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For Peer Review BJPsych It is ethical to diagnose a public figure one hasn't personally examined Summary-Should psychiatrists be able to speculate in the press or social media about their theories? Professor John Gartner argues the risk to warn the public of concerns about public figures overrides the duty of confidentiality; whilst Dr. Alex Langford suggests this is beyond the ethical remit of psychiatric practice. Journal: BJPsych ManuscriptFor ID BJPsych-18-0553 Peer Review Manuscript Type: In Debate Date Submitted by the 06-Jun-2018 Author: Complete List of Authors: Gartner, John; Independent Practice, N/A Langford, Alex; Oxford Health NHS Fundation Trust, N/A O'Brien, Aileen; St. Georges University of London, IMBE Keywords: diagnosis, History of Psychiatry, media Cambridge University Press Page 1 of 25 BJPsych It is acceptable for mental health professionals to propose a diagnosis in a public figure they have not examined personally? “I think a guy running for office who says exactly what he really thinks would astound a hell of a lot of peopleFor around the Peer country”. The Review words of an anti- establishment maverick businessman turned politician, standing as the republican candidate for the US Presidency. Public disquiet about his mental health leads to psychiatrists speculating about potential psychiatric diagnoses. This is 1964, the candidate is Barry Goldwater and the case leads to the American Psychiatric Association (APA) stating that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement.” During his tenure as President of the Royal College of Psychiatrists Simon Wessley suggested UK psychiatrists should abide by the same principal. However on both sides of the Atlantic speculation about the mental health of public figures is rife. When this debate was commissioned the aim was to avoid a focus on Donald Trump, but it became apparent that this would be disingenuous; it is Trump who is taxing the limits of Goldwater and Trump is the reason this issue is being discussed. 1 Cambridge University Press BJPsych Page 2 of 25 Here, US and UK psychiatrists-Professor John Gartner and Alex Langford- debate the ethical principles and practical implications of abiding with the Goldwater rule or UK equivalent. Should speculation about diagnosis be limited to the individual’s doctor with their consent; or is there a duty to warn the public if we are concerned about the mental health of our leaders? For Peer Review It is acceptable for mental health professionals to propose a diagnosis in a public figure they have not examined personally. John Gartner, Ph.D. In 1964, a now defunct magazine, Fact, published a survey of psychiatrists weighing in on the mental health of then presidential candidate Barry Goldwater: “1,189 psychiatrists say Goldwater is psychologically unfit to be president!” Goldwater lost the election, in part because his opponent, Johnson, exploited the image of Goldwater as an unstable finger on the nuclear button. But after the election Goldwater won his libel suit against the magazine. Embarrassed by the incident, the American Psychiatric Association adopted the 2 Cambridge University Press Page 3 of 25 BJPsych principle that a psychiatrist should not diagnose a public figure unless they had both personally examined them and received their permission. Few in the general public had ever heard of this obscure rule until the emergence of Donald Trump. Many mental health professionals felt they had a “duty to warn” the public about the frank signs of dangerous mental disturbance they saw in Trump, just as they have an ethicalFor and legalPeer statutory “duty Review to warn” any potential victims of violence who might be threatened by one of their patients. This ran afoul of the Goldwater rule, precipitating enormous controversy and debate, not only within the profession, but in the U.S. media, as well as that of other countries, including the UK. Duty To Warn, an association of mental health professionals that I lead, advocates for Trump’s removal on the grounds that he is dangerously psychologically disordered and unfit, arguing that warning the public about a dangerous president trumps the Goldwater rule. Goldwater was intended to be a “principle” not a “rule” When I spoke with Dr. Allen Dyer, the last living member of the original APA ethics committee that drafted Goldwater in 1974, he said the current interpretation of Goldwater had drifted far from the framers intentions. Goldwater was meant to be a “principle,” that professionals needed to keep in mind, not a “rule” to be followed slavishly in all circumstances. The “Goldwater Principle” has been “ossified,” applying “rule-based legalistic thinking to a matter of professional judgment.” 