Goldwater redux: Shifting rationales for ethical noncompliance

 

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.

 

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

 

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

 

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

 

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.

 

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

 

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

 

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

 

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.

 

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

 

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

 

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.