Goldwater redux: Shifting rationales for ethical noncompliance

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.