Donald Trump’s candidacy for president ignited an argument about the ethics of mental health professionals talking publicly about the psychiatric well-being of prominent individuals. His actions in office have not quelled this conversation. Those opposed to such commentary focus on potential violations of the president’s confidentiality, while the proponents of such revelations target the danger to the country arising from not clinically addressing his behavior. Organized psychiatry maintains that psychiatrists should not comment on the mental health of public officials without a personal evaluation and the individual’s consent, a decree known as the Goldwater Rule.
The topics of confidentiality and dangerousness highlight the ethical principles of autonomy (patients have the right to make decisions about their health care, including releases of information), beneficence (doing good for the patient or society), and non-maleficence (minimizing harm to the patient or to society). The ethical principal of veracity — that all commentary be true and accurate — has lurked silently in the distant background of this conversation — a particular irony in the Age of Trump. We need to discuss veracity because it undergirds the Goldwater Rule.
The Goldwater Rule was created in response to the election of 1964, when several hundred psychiatrists answered an opinion poll by Fact magazine regarding Arizona Senator Barry Goldwater’s fitness for the presidency. Goldwater successfully sued the magazine for libel because many of the quotes from psychiatrists, although cloaked in psychoanalytic and psychiatric terminology, were patently personal and political attacks. Interestingly, Goldwater himself claimed to be more traumatized by the implications that he was homosexual than by accusations that he was a “megalomaniac” or “a paranoid schizophrenic.” The American Psychiatric Association appended the Goldwater Rule to its Principles of Medical Ethics in 1973 both for ethical reasons and to avoid further professional embarrassment from psychiatrists sounding judgmental, inconsistent and inaccurate. Our lack of veracity created a bigger negative impression than our lack of probity. In some aspects, the Goldwater Rule represents “guild tripping” - an attempt to coerce silence to safeguard the reputation of the psychiatric guild.
Ethical commentary depends on veracity; all false statements about the mental health of public figures are inherently unethical. The Goldwater Rule addresses veracity by implying that anything less than an in-person interview constitutes conjecture rather than a thorough evaluation. However, a large body of research demonstrates the fallibility of the in-person interview for psychiatric diagnosis. Disagreements about what condition an individual manifests occur even when clinical researchers follow carefully scripted questionnaires. In numerous court cases, experts who have interviewed defendants arrive at diametrically opposed assessments regarding culpability, motivation, and even basic diagnosis. I routinely see adults who robustly and unequivocally meet the full definition for ADHD who previously were only identified and treated for depression, anxiety, or substance abuse problems.
Psychiatry has attempted to reduce diagnostic subjectivity by increasingly basing decision-making on observable behaviors rather than on feelings, motives, or putative psychodynamic progenitors of a condition. In the modern era, society has created vast video libraries of the behavior of public personalities, in a variety of settings, often over a span of years. The public record also encompasses collateral information from numerous sources, and occasionally even inklings of an individual’s motivations, feelings, and internal thoughts, when reporters, acting as surrogate clinicians, have elicited such personal commentary. These public archives contain more pertinent, behavioral information about Mr. Trump and other prominent individuals than we can obtain from a few hours of in-patient interviews. Furthermore, diagnoses established from public records can’t violate confidentiality, since they don’t rely on any private information.
Many of our behaviorally-defined psychiatric diagnoses actually also require knowledge of the motivations for given behaviors. Personality disorders defined by patterns of behavior demonstrating “disregard for the rights of others,” “a need for admiration,” or “attention-seeking,” demand awareness of both the behaviors and the reasons for the behaviors. In contrast, simple behavioral symptoms (e.g. interrupting others, being inattentive, fidgeting), devoid of any imputation about the driving motivation, define ADHD. The vast public record available for Mr. Trump and others suffices to allow a diagnosis of adult ADHD; the in-person clinical evaluation can not remain the gold standard when it provides less information.
In a democracy, citizens require knowledge about conditions that impair a candidate’s judgment or decision-making in order to make informed voting decisions. Psychiatrists, with expertise in identifying mental illnesses and their consequences, should be leading discussions regarding the mental health of public leaders who have clear evidence of psychiatric disorders. It is unethical, on the grounds of veracity and non-maleficence, to abdicate our obligation to society and relegate these conversations to those with less training or knowledge. That would be like relegating public discussion of global warming to TV weathermen, untrained pundits or anyone who has been rained on, while forbidding commentary from climate scientists. We should strive to provide the public with the most accurate information available, whether or not people use that information wisely.
The Goldwater Rule was formulated a half century ago when all psychiatric diagnoses were conjectures, all mental illnesses were deeply stigmatized, and our notions of privacy were radically different. If we have achieved substantively greater diagnostic veracity, then we have altered the entire framework for determining beneficence and non-maleficence in making a psychiatric diagnosis. Our changing psychiatric knowledge and privacy standards have thrown cold water on the Goldwater Rule. We must upgrade the Rule to reflect how ethics apply in our modern world.
In the early days of the AIDS epidemic, ACT-UP promoted the slogan “Silence Equals Death.” In our own era, an impulsive action by the president could easily trigger nuclear combat or conventional war. Rationality and ethics demand an honest, accurate and public evaluation and discussion of the origins of his impulsivity. If we do not revise the restrictions imposed by the outdated Goldwater Rule, we may well be colluding in a situation where our professional Silence Equals Death.
John Kruse MD, PhD is a San Francisco based private practice psychiatrist who has specialized in adult ADHD for the last twenty-five years.