his EMT license expired in 2006.
The jury found that Chris he was responsible for the delay in obtaining medical treatment. Brandon was showing signs of distress around 2:00, shortly after the administration of Kambo. He was not responsive at 5:00, and around 8:00, was given cane sugar water, and shortly afterward, he had a seizure. Chris called 911 at 8:09, and Brandon was unresponsive and unconscious when emergency medical assistance arrived.
I kept the preparation materials and the schedule from Soul Quest from March 2018, a couple of weeks before he died. They were having Kambo on Sundays at 11:00 after the Friday and Saturday night ayahuasca ceremonies, and the Saturday daytime ceremony. Kambo is not a psychedelic but frog venom that causes severe shock and disruption of the autonomic nervous system. The materials have instructions that encouraged people to drink a lot of water the morning of a Kambo ceremony. Brandon had attended Soul Quest the weekend of February 23–25, 2018, and did not have Kambo.
The tragic events and the verdict are a cause for carefully considering precautions, but I believe the verdict itself is a precedent with numerous factors and deficiencies: it is not only the ayahuasca, or only the combination with Kambo, that were deemed to be the cause of death. The tragedy took place after Kambo, combined with several hours of lack of response when emergency treatment was needed, and honey water. The verdict considered a variety of compounding problems from these various factors, not just the ayahuasca and Kambo together that make an unsafe product. Chris Young’s decision to mix the two at Soul Quest and not take urgent action may be a fatal flaw for Soul Quest, but the result should not be interpreted to discredit this powerful spiritual medicine.
I hope that people will not view that weekend as representative of the level of care that Soul Quest has provided to this time. I think Soul Quest improved itself with strong leadership by the women and men it developed as facilitators and guardians. From September 2020 until January 2022, I was volunteering with the Sunday service production team with Scott and four core people. At its peak, there were about 26 online integration groups, a medical director, paramedics, with layers of accountability: facilitators, guardians, and volunteers. They trained many volunteers, and provided screening, orientation, preparation calls, advice and directions on diet, supervision, programs like yoga for grounding, and integration. The period from mid-2020 to late 2022, when I was participating and volunteering, I felt there were excellent staff and a great volunteer program. I noticed in early 2023 that Soul Quest lost almost every one of the exemplary leaders I had known; they did not retain the facilitators and guardians I knew, and they have moved onward.
The facilitators were responsible for securing the premises and making decisions about treatment challenges, supported by guardians. There was an onsite medical team led by Tiffany Riley, an emergency medicine and natural medicine practitioner. There were therapists and life coaches who would lead groups, with significant experience, and they would take a five-month training course called Being True to You. There was a very diverse group of participants and leaders. It was a healing space with people of different races, ages, and backgrounds. There was a purification ceremony, and a prayer before we would drink dosages of varying amounts deemed appropriate for one’s experience and condition. The volunteers would wear white clothing and escort people who had to go to the bathroom. Spiritually evocative music from different traditions would be played.
Many people would come to help heal trauma and addiction, and problems such as dependency. Soul Quest provided insight from Dr. Gabor Mate and the therapists and life coaches. The leaders encouraged intentions of reverence, openness, and respect, to cooperate with the ayahuasca experience, which was understood to reveal the universal source and presence that are part of the inner essence that is joined with creation. The experience revealed layers of resistance that can be released and help one connect more deeply with one’s soul, to be more alive, open to positive changes in relations and wellbeing, and gratitude, forgiveness, and love.
The online groups included lessons from A Course in Miracles and other sources. There were groups for paramedics and there was a lot of effort to serve veterans and military personnel. Sometimes indigenous facilitators would preside, including the Kuntanawa and Yawanawá. Factors such as the retreat format, irregular attendance, the absence of a central set of theological beliefs, the presence of for-profit health care aspect, the Natural Healing Center, and the wrongful death case, led to the conclusion by the DEA that it was not a sincere religious organization.
John P. Begley, personal representative for Brandon K. Begley v. Soul Quest Church of Mother Earth, Inc. et al., Orange County Circuit 2020-CA-003387-O (May 15, 2024):
On May 15, 2024, an Orlando, Florida jury returned a $15,048,526.25 wrongful death verdict against Soul Quest Church of Mother Earth, Inc., and Christopher Young, the CEO, president, and co-owner of Soul Quest, after a seven-day trial with several witnesses including medical doctors in nephrology, forensic pathology, and toxicology, and an expert psychiatrist, Charles Grob, M.D. The exhibits included medical and emergency records, the autopsy report, corporate records, and documents related to Soul Quest’s safety guidelines and practices. The jury found Chris Young liable for failure to exercise ordinary care in causing Brandon Begley’s death, and that Soul Quest served a dangerous product, apparently the Kambo combined with ayahuasca, leading to a wrongful death that occurred in March 2018. The verdict apportioned 40% liability to Soul Quest, $6,019,410.50, and 60% liability to Chris Young, $9,029,115.75.
