SAN DIEGO – Do psychiatrists who question the mental state of President Donald Trump have a professional or personal obligation to speak out if they fear his words and actions endanger the nation?
That question prompted a packed and sometimes heated panel discussion early Sunday during the annual meeting of the American Psychiatric Association here. The answer for many, including some prominent members of the profession, was a resounding "yes."
But a 1973 APA policy known as the Goldwater Rule tells them they can't -- not without conducting an examination of the man and receiving proper authorization or consent -- lest they be found guilty of unethical behavior, face professional rebuke, and ultimately, get themselves kicked out of the association.
It doesn't look good for the APA if its members are spouting off about public figures they only know through media; that's one reason why the profession and the association must uphold its standards, argued APA past president Paul Summergrad, MD, psychiatrist-in-chief at Tufts University in Boston, who was one of the panelists.
But many in the room disagreed. Some called the Goldwater Rule nothing more than a "gag" rule, a violation of their right to free speech, especially during these particularly tempestuous first months of the administration. They want the APA to eliminate the rule, or seriously modify it, because they need to be "liberated" to speak out about the clear signs and symptoms they're trained to recognize, and which they believe suggest the president could lead the nation into an unnecessary war.
Unusual Times
Jerrold Post, MD, a panelist and George Washington University professor who has assessed the mental health of political leaders for 21 years for the Central Intelligence Agency, asked whether this "election campaign [is] not one of those circumstances" when psychiatrists should speak out.
"Is this not a time when it is in fact unethical to be silent, when we were particularly called upon to contribute?" Post said.
"One of the things I'm generally concerned about – I'm not sure if it's because I'm a psychiatrist, but as a citizen -- is if that interesting character in charge over in North Korea, Kim Jong-un, and that interesting character who happens to be our president at this point, get into a spiral, I really worry they could play off each other and we could stumble into an international war," Post continued.
Post wants the APA to convene a commission to reconsider the rule, and "examine more flexible ways of dealing with the dilemma of contributing in an ethical manner when the political psychological behavior of a public figure is of such concern."
But in an APA committee meeting in March, the rule -- with a few modifications -- was reaffirmed. It's been part of psychiatry's culture for a long time, stemming from the results of a 1964 survey on "The Mind of Barry Goldwater," published by Ralph Ginzburg in Fact magazine, in which nearly 1,200 psychiatrists responded that the presidential candidate was unfit to run the country.
Many offered a number of specific diagnoses based on their observations from afar, through newspapers and TV: Goldwater had schizophrenia, psychosis, persecution complex, paranoia, or was sexually confused, to name a few.
To some of them, Goldwater was just like Hitler, or Stalin.
While Goldwater won a $75,000 libel case that put Fact out of business, and sanely served several more decades in Congress, the fact that so many psychiatrists -- even APA members – had weighed in, many with their own stark diagnoses of the candidate, caught the association off guard.
An Embarrassment
"The whole episode was clearly an embarrassment for psychiatry," said Paul Appelbaum, MD, a panelist and director of the division of Law, Ethics, and Psychiatry at Columbia University, who defended the rule.
The rule has to stay, he said, to protect people "who are the subject of our statements ... who might be harmed by our blind speculation."
Additionally, if psychiatrists were allowed to willy-nilly diagnose people they've never seen clinically, it may dissuade people from seeking needed psychiatric help because they'd fear being stigmatized by statements from psychiatrists whose opinions may seem authoritative to the public, but are actually not.
Besides, Appelbaum said, although a lot of information is available through social media, TV, and Twitter about one public figure in question, that's "inadequate as the basis for a psychiatric diagnosis or a formulation of any reliable sort."
That hasn't prevented many of his colleagues from making comments "all over the map," saying the president suffers from "narcissistic disorder to bipolar disorder to attention deficit hyperactivity disorder to psychosis to sociopathy – to name just the most prominent possibilities that are suggested," he said. "None of them are terribly accurate or at least can be assumed to be reliable."
