The age of Donald Trump has brought with it a conundrum for many of the nation’s psychiatrists: Should they speak out about what they see on their TVs and their Twitter feeds every day? Should they openly speculate about the mental state of the most unusual, impulsive president the country has elected in modern history?
Technically, they can’t. As psychiatrists, they are subject to the American Psychiatric Association’s Goldwater Rule, so-called because it was written in the wake of an embarrassing 1964 episode in which almost 1,200 psychiatrists responded to a survey commissioned by Fact magazine by saying they thought Arizona senator and presidential candidate Barry Goldwater, who was running against Lyndon B. Johnson, was psychiatrically unfit for the office. The issue was larded with over-the-top, unscientific language; one doctor, for example, called Goldwater a “dangerous lunatic.” After losing the election badly, Goldwater sued the publisher and won $75,000, or about $586,000 in today’s dollars. The APA responded in 1973 by instituting the rule, which, as the organization’s website summarizes, “prohibits psychiatrists from offering opinions on someone they have not personally evaluated.”
And there the rule has sat, an annotation to the ungracefully titled APA publication Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, for the most part uncontroversial until this election cycle. But the emergence of Trump has caused a number of psychiatrists — as well as psychologists, whose field’s own governing body has no Goldwater Rule — to write and be quoted in stories claiming Trump could have a condition such as narcissistic personality disorder. This, in turn, has ignited a controversy over the Goldwater Rule.
Now, though, the rule faces its first potentially serious challenge: As Stat News reported yesterday, earlier this month the executive committee of the American Psychoanalytic Association told its 3,500 members in an email that they should feel free to flout the Goldwater Rule. “We don’t want to prohibit our members from using their knowledge responsibly,” a past president of the organization told Stat’s Sharon Begley, especially in light of the fact that, as far as presidents of the United States go, “Trump’s behavior is so different from anything we’ve seen before.” To be sure, this is a drop in the bucket in terms of the wider world of psychiatry, given that the American Psychiatric Association has more than 37,000 members, but it’s still a noteworthy act of pushback against what has, for decades, been seen as a fairly important rule. It’s also one that should be welcomed: The Goldwater Rule is an outdated mandate that does more harm than good.
Perhaps the best way to understand why is to examine the various ways the arguments for the rule fall flat. “Supporters of the Goldwater Rule have cited three main rationales for adhering to it,” wrote Benedict Carey in the New York Times last year. “Most diagnoses made from a distance turn out to be wrong; the labels themselves can cause real harm to the person and family members; and the practice undermines the field’s credibility, particularly its commitment to confidentiality.”
None of these reasons is compelling. Surely psychiatrists can comment upon public figures without diagnosing them. In fact, any such commentary absolutely must be accompanied by the disclaimer that without evaluating a patient in person, an official diagnosis isn’t possible. Rather, a psychiatrist commenting on a public figure is simply making informed inferences based on the publicly available information, in much the same way an aviation expert might comment on a deadly plane crash without having direct access to the crash site or the details of the subsequent government investigation.
And, yes, it can be harmful for a public figure and his or her family to have psychiatrists suggest there is evidence that they are unsuited to a given position. This ties into the broader, commonly made claim that to talk about Trump’s — or some other major figure’s — mental-health problems in a certain way is to contribute to the overall stigma that hangs heavy over the subject. But there has to be some balance here; surely some psychiatric problems should be disqualifying for certain positions that entail responsibility for other people’s well-being. Were it the case that Trump has untreated narcissistic personality disorder (as some experts believe he does), that would suggest he is a bad fit for a position like president of the United States. The logic extends far beyond Trump, of course: Going back to the air-disaster example, nobody thinks an individual with untreated, suicidal depression should pilot an aircraft. Imagine if after such a disaster a psychiatrist went on TV and said, “Based on the available evidence — his text-messages and emails and conduct with his co-workers — I think there is a real chance this pilot suffered from major depressive disorder, though I can’t say with certainty and we will never know for sure since he is no longer alive.” Could that label harm the pilot’s family, or cause some people to wrongly believe it’s common for depressed people to harm others, contributing to stigmatization? Sure. But on the other hand, the psychiatrist’s informed opinion could be an important contribution to the public debate over what happened and how to prevent similar disasters from unfolding in the future. (Carey’s final point, regarding confidentiality, simply doesn’t apply to situations in which a psychiatrist isn’t discussing their own patient — the only ethical rule prohibiting psychiatrists from commenting responsibly on public figures is the Goldwater Rule, not any of the rules or laws pertaining to confidentiality.)
It’s also worth pointing out that in terms of its real-world enforcement, the Goldwater Rule is paper-thin; as written, it doesn’t even carry any penalties. “In principle the psychiatric association could file a complaint with a member’s state medical board,” writes Begley in Stat, but that “has apparently never happened.” So it’s unsurprising that some psychiatrists are simply ignoring it, opining about Trump in print or on TV. This has led to an unfortunate situation in which the only psychiatrists truly gagged by the rule are those who are conscientious enough to follow it in the first place. This probably skews the sample of psychiatrists willing to comment on Trump’s mental health so that it’s mostly those with relatively extreme opinions — that Trump is a clear and present danger to the republic, or that even bringing up the potential that he has mental-health problems is staggeringly out of bounds — taking part in the conversation. A more diverse range of voices would make that conversation more intelligent and less hysterical.
Supporters of the Goldwater Rule are coming from a good place. Accusations that people are too mentally ill to do certain jobs, or to do them well, shouldn’t be hurled around willy-nilly, and can be stigmatizing in certain situations. Moreover, the last thing anyone with an interest in mental health should want is for every political debate in the U.S. to descend into an uninformed slugfest over over which candidate is “crazier.” But perhaps because these concerns are so colored by a single, unfortunate outlying event — that legally troubled, scientifically questionable issue of Fact magazine — some of them are overstated. In reality, it is very unlikely that credible psychiatrists would make public statements of concern about public figures’ psychiatric well-being in all but the most urgent cases, given the potential hit to their professional reputations. Those who would take these claims too far, who would politicize vital questions of mental health, would be drowned out and ostracized by their more professionally responsible colleagues. Overall, given how emotionally charged the debate over Donald Trump’s strange, frequently abusive behavior is, it would be useful to have more expert voices participating — the benefits clearly outweigh the costs. The psychiatric establishment should follow the American Psychoanalytic Association’s defiant lead and retire the Goldwater Rule altogether.