The jury concluded that the decedent died after severe, acute hyponatremia resulting from the decedent’s experience with Kambo following his ayahuasca ceremonies. It is a condition of low sodium, which can result from overhydration or excessive vomiting. The jury rejected the defense’s contention that Brandon Begley was negligent in causing his death. Chris Young was called as a witness for both sides and he apparently acknowledged at trial that he got it “wrong” and that he did not know what severe, acute hyponatremia was. According to the verdict, the jury concluded that the decedent had not misrepresented a prior medical history or contributed to causing the hyponatremia, and that Chris Young’s delay in calling for medical attention after a medical emergency, with Mr. Begley having seizures, precluded an opportunity for medical attention to save his life. Saline solution used between 2:00 and 8:00 likely would have saved Brandon Begley’s life.
Soul Quest had wonderful leadership by women, particularly Tiffany Riley, the on-site medical director, several facilitators and guardians, Laurie Maddox, Norelle Adams, Lori Drell, Lenoria Kroos, Lora Parsons Wilson, Colleen Mix. Grace Charles was an active volunteer and originally from a Haitian family. Ben Heimann, Carlos Guzman, Scott Irwin, Brandon Pickard, and many other men also provided strong leadership at important times. I would like to praise the facilitators, guardians, and the volunteers who improved Soul Quest and to thank everyone committed to risk reduction who can apply lessons learned. We should encourage careful preparation with appropriate nutrition and healthy ways to approach this profound experience.
Soul Quest had screening and preparation practices and informed consent and waiver of liability forms, as well as medical screening measures. The exculpatory documents were not admitted as defense exhibits. The signed forms did not identify the proper parties, and they were objectionable as violative of public policy because of the illegal status of the sacrament and the adverse opinion in the Eleventh Circuit, as well as the presence of a claim for strict liability for serving a defective product (which involved the multifaceted issues) that was unreasonably dangerous.
The proof revealed a very bad case characterized by a combination of ceremonies with ayahuasca followed by a later session with Kambo, compounded with an unreasonable delay in calling emergency medical services. The case should not be interpreted to support a general principle that ayahuasca is an unsafe medicine. Serving the two substances in series was deemed to be an unsafe product. The jury was informed that ayahuasca is a “Schedule 1 controlled substance,” and there was evidence that Kambo created a physiological hazard. The combination of events and evidence at trial provide a way to distinguish the result, and Soul Quest’s improved supervision and risk reduction practices resulted in more favorable results since 2018.
The verdict is a warning to other facilities not to hesitate to call 911 in emergencies, to be able to recognize health emergencies, not to overdo the dieta requirements, and not to compound risks by offering Kambo in conjunction with ayahuasca. It also will increase skepticism by institutions like the DEA and academicians, and inhibit domestic practices with ayahuasca in large retreat settings, and steer people toward small ceremonial circles using best practices. The case about Soul Quest’s religious protection was decided against it on appeal, and I do not think the petition for rehearing is going to change it, so it is almost final. Maybe it could reform as a different entity, and try to be a better model that will gain protection as a religious entity. The corporation and owner could get some relief in bankruptcy.
Coincidentally, on May 24, 2024, an article in The Guardian discussed a coroner’s investigation of the death of a 46-year-old Australian man, Jarrad Antonovich, on October 16, 2021, at a Dreaming Arts Festival in New South Wales. The investigation revealed that a ceremony combined ayahuasca and Kambo. The decedent was becoming was becoming increasingly ill but he was opposed to going to a hospital and he later died of a perforated esophagus. A witness said he had not disclosed to the facilitators that he had asthma. Leaders at the ceremony apparently were opposed to seeking medical help and one of the facilitators said he was being looked after appropriately. The facts indicated that the facilitator and decedent were inhibited by the illegality of the medicine and the desire to protect themselves, and there was evidence that one of the facilitators made efforts to discourage a witness from revealing facts. After an investigation, the case was referred by the coroner to the Director of Public Prosecutions as a criminal matter.
