The British Journal of Psychiatry (2018) 213, 633–637. doi: 10.1192/bjp.2018.132 In Debate It is ethical to diagnose a public figure one has not personally examined John Gartner, Alex Langford and Aileen O’Brien Summary mental health professionals who advocate the president’s Should psychiatrists be able to speculate in the press or social removal under the 25th Amendment on the grounds that he is media about their theories? John Gartner argues the risk to warn psychologically unfit and dangerous. the public of concerns about public figures overrides the duty of confidentiality; whereas Alex Langford suggests this is beyond Keywords the ethical remit of psychiatric practice. Diagnosis; history of psychiatry; media. Declaration of interest A.O’B is joint debates and analysis Editor of the British Journal of Copyright and usage Psychiatry. J.G. is the founder of Duty To Warn, an association of © The Royal College of Psychiatrists 2018. Introduction 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 what they viewed as the ‘I think a guy running for office who says exactly what he really frank signs of dangerous mental disturbance they saw in Trump, just thinks would astound a hell of a lot of people around the country’ as they have an ethical and legal statutory ‘duty to warn’ any poten- (p. 68).1 The words of an anti-establishment maverick businessman tial victims of violence who might be threatened by one of their turned politician, standing as the Republican candidate for the US patients. This ran afoul of the Goldwater rule, precipitating enor- Presidency. Public disquiet about his mental health leads to psychia- mous controversy and debate, not only within the profession, but trists speculating about potential psychiatric diagnoses. in the US media, as well as that of other countries, including the UK. This is 1964, the candidate is Barry Goldwater and the case leads ‘Duty To Warn’, an association of mental health professionals to the American Psychiatric Association (APA) stating that ‘it is that I lead, advocates for Trump’s removal on the grounds that in unethical for a psychiatrist to offer a professional opinion unless their view he is dangerously psychologically disordered and unfit, he or she has conducted an examination and has been granted arguing that warning the public about a dangerous president proper authorization for such a statement’.2 During his tenure as trumps the Goldwater rule. President of the Royal College of Psychiatrists Simon Wessely sug- gested UK psychiatrists should abide by the same principle. ‘ ’ ‘ ’ However, on both sides of the Atlantic speculation about the Goldwater was intended to be a principle not a rule mental health of public figures is rife. When this debate was When I spoke with Dr Allen Dyer, the last living member of the ori- commissioned the aim was to avoid a focus on Donald Trump, ginal APA ethics committee that drafted Goldwater in 1974, he said but it became apparent that this would be disingenuous; it is the the current interpretation of Goldwater had drifted far from the debate about Trump which is taxing the limits of Goldwater, and framers’ intentions. Goldwater was meant to be a ‘principle,’ that Trump is the reason this issue is being discussed. professionals needed to keep in mind, not a ‘rule’ to be followed Here, US and UK psychiatrists – John Gartner and Alex slavishly in all circumstances. The ‘Goldwater Principle’ has been Langford – debate the ethical principles and practical implications ‘ossified,’ applying ‘rule-based legalistic thinking to a matter of pro- of abiding with the Goldwater rule or UK equivalent. Should specu- fessional judgment’. lation about diagnosis be limited to the individual’s doctor with In ethics there is often a conflict between two competing prin- their consent; or is there a duty to warn the public if we are con- ciples. ‘There might be a conflict within the conscience of a particu- cerned about the mental health of our leaders? lar psychiatrist between the principle of restraint and a more overriding principle, like the duty to warn’ he said. The resolution ’ Aileen O Brien of that conflict should be ‘up to the professional judgment of the individual professional’. Therefore, Goldwater should not ‘constrain psychiatrists from making a useful contribution to society’ if that means warning about a ‘potentially dangerous president’. The For Goldwater principle was not intended as ‘a gag order’. This May, the APA expanded Goldwater, barring not just diag- In 1964, a now defunct magazine, Fact, published a survey of psy- nosis, but the ‘rendering any professional opinion’ whatsoever chiatrists weighing in on the mental health of then presidential can- about a public figure. Dr Rebecca Brendel, of Harvard, a consultant didate Barry Goldwater: ‘1,189 psychiatrists say Goldwater is to the APA ethics committee, wrote: ‘even if a “psychiatrist, in good