Op-Med is a collection of original articles contributed by Doximity members.
With a new election season now upon us and a re-intensifying of the debate over the current president’s “mental fitness” for the office, it is inevitable that the dreaded “Goldwater Rule” will once again rear its ugly and outdated head. What exactly is this rule? And what is its relevance? It is a self-imposed gag order, adopted by the American Psychiatric Association in 1973, enshrining the name of the 1964 ultra-conservative Republican presidential candidate into its “code of ethics.” The Rule forbids psychiatrists from speculating on the psychopathology of any public figure without having examined him or her as a patient, and without their written permission.
In the current political climate, this rule has made both minor and major headlines here and there as there has finally been some debate over whether the rule violates the more basic right to free speech. I would argue the rule more egregiously violates common sense. The Goldwater Rule was already badly outdated when it was formally adopted nine years too late in 1973.
First, some badly needed historical context:
During the presidential campaign of 1964, Senator Barry Goldwater received the passionate endorsement of the Ku Klux Klan as, in full Klan regalia, they marched in support outside the convention center in Daly City, California. The then-presidential candidate spoke quite openly of his intention to use nuclear missiles as “tactical weapons” in Vietnam. And when pressed, stated further, “Let’s lob one into the men’s room at the Kremlin.” Indeed, he had a bizarre penchant for quoting hyper-nationalistic ancient Roman senators, leading to the Democratic rebuttal of his own party’s slogan, “In your heart you know he’s right” with the pithier, “In your guts you know he’s nuts.”
In this political climate, fraught with Cold War anxiety, an American political tabloid, Fact Magazine, published and aggressively marketed a special issue titled, The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater. This was a take on Goldwater’s own recent bestselling book, The Conscience of a Conservative. The magazine surveyed 12,356 members of the American Psychiatric Association at that time, gathering 2,417 responses. The question was simply, “Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” There was space to elaborate.
The results were as follows: 50% stated plainly that Goldwater was unfit; 27% believed him fit; 23% could not form an opinion. 38 pages were devoted to select “comments”, mostly of a psychodynamic nature, some critical of the survey in general.
Goldwater lost to Lyndon Johnson in a landslide. Whether or not this survey played a role remains unclear. If it did, those responding psychiatrists, clearly less concerned with the ethics of diagnosing a very public figure than with the real world catastrophic possibilities of his election, certainly deserve applause. (Goldwater, by the way, did, in fact, go on to “successfully” sue the magazine — as is frequently noted by those in favor of the rule — winning a $1 award compensation.)
Over the subsequent decade, an embattled American Psychiatric Association — coming under fire from civil liberties organizations (civil commitments were increasingly portrayed as antiquated remnants of the old “moral treatment”), from gay rights activists (homosexuality was still a “disease”), from an increasingly cohering “anti-psychiatry” movement led by pop culture psychiatrists and philosophers, and popular science fiction writers, and from the rest of the medical establishment for its lack of diagnostic cohesion in general, indeed in a world spinning out of control — had every reason in the world to do its part for conservatism. The so-called “Goldwater Rule” was summarily adopted, without the popular vote, as part of the APA code of ethics in 1973.
Since then it has been deemed “unethical” for psychiatrists to express an opinion publicly of a public figure. If one were allowed to do so, one just might speculate over the paranoia of the APA leadership at the time, and whether creating such a rule was the equivalent of a schizophrenic wearing a tin foil helmet or, more simply, a child sticking his fingers in his ears and shouting, “La-la-la-la!”
The “rule,” like most rules that discourage critical thought, has since become dogma.
Interestingly, concurrent with the adoption of the Goldwater Rule was the establishment of the CIA’s Center for the Analysis of Personality and Political Behavior. This is the branch of the CIA responsible for psychologically profiling world leaders. Since then, the FBI, as well as several city police departments, have adopted similar techniques in the name of greater security. Clearly, there is some value to these psychological profiles. Clearly, too, if such analyses were run internally these results would remain highly classified. As for the possibility of psychiatrists publicly speaking their minds, the government has only to rely on the Goldwater Rule to ensure silence.
In fact, this rule has become so dogmatic that during the most recent presidential campaign there was a flurry of journal articles re-stating the Rule — without historical context — as a de facto threat, and the invariable “argument” that “…breaking the Goldwater Rule is…definitely unethical.” Psychiatrists Claire Pouncey and Jerome Kroll, on the other hand, stood out as taking the only critical shot specifically at the Goldwater Rule during this last election, concluding that the Goldwater Rule was “an excessive organizational response to what was clearly an inflammatory and embarrassing moment for American psychiatry.”
That said, however, I find myself once again reluctantly agreeing with DSM-IV architect and scholarly curmudgeon Dr. Allen Francis that all this diagnostic speculation, after the fact, is meaningless. The “problem” remains that being either a mentally unstable ruler, or frankly, a thug, does not preclude one’s being quite popular with one’s subjects, and “legitimate” rule in no way should imply reasonable rule. The people have spoken, and mental illness does not, and should not, preclude election to office.
This does not mean, however, that the public should not be educated as to the concerns associated with certain types of psychopathology. And this by the experts.
It is perversely not ironic that one of the most famously un-critical thinkers in history has lent his name to what amounts to a gag order on critical thought by the entire profession of psychiatry. With plain and simple thuggery running rampant among the highest offices in the land, more than ever the Goldwater Rule needs less revision than to be utterly stricken from the code of ethics as an embarrassing historical chapter. Again, I would suggest psychiatrists rely on their common sense. They should learn a lesson from their forebears in 1964 — who just may have had a role in averting nuclear disaster — and speak out more broadly, critically, especially in potentially dire circumstances.
Elliott Martin, MD, is a board-certified adult and child psychiatrist at Newton-Wellesley Hospital, as well as the Director of Consultation and Emergency Psychiatric Services at Newton-Wellesley Hospital, and Assistant Clinical Professor of Psychiatry at Tufts University School of Medicine. He is a 2018–19 Doximity Author.