ICEERS report on worldwide ayahuasca deaths:
There was a June 2023 overview by International Center for Ethnobotanical Education, Research and Service (ICEERS) of the global reported deaths in the media associated with ayahuasca retreats. It concludes that the acute effects of ayahuasca intoxication using the traditional formulas for ayahuasca without other admixtures probably did not cause of any acute deaths. Extrapolating from various sources, it estimated about 4.24 million people had consumed ayahuasca with about 824,000 individuals doing so in 2019. About 1.3 million people from the U.S. have had ayahuasca, with about 200,000 having it in 2019. Most people who had the experience, 62 %, had a bachelor’s degree or more education, and a similar proportion were professionals. 94 % would have it in a ritual context under the leadership of a specialist. Most of the retreat centers were in Peru, 173, with 20 in Costa Rica, 14 in Colombia, 13 in Ecuador, 7 in Brazil, and 5 in Bolivia. The settings typically are one-week retreats with 3 to 4 ceremonies. About 567,000 Brazilians had experience with ayahuasca, in religious settings like União do Vegetal, Santo Daime, Barquinha, or neo-shamanic traditions.
From 1994 to 2022, there were 16 cases of death after consumption of ayahuasca, involving possible adverse reactions to ayahuasca, but the study concluded that these reactions could have been instances of contraindicated drug use or an admixture such as Brugmansia. There was a bone fracture and a case of hyponatremia or heart attack. Although there were 58 reports of deaths associated with ayahuasca, some apparently had not involved consumption. There were 8 homicides, 14 suicides, 3 drownings, and 4 tobacco infusions in the context of the ceremonies. The study concluded:
The deaths that the media reported were indirectly from ayahuasca could have been avoided by incorporating safety standards when admitting participants, supervising the experience, and integrating it afterward, or offering psychological follow-up if necessary. Based on our preliminary analysis, the ratio between the deaths directly or indirectly attributed to ayahuasca and the number of people taking it worldwide seems to be very low.
Lightning In a Bottle case
Gatlin et al. v. Do Lab, Inc., and MAPS, the Multidisciplinary Association for Psychedelic Studies, Inc., California Civil Court, Case №20CV002753 (Nov. 30, 2022).
On May 28, 2017, a 20-year-old woman, Baylee Gatlin, died from multiple organ failure from heat stroke after she had been cared for at the Zendo sanctuary harm reduction tent at the Lightning in a Bottle festival. She had been sent by the medical tent personnel to the harm reduction tent without indicating that she was in great distress. The peer support staff did not know what substance she had taken, or appreciate the extent of her heat stroke. Her vital signs were checked at the Zendo tent, and after her condition deteriorated, she was moved to the medical tent and later died after being transported from the festival by emergency medical service providers.
A wrongful death suit was filed by her parents in Los Angeles. The jury found a breach of the duty to exercise ordinary care with respect to training of volunteers to identify medical emergencies and call for medical or emergency services. The jury found that this led to postponing calling for emergency services. The finding of breach of the duty of care involved representations that created the reasonable expectation that there would be safety at Zendo’s support tent. The festival was not close to outside medical facilities, and the volunteers at the sanctuary tent had received admission to the festival for their services without receiving extensive training.
Although the Zendo project limited its role to support services, the liability determination shows that peer support providers are working within an unpredictable environment supporting others. Volunteers need to be able to identify a medical emergency and call for emergency services.
MAPS indemnified its volunteers and staff under respondeat superior principles. It was found to be 25 % liable under comparative fault principles for Ms. Gatlin’s death. MAPS paid the portion of a $ 4 million verdict, $ 1.33 million, of its subsidiary, Zendo, to her parents. While the medical provider was held to be 50 % liable, there had been a settlement the previous year between the personal representatives and the event producer, Do Lab Inc., and the medical providers, Richard Gottlieb, individually and doing business as RGX Medical, for $ 4 million. The medical providers were insured to provide medical services at the festival, while MAPS was self-insured.
Zendo is a nonprofit corporation that was founded in 2012, and it has provided harm reduction for over fifty events. Originally, it was part of MAPS, which began offering peer support in the early 2000s. Zendo has been independent since May 2023, and it has secured liability insurance. The director of Zendo, Chelsea Rose Pires, stated that since the 2017 tragedy, Zendo has developed protocols to require eight hours of training per event, increased communication with medical providers, enhanced digital record keeping with documentation of medical involvement, and involvement of medical personnel in each shift. Zendo has adopted an interdisciplinary healthcare Pulse Team to provide additional support. A medical triage volunteer will monitor for signs of dehydration, heat exposure, and physical distress. When peer support providers have questions about the health of a guest, they will need to contact medical staff immediately and document the information.