psychologically unfit to be president!’3 Goldwater lost the election, faith, believes a public individual poses a threat to the country or in part because his opponent, Johnson, exploited the image of national security,’ he should remain silent”.4 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 APA adopted the principle that More important than national security? a psychiatrist should not diagnose a public figure unless they had Imagine a gunman entering the New York Public library, brandish- both personally examined them and received their permission. ing a pistol. If a patron shouted ‘call the police,’ librarian Brendel 633 Downloaded from https://www.cambridge.org/core. 02 Oct 2021 at 04:57:29, subject to the Cambridge Core terms of use. Gartner, Langford & O’Brien would chastise them: ‘Sir, you must remain silent. No speaking receives multiple death threats. We are trolled by hundreds. My allowed in the library’. Yes, that is a rule – but no sane person private practice dwindled by half until I realized my Google rating would follow it under those circumstances. had been downgraded to two stars in response to an organized Unfortunately, this analogy understates our actual situation. online effort, involving dozens of people, to systematically drive Trump is brandishing, not just a gun, but nuclear weapons, and down my professional rating. he has threatened to ‘destroy the country of North Korea’. See some- thing, say nothing, would appear to be the current national security Diagnosis can be essential information for the policy of the APA. public’s safety One of the common arguments against diagnosing Trump is that it is unnecessary. The public can observe his behaviour for themselves, An accurate diagnosis does not necessarily require a the argument goes and throwing in a diagnosis does not add any- psychiatric interview thing useful to the public debate. On the face of it, it is really hard ‘ The critical comments about Goldwater in Fact,tookplacein the era to believe that our decades, centuries really, of research and clinical of DSM-II, which was theoretically based, relying largely on psycho- experience have no information value. ’ 5 ‘ analytic theory, wrote Dyer. Chargessuchashewas scarred by his But more specifically, we know in both psychiatry and medicine, ’ ‘ ’ ‘ potty training or a latent homosexual were frivolous extrapolations diagnosis yields information about prognosis. Before the election, ’ ‘ that had no basis in reality . We might have written the principle dif- I wrote in the Huffington Post that Trump was in my view a malig- ’ ‘ ferently if DSM III had existed at that time, said Dyer. We might not nant narcissist.8 At that point, in June of 2016, there was still a ’ have made such a hard and fast stand on interviewing the patient, as a strong hope that Trump would ‘pivot’ and become more ‘presiden- ‘ necessary condition for making a public statement. Because then it tial’. I argued, ‘the idea that Trump is going to settle down and ’ would be possible to explain to the public our evidence and rationale . become presidential when he achieves power is wishful thinking. The goal of DSM-III was to establish diagnostic criteria that Success emboldens malignant narcissists to become even more ’ were behaviourally observable and did not rely either on a clinician s grandiose, reckless and aggressive. Sure enough, after winning the theoretical outlook or inferences about internal psychic processes. nomination, there has been no “pivot” towards more reasonable From that, it logically follows that if I could directly observe a behavior and ideas, just the opposite. He has become more shrill, ’ patient s behaviour, read his communications and hear from close combative and openly racist’.8 And, in my view, since winning the informants, I would be able to make a valid diagnosis. In the case election he has, predictably, deteriorated further. of Donald Trump, I have observed literally hundreds of hours of Imagine a different 2016, one where the public had been ’ Donald Trump s behaviour. I have read thousands of his tweets. adequately informed that, contrary to their optimistic hopes, And I have read the testimony of dozens of informants. I would based on a diagnosis, it was far more likely he would become dare say I have a stronger basis for diagnosing Trump than most much worse. If the public had been allowed to receive such informa- of the patients in my practice. tion, history might have turned out very differently. ‘The Goldwater Rule privileges the personal interview as the ’ standard by which a practitioner may form professional opinions, You do not have to diagnose to warn wrote Kroll & Pouncey,6 even though research shows the psychiatric Many psychiatrists have endeavoured to resolve the Goldwater interview is not the magic Rosetta Stone to divining a patient’s dilemma by refusing to diagnose him, often explicitly stating, illness.