Appelbaum made another point to those who would do away with the APA's restrictions: "The narcissism is not outside of our profession. The narcissism is within our profession. We have the notion that only we can save the republic. [That if] only we can get somebody to listen to us ... that this president has the following diagnosis ... they would completely abandon their political principles which led them to support that candidate in the first place."
Appelbaum added that there are "very few unemployed steelworkers in Michigan whose votes would have been changed by hearing me, as a psychiatrist at an elite university in New York, opining that I thought the candidate they were going to vote for was unbalanced and should not attract their support."
Summergrad added that the duty of psychiatrists to warn of impending danger "specifically implies a treatment relationship."
"I'm not sure any of us would want to have a new duty applied to us ... to scrub the behavior of all our political leaders such that ... we could be sued for breach of that duty. I'm not sure I want to have that liability."
Besides, he said, "at the end of the day, these are things that ultimately end in the political branches of government ... the legislature. There's a reason why they're number one."
Love the APA or Leave?
If psychiatrists don't agree, he said, they can "make a decision ... as others have done, [and] resign their membership and speak whatever they want. The only ethical constraint here is one that's bound by membership. It's not a licensing board type of issue."
That prompted several questions from attendees. "Is this love it, leave it?" asked one.
Another posed this question to Summergrad, or anyone who supports the existing rule: Can you conceive of a behavior or assertion by the current U.S. president that would be a potential threat to national security and could "compel a revision of this rule, or is it really unconstrained by anything he might say or do?"
Appelbaum replied that in "every election since Goldwater," mental health professionals including psychiatrists have expressed public concern about the mental stability of a major political candidate. And the comments "align perfectly with the political inclinations" of the speakers.
Still another attendee said she could give her opinion based on "the thousands of hours of videos, and hundreds of tweets, and past documents of behavior, et cetera, and I think it would be reasonable for me to be able to say this."
One of the panelists, Claire Pouncey, MD, a psychiatrist in private practice in Bala Cynwyd, Pa., made the free speech argument, noting that when the Goldwater Rule "tells us we may not speak out about our concerns or passions or fears that we really feel convinced about, it functions as a gag rule and then the Goldwater Rule is in itself unethical," she said. "If I say I'm Claire and I'm a psychiatrist and I think that guy's a whackadoodle, am I speaking colloquially or am I speaking as a psychiatrist?"
She added that if she can get arrested for protesting a healthcare plan without violating the APA's ethical principles, "then why can't I speak publicly about my professional opinion about a public figure's alarming behavior?"
Constantly Violated
Panelist Nassir Ghaemi, MD, of Tufts University, opposed the Goldwater Rule in part because the two elements it requires for a psychiatrist to give his or her professional opinion -- having conducted an examination of the individual and having been given authorization to make a statement -- are constantly violated in professional practice.
First, he said, psychiatrists frequently diagnose patients without their consent -- when people are brought into the emergency room by paramedics or police, for instance.
The Goldwater Rule requires psychiatrists to get a thorough history "mainly from the patient," but studies show many patients have no insight into their illnesses. More accurate information comes from parents and friends; but taking a patient's history from other people breaks the Goldwater Rule.
On the concern that a psychiatrist's professional opinion could stigmatize a public official, as it did in the Ginzburg case, Ghaemi said that a label isn't always necessarily bad. Many leaders excel in their roles maybe partially because of them, rather than psychiatrists "sending a message to the world ... that psychiatrists think it's bad to get diagnosed with a psychiatric illness." Instead, he said, the profession should be openly talking about it, coming out of the closet.
"Why shouldn't our leaders be encouraged to do that?" he said.
"If you have a public figure who can influence your life, who can tell you, 'I want 10% more of your income this year in taxes' or 'I want to send your son or daughter to war to die,' and you as a citizen can't actually say no, that private individual has to seek our consent to give them the power to ... start wars and to kill people," Ghaemi said.
"The public has a right to medical and psychiatric knowledge of its leaders," he added, "at least in a democracy."