3 Cambridge University Press BJPsych Page 4 of 25 In ethics there is often a conflict between two competing principles. “There might be a conflict within the conscience of a particular psychiatrist between the principle of restraint and a more overriding principle, like the duty to warn” he said. The resolution of that conflict should be “up to the professional judgment of the individual professional.” Therefore, Goldwater should not “constrain psychiatrists from making a usefulFor contribution Peer to society” Review if that means warning about a “potentially dangerous president.” The Goldwater principle was not intended as “a gag order.” This May, the APA expanded Goldwater, barring not just diagnosis, but the “rendering any professional opinion” whatsoever about a public figure. Dr. Rebecca Brendel, of Harvard, a consultant to the APA ethics committee, wrote: “even if a “psychiatrist, in good faith, believes a public individual poses a threat to the country or national security,” he should remain silent. (1) More important than national security? Imagine a gunman entering the New York Public library, brandishing a pistol. If a patron shouted “call the police,” librarian Brendel would chastise them: “Sir, you must remain silent. No speaking allowed in the library” Yes, that is a rule—but no sane person would follow it under those circumstances. Unfortunately, this analogy understates our actual situation. Trump is brandishing, not just a gun, but nuclear weapons, and he is threatening to “destroy the country of North Korea.” See something, say nothing, would appear to be the current national security policy of the APA 4 Cambridge University Press Page 5 of 25 BJPsych 2) An accurate diagnosis does not necessarily require a psychiatric interview. The critical comments about Goldwater in Fact Magazine, took place in “the era of DSM-II, which was theoretically based, relying largely on psychoanalytic theory,” wrote Dyer. (2) Charges such as he was “scarred by his potty training” or a “latent homosexual”For were Peer “frivolous extrapolations Review that had no basis in reality.” “We might have written the principle differently if DSM III had existed at that time,” said Dyer. “We might not have made such a hard and fast stand on interviewing the patient,” as a necessary condition for making a public statement. Because “then it would be possible to explain to the public our evidence and rationale.” The goal of DSM III was to establish diagnostic criteria that were behaviorally observable and didn’t rely either on a clinician’s theoretical outlook or inferences about internal psychic processes. From that, it logically follows that if I could directly observe a patient’s behavior, read his communications, and hear from close informants, I would be able to make a valid diagnosis. In the case of Donald Trump, I have observed literally hundreds of hours of Donald Trump’s behavior. I have read thousands of his Tweets. And I have read the testimony of dozens of informants. I would dare say I have a stronger basis for diagnosing Trump than most of the patients in my practice. 5 Cambridge University Press BJPsych Page 6 of 25 “The Goldwater Rule privileges the personal interview as the standard by which a practitioner may form professional opinions,” wrote Kroll and Pouncey, (3) even though research shows the psychiatric interview is not the magic Rosetta Stone to divining a patient’s illness. “Personal examinations are notoriously flawed… because of conscious (intentional) and unconscious distortions” In particular, patientsFor with severe Peer personality Reviewdisorders, like Trump, are famously adept at fooling and manipulating others, including therapists. History, records, informants, and if possible direct observation, can be far more reliable. Bandy Lee wrote: “possibly the oddest experience in my career as a psychiatrist has been to find that the only people not allowed to speak on an issue are those who know the most about it. Hence, truth is suppressed.” (4) If the only people not allowed to comment on climate change were climate scientists, society would always be kept in the dark. Blindly following Goldwater legalistically paints us into a logical corner—a reductio ad absurdum. Since, Trump will never voluntarily consent to a psychiatric interview, the truth about his psychiatric state becomes an unknowable mystery, or simply a matter of opinion, like the existence of God. No matter how grossly impaired Trump is, or becomes, no matter how overwhelming the evidence, reality will always be unknowable, even when the emperor clearly has no sanity. We now live in a pre-Fascistic society, where the press, science, and facts in general are dismissed as fake news. Forces on the right have exploited Goldwater to mean since it is impossible to know whether Trump is truly ill or 6 Cambridge University Press Page 7 of 25 BJPsych dangerous, all who speak out--even if they speak the truth--can be dismissed as unethical partisan liars who should be discredited and punished. 3) Diagnosis can be essential information for the public’s safety One of the common arguments against diagnosing Trump is that it is unnecessary.
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