T

he once-obscure Goldwater rule, propounded by the American Psychiatric Association in 1973 to prevent reckless speculation by psychiatrists about public figures, has become a flashpoint. The timing, of course, is no coincidence: Donald Trump’s presidency has shattered the broad agreement among psychiatrists about whether it is ethical to comment on individuals they haven’t personally examined.

The rule was created in response to a 1964 survey conducted by the editors of Fact magazine. They asked 12,356 psychiatrists, “Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” Some of the answers printed in the magazine clearly reflected bias. The episode chastened the APA, which established the rule in 1973.

The Goldwater rule exalts the doctor-patient relationship. But here’s rub: Unless the public figure in question happens to be your patient, there is no doctor-patient relationship. Across other branches of medicine, it is commonplace for physicians to offer insight when a public figure’s medical condition is in the news. Orthopedists weigh in on the star quarterback with a high ankle sprain; cardiologists on a political candidate who has a fainting spell. Everyone knows that the physician is not making a definitive diagnosis, but is instead helping the public understand the implications of a condition that is within the specialist’s domain.

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The amicable consensus around appropriate parameters for public speech by psychiatrists came apart after Trump was elected president.

Last year, I was one of 35 psychiatrists who signed a letter to the New York Times decrying the fact that among the plethora of op-ed columns expressing concern about the mental state of the president, the Goldwater rule had blocked psychiatrists — the medical specialists with the most training to comment on that topic — from doing so.

A month later, possibly in response to that letter, the APA doubled down, expanding the rule beyond its traditional “no diagnosis from afar” meaning to prohibit psychiatrists from making any comment about a public figure’s mental health.

That opened a schism in American psychiatry. The APA accused those who spoke out of practicing “armchair psychiatry.” Supporters of the APA position reproached us for jeopardizing patient trust and enhancing stigma, and of acting like the psychiatrists who colluded with “crimes of eugenics in Nazi Germany and political repression of the Soviet Union.”

Others, myself included, bemoaned organized psychiatry’s “gag rule,” applauded those who were speaking out about Trump and about the rule as responsible contributors, and argued that psychiatrists have a “duty to warn” of dangers to the public’s well-being. Respected researchers who were not affiliated with our group did an extensive review of the literature and found the Goldwater rule to be “outdated and premised on dubious scientific assumptions.”

As this debate raged, 27 of us wrote a book, “The Dangerous Case of Donald Trump.” Notably, its title and editorial stance conspicuously avoided diagnosis, and instead focused on the issue of dangerousness. We maintained that the psychiatric community has a broader social responsibility to sound an alarm when it recognizes danger, acting as what psychiatrist Robert Jay Lifton called “witnessing professionals.” We view such speech as an ethical imperative, not a transgression.

We believed that the APA had effectively backed itself into the untenable position of asserting that all speech by psychiatrists constitutes medical opinions of the kind given in the consulting room, and thus must meet the standard of an in-person examination and requires the individual’s consent. Perhaps the APA felt that the public would not be able to recognize our speaking as informed specialists in a public role.

This extension of the Goldwater rule gets into regulating not just psychiatrists’ clinical practice, but also what we’re permitted to do as citizens in the public sphere, as though psychiatrists don’t regularly voice opinions as teachers, researchers, writers, and expert witnesses. This narrow view, at odds with real life, precludes recognizing our responsibility to the community at large.

Mental health professionals, like much of the society we live in, seemed to be hopelessly polarized and deadlocked over the Goldwater rule. A group of us, including the majority of the authors of “The Dangerous Case” book, are offering a fix.

Our proposal urging the APA to recognize that psychiatrists have a responsibility to warn of dangers that threaten the community will be presented to the association today by Dr. Lifton, the esteemed psychiatrist who actually did the ground-breaking research on Nazi and Soviet physician collaborators, and Dr. Judith Herman, a renowned expert on trauma.

The main points of our proposal (discussed elsewhere in STAT) are:

  • The APA should acknowledge that psychiatrists have a social responsibility to warn the public when they discern a danger to the public’s well-being arising from the mental state of an official who is in a position to cause great harm. This acknowledges the role of psychiatrists as “witnessing professionals.” When doing so, it is important for those commenting to identify themselves as psychiatrists so the public can register that they speak as professionals from their training and experience, and are not speaking casually or from personal bias.
  • The APA must recognize that psychiatrists’ duty to use their professional knowledge to educate the public on matters that fall within their areas of expertise does not violate the confidentiality or privacy rights of public figures because such constraints on speech do not apply where there is no bona fide doctor-patient relationship.
  • The APA’s assertion that it is unethical for a mental health professional to comment on a public figure’s psychological functioning without an interview rests on shaky scientific ground. In the 45 years since the Goldwater rule was adopted, substantial multidisciplinary research has cast serious doubt on the primacy and necessity of an in-person interview as the sole basis for assessment in all circumstances.
  • We affirm the duties of confidentiality in the care of our patients and urge those who speak out to exercise restraint in the use of psychiatric terms to avoid potentially stigmatizing patients who seek and deserve conscientious treatment.

