Jul 31 2017

The Goldwater Rule Revisited

goldwaterIn 1964 Fact Magazine published an article titled: “1,189 Psychiatrists say Goldwater is Psychologically Unfit to be President!”  They were later sued successfully for defamation. This incident led the The Goldwater rule – Section 7 in the American Psychiatric Association’s (APA) Principles of Medical Ethics, which states it is unethical for psychiatrists to give a professional opinion about public figures they have not examined in person, and from whom they have not obtained consent to discuss their mental health in public statements.

This rule has held sway for the last 50 years. However, recently the American Psychoanalytic Association (APsaA) e-mailed its members to inform them that they are not constrained by the Goldwater rule. So which stance is correct?

There are two competing ethical principles at stake. The first is the ethical responsibility of professionals not to cause harm to someone else by making public statements they have no business making. This is especially true when it comes to psychiatric diagnoses, because they carry a heavy and (in my opinion) unjustified stigma. The mere fact of being a public figure does not mean that medical professionals are free to bypass confidentiality and consent to make public speculations about your mental health.

Further, psychiatric diagnoses are especially complex and subjective. In order to make a accurate diagnosis you need a lot of background information about a person, and you need some professional interaction. This should ideally be a personal examination, however watching a video of another professional conducting an examination could suffice. But even then, the purpose of psychiatric diagnoses is to guide therapy. They are still fuzzy and subjective entities. It seems profoundly unethical to turn them against an individual, and use a formal diagnosis to medicalize their personality and behavior for non-therapeutic purposes.

When dealing with politicians, it is further very difficult for professionals to filter out their own ideology or personal feelings. It becomes too easy to use the tools of medicine for political fighting.

One might argue, however, that there is a competing ethical principle – a duty to publicly comment on a public figure who holds (or is vying for) tremendous power. Are there any cases extreme enough to justify breaking the Goldwater rule? I think theoretically there could be, but even then mental health professionals should tread very carefully, and err on the side of saying nothing.

What about for non-professionals? I wrote about this earlier. I think generally non-professionals should not speculate about the mental health of other people. To clarify, everyone has the right to make their own judgments about other people, especially public figures asking for their vote. If you think a candidate is unstable, you are free to consider that in your voting decision. I recommend, however, not medicalizing your judgments. Don’t frame them as specific psychiatric diagnoses you don’t have the expertise to make. Further recognize that your judgment is likely to be overwhelmed by political ideology and tribalism.

I also feel it is harmful to use a medical diagnosis as a weapon – to accuse someone else of mental illness in order to exploit the stigma of such diagnoses. This kind of behavior was rampant during the 2016 campaign and I condemned it on both sides.

What about non-psychiatric diagnoses? In such cases I think the same general principles apply, but the thresholds are different. A medical diagnosis can be more objective and carries less of an unfair stigma.

One situation in which I think it is completely justified to publicly comment on a medical diagnosis is when someone has made their personal medical history part of their own public commentary. For example, if someone claims they were injured by a vaccine as part of their anti-vaccine political speech, then I feel it is fair game to analyze the evidence they present for their diagnosis and the alleged cause. They have essentially entered their medical condition into the arena of public commentary – they cannot then claim privacy for that same information.

I would further add that professionals should never recommend specific interventions based on remote information and without having a therapeutic relationship with a patient. But that is very different from simply commenting on information placed into the public domain.

Another factor to consider is the diagnosis itself. Some diagnoses are mostly visual. You can make them confidently based upon casual video. Parkinson’s disease is a great example. People with this disorder have a certain facial expression, posture, way of moving, and may have a characteristic tremor. It is what we call an “Across the room diagnosis.” I still would not presume to make management recommendations without a personal history and exam, but it is possible for an expert to make a confident diagnosis of at least the general category of Parkinsonism based purely on video.

What about public figures who have not made their own health a public issue? I think this goes to the more general question of how much privacy public figures deserve and have a right to expect. If we return to the president, for example, pretty much when you run for president everything about your life becomes fair game. Candidates are expected to turn over their health records, for example.

I think this is reasonable. When you are asking for the responsibility of the most powerful position in the country, it only seems reasonable that the public deserves to know as much as possible about the person they would put in that position. If you want privacy, don’t run for president.

There is also the matter of the 25th amendment, which contains procedures for declaring a sitting president unfit for duty. This only states that congress, or the cabinet, or other suitable body, “transmit their written declaration that the President is unable to discharge the powers and duties of his office.”  This could be an obvious situation, like being under general anesthesia. But it may also simply mean that the president is medically or cognitively unfit.

It is now clear, for example, that Reagan was in the early stages of Alzheimer’s disease toward the end of his presidency. He clearly wasn’t as sharp as he was toward the beginning, and those around him were doing their best to cover for him. However, from the public perspective this change could simply have been from normal aging and the stress of the job. After he left office the official diagnosis of dementia was announced, and it became clear that we were seeing the early stages of this, not just normal aging.

Was there a point, however, when the 25th amendment should have been invoked? What if  a dementia expert, examining the copious video of Reagan, determined that it was very likely he had early dementia. Should they tell someone? Should they have made a public statement? It does seem reasonable that at some point the concerns of the country outweigh other concerns.


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