For volunteers who support people having challenging psychedelic experiences, it is important to build relationships with providers of security, law enforcement, medical services, and festival producers. Sara Gael, who has been involved in the leadership of Zendo, was present in 2017. She noted that people do not ordinarily test their drugs and that they did not know what Ms. Gatlin had taken. She seemed like hundreds of other distressed guests that they had served over the years. Adulterated and novel substances often have lethal doses, and drug testing could be an important safeguard going forward.
Psychedelic peer support services are offered to reduce the risk of adverse consequences from experiences with psychedelics, which can provide important experiences that are also difficult and frightening. Intense emotions and altered emotions arise from confronting unfamiliar and deeper parts of the psyche, which can result in existential distress. This is amplified in cases of inadequate preparation, unfamiliarity with the experience, large doses of substances, difficult circumstances, and uncomfortable settings.
Compassionate care services like Zendo, which involve volunteer support, can help prevent serious adverse consequences. Peer support traditions include the Hog Farm at Woodstock, and similar services were offered at earlier festivals, as discussed in Dr. Larry Brilliant’s book, and in Grateful Dead parking lots, at Rainbow Gatherings, and at the Boom Festival.
Sitters can provide support in grounding guests who are medically safe by offering empathy and assurance in a gentle and ethical manner and a peaceful space, alongside medical treatment options and mental health services for individuals requiring services outside the parameters of peer support. They can help people gradually become grounded and transition through difficulties to synthesize and learn that “strength, resilience, surrender, and deep wisdom are often forged in the fires lit in our darkest times.”
Raymond Allen, the general counsel for MAPS, stated in October 2023 that organizations need to have clear contracts and exercise due diligence before partnering with individuals and organizations. He advised that there should be clear lines of authority, clear roles and job descriptions, training and management standards, and terms providing for medical responsibility and legal liability. He stated that a harm reduction organization should have its own liability insurance coverage.
Attorney Allison Hoots discussed the case in May 2023, and discussed the liability risks facing volunteers and providers of support. Public perception and society’s prohibitionist policies can create pressures that inhibit efforts to make consumption safer. Safety measures are subject to consequences under the 2003 “Rave Act,” The Illicit Drug Antiproliferation Act of 2003. This legislation enhanced penalties under a prior law, the “Crack House” law, that punish activities that knowingly allow drug use. The Rave Act was directed at organizers of electronic dance parties, creating liability for promoters and club owners. It provides fines up to $ 250,000 and civil penalties for knowingly leasing, using, or profiting from a space where illegal drugs are being stored, manufactured, distributed, or used. The law inhibits measures like providing medical or educational services for people who are taking drugs. It can confuse harm reduction and safety measures, like medical support and traditional mental health crisis responses, with encouragement and persuasion to use illegal substances.
Ms. Hoots advised that people should be encouraged to consult in advance with their personal physicians. She emphasized that a Third Circuit decision in 2021 held that the “Crack House” law applied to the activities of a nonprofit safe house, punishing efforts to reduce risks.
Dance Safe and Test Your Poison sell testing kits online for detecting contaminants in substances. Contamination and heat exposure are serious dangers in this area.
For people sitting for people having psychedelic experiences, even well-worded waiver forms and informed consent forms, asserting that the user knowingly and voluntarily agrees to accept the risks of medical contraindications and mental health risks, are by no means a guarantee of protection. Insurance companies do not cover illegal activities, and even making referrals or recommendations for centers operating outside of the county can create liabilities for problems people face at their destinations.
The Substance Abuse and Mental Health Services Agency, SAMHSA, a division of the federal Department of Health and Human Services, leads public efforts to advance behavioral health and improve outcomes for people impacted by substance use disorders. In the summer of 2023, Zendo was invited to discuss integrating psychedelic harm reduction into federal initiatives. In addition to counseling through the Fireside Project, Dance Safe offers drug testing kits, to help prevent overdoses or other harm from adulterants or contamination.
It makes good sense to have legal protection for ceremonial practice with psilocybin, as well as San Pedro cactus, which do not present the same danger from contraindicated medications. In May 2024, there was a performance audit report by the U.S. Government Accountability Office to congressional committees, which was highly critical of the DEA religious exemption process with respect to psilocybin-based spiritual practices. It revealed that the agency was creating barriers to protecting ceremonial practices with psilocybin through artificially restrictive and unclear reporting demands, failing to follow through with the review process, and rejecting applications. The agency was admonished and placed on an improvement plan to improve its process for recognition of Religious Freedom Restoration Act claims.