These limited, practical revisions to the Goldwater rule would correct its most severe shortcomings and facilitate psychiatrists’ responsible engagement with our complex society.

Leonard L. Glass, M.D., is associate professor of psychiatry at Harvard Medical School and senior attending psychiatrist at McLean Hospital in Belmont, Mass. He resigned in protest from the American Psychiatric Association in April 2017.

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  • The Goldwater Rule needs to stay at least until the American Psychiatric Association cleans up its diagnostic act. In their latest Diagnostic and Statistical Manual, Fifth Edition (DSM-5) the reliability coefficients for diagnoses relevant to Donald Trump, such as various personality disorders or early cognitive impairment, are pitiful… just pitiful at around 0.2-0.4. Those numbers tell us that 2 psychiatrists assessing the same patient will disagree in between 20% and 40% of cases. Until the APA cleans that up, debates about the Goldwater Rule are a waste of time.

  • Good grief, where to start?
    Physicians possess unique privileges, and their opinions carry unique weight with the public (at least for now…). It seems common sense that physicians must accept unique restrictions on their pronouncements. If they do not, they run the risk of making ridiculous mistakes in public diagnosis from afar but andvembarrassing the entire profession with their rush to politically colored judgement, undermining the public’s trust by appearing to be political animals rather than scientists. Dr Glass gives physicians far too much credit for the ability to segregate their political biases from their medical conclusions. Physicians are as likely to be mislead by their biases as the average person. Research has confirmed this over and again. Moreover, even at their most objective after a thorough in-person examination, physicians are at times wrong in their diagnoses, particularly when it comes to the inscrutable world of mental illness. Do we really want to put diagnoses—and inevitable misdiagnoses—on public display to confirm the public’s perception of fallibility? Medicine already possesses a reputation for narcissistic practitioners, elitism, and arrogant disregard for the thoughts of patients and the non-initiated. Dr Glass and colleagues seem hellbent on giving that reputation steroids. Physicians are not licensed pundits nor superheroes. They have no duty to save society from itself. Declamations by physicians on the mental fitness of public figures will not reform public opinion; rather, they will convince the public medicine deserves less trust. You think a lot of parents avoid vaccinations now? Wait until a group of pediatricians (or some such) with a conservative axe to grind decide the 2020 Democratic presidential candidate suffers from “womanly hysteria” or “an obvious personality disorder brought on by a dysfunctional childhood and overblown self esteem.” We’ll have physicians in a public war of opinion to the detriment of all, and patients will suffer. I have had people tell me, “I am afraid to have my doctor discover I’m a conservative, that he secretly won’t like treating me, give me worse care.” Some research suggests these patients’ fears are not unfounded. Physicians cannot run the risk of inflaming suspicions of bias, of becoming “them,” “elitist liberal professional types” who look down on patients for political affiliation, or consider some political views correlative of mental illness. Physicians already face similar longstanding suspicions among women and minority groups. They should work on correcting the perception of a hierarchy of care rather than reinforcing it.

  • The issue is not one of whether the celebrity has the right to privacy, it’s that any psychiatrist who believes they have the ability to objectively diagnose mental illness in a celebrity through the polarized lens of television, social media, or news articles, is either greatly overestimating their own ability discern truthful information or greatly underestimating how warped the information is that they’re drawing from.

    Information created from any major media source was made for the purpose of engagement, persuasion, or entertainment. It was not made for the purpose of diagnosis and care. To diagnose a celebrity based on information taken from television, newspapers, editorial magazines, or social media is to trust a selective curation of facts, taken from sources with their own motivations and biases, and use them to make a diagnosis.

    It does not matter how experienced you are or how objectively you attempt to look at the information at this point, because you are building a diagnosis from faulty materials.

    This is very reckless, and deserves the condemnation it draws. If you wish to enter the political arena, you are more than welcome to do so, but do not do it armed with the title of psychiatrist, as that title is meant to be used only in pursuit of helping and healing.

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