This article is more than 5 years old. Information may no longer be current.
Debating the Goldwater Rule: Should psychiatrists weigh in on Trump?
Click Here to Manage Email Alerts
SAN DIEGO — In a symposium here at the American Psychiatric Association Annual Meeting, experts debated the statutes of the Goldwater Rule, which states that psychiatrists should not provide professional opinions about the mental health of individuals they have not treated.
The Goldwater Rule was established following the 1964 Presidential election, in which Fact magazine published a survey that asked 12,356 psychiatrists whether candidate Sen. Barry Goldwater, the GOP nominee, was mentally fit to be president.
Of the 2,417 psychiatrists who responded, 1,189 reported Goldwater was unfit to serve.
Goldwater later sued the magazine, which was found liable for damages.
“Psychiatric expertise in reaching diagnostic conclusions about a person requires much more than merely checking off the list of criteria in the DSM,” Paul Appelbaum, MD, of Columbia University, said in during the symposium. “There has been no shortage of articles over the last year on behalf of both mental health professionals and others who are willing to focus on some aspect of the character, behavior or statements of major political figures, candidates, and of course this continues with the president, to offer their diagnostic conclusions. These conclusions are all over the map, ranging from narcissistic disorder to bipolar disorder, ADHD, psychosis to sociopathy, just to name the most prominent possibilities that have been suggested.”
Appelbaum expressed similar concerns that the Goldwater Rule addresses, including protecting the integrity of the mental health profession, the impact on real individuals, and discouraging individuals from seeking psychiatric care.
Concerns with the Goldwater Rule
Jerrold Post, MD, of George Washington University, who served as a political psychologist with the CIA for 21 years, reflected upon his experiences with the interaction between politics, psychology and ethics.
“I have frequently been approached regarding leaders of concern. With the exception of the discussion of the Goldwater Rule [in the New Yorker], I have foresworn that opportunity, citing the Goldwater Rule,” Post said. “I’m increasingly uncomfortable in not having commented on the wealth of psychiatric diagnoses offered by people without psychiatric training. It feels to me unethical not to contribute at this perilous time.”
He recommended the APA reconvene to reconsider the Goldwater Rule and “examine more flexible ways in dealing with the dilemma of contributing in an ethical manner when the political psychological behavior of a public figure is of such concern.”
In March 2017, the APA reinforced the Goldwater Rule, which included new clarifications and specifications of certain phrasings, highlighting lack of consent, application of diagnostic standards and causing or increasing stigma.
Claire Pouncey, MD, PhD, of the University of Pennsylvania, expressed dissent with the reinforced Goldwater Rule.
“This raises a number of questions. If there’s no consent from the public figure of whom I might want to comment publicly, then it’s not a diagnosis by definition, tautologically. It is not a professional opinion, it’s an opinion expressed by a person who happens to be a mental health professional. But there’s still an ambiguity there that is not clarified by the new wording,” Pouncey said. “It’s also odd to me that by specifying that we’re not supposed to comment on an aspect of a mental status exam, we also don’t get to comment on most aspects of human behavior... I also want to know how does me choosing to speak publicly about a public figure threaten my integrity or the integrity of the profession? Do I not make a good arbiter of my own integrity?”
Legal courts are in place to hold individuals accountable for potentially slanderous statements, according to Pouncey, so why does the APA need to make a rule specifically for psychiatrists?
“I’m not really sure how this would reflect directly on the APA, assuming we don’t have an identical situation to the Fact magazine extravaganza,” she said. “The last thing I want to know is how me speaking out, or any of us of speaking out about a public figure who concerns us as citizens or psychiatrists, how does that stigmatize persons with mental illness?”
Nassir Ghaemi, MD, MPH, of Tufts University School of Medicine, echoed these concerns.
He argued differences between the consent of a private individual with no public role vs. a public figure who may influence lives, such as instating income tax laws or a military draft.
“If that’s the consent we’re talking about, [of that] private individual, that private individual has to seek our consent to give them the power to do these things like start a war,” Ghaemi said. “Democracy, as you know, rests on the consent of the governed, and that’s not being taken into account. The public has a right to medical and psychiatric knowledge of its leaders, at least in a democracy.”
Further, Ghaemi stated that the Goldwater Rule itself stigmatizes the act of being diagnosed with a mental health disorder.
Proceed with caution
In response to the varied opinions of Appelbaum, Post, Pouncey and Ghaemi, Paul Summergrad, MD, of Tufts Medical School, shared concerns with both sides.
In opposition to Ghaemi, Summergrad stated that an appropriate psychiatric diagnosis requires more than just a behavioral assessment.
“I do think that most psychiatrists, certainly in inpatient and emergency settings and other places where one deals with severe illness, do receive collateral information. I do [physical exams] when it is clinically indicated and even if I don’t, I certainly refer people. I review laboratory data, and get MRIs and other medical evaluations and tests. Indeed, that information is critical to make an appropriate diagnosis,” Summergrad said. “I think that if we assume that the limits and the nature of psychiatric diagnosis are simply to observe the behavior that one receives in a way that may be biased through the media or may be subject to confirmation bias, we lose the opportunity for a more in-depth understanding, including the degree to which somebody may or may not be suffering or creating suffering, both of which are important considerations in making a psychiatric diagnosis or in not making a psychiatric diagnosis.”
He agreed that many leaders, such as Abraham Lincoln and Winston Churchill, have had mental health or neuropsychiatric disorders but also achieved greatness.
“While I personally don’t believe psychiatric illness or various forms of neurodiversity are necessarily a burden or intrinsically negative, again, we’re dealing with where the general public is and where the world is and frankly, where our understanding is, of many of these illnesses. While we have responsibility to advance those. I don’t think that is, in it of itself, enough to overturn the limitations in the Goldwater rule.” – by Amanda Oldt
Reference:
Appelbaum P, et al. The Goldwater rule: Pro and con. Presented at: American Psychiatric Association Annual Meeting; May 20-24, 2017; San Diego.
Disclosure: Ghaemi reports financial ties with Sunovion Pharmaceuticals Inc. The other researchers report no relevant financial disclosures.