Arthur S. Reber

The standard ethical position in psychiatry and clinical psychology has long been that a diagnosis of an individual should not be made without a personal diagnostic work-up. It’s called the Goldwater Rule and was put in place after unprofessional and distinctly unflattering opinions were put forward by psychiatrists about Barry Goldwater’s mental health during the ‘64 presidential campaign. It was painfully clear that these “remote” diagnostic conclusions about his mental state were being driven, not by legitimate psychiatric considerations, but by politics. It’s worth noting that Goldwater sued the magazine that published the so-called diagnosis and won a substantial award.

Since then, mental health care professionals have adhered to the principle which is enshrined in the code of ethics of the American Psychiatric Association. Section 7.3 of the code states that ”… it is unethical for psychiatrists to give a professional opinion about public figures they have not examined in person, and obtained consent from, (or) to discuss their mental health in public statements.” The American Psychological Association has a similar clause in its ethical guidelines.

However, there is a movement afoot that is challenging this principle and, of course, it is being driven by concerns about the mental health of one Donald John Trump. An article outlining the issue and arguing in favor of a reconsideration of the Goldwater Rule was published recently by Rosemary Sword and Philip Zimbardo and can be found here.

Zimbardo, it’s worth noting, is one of the country’s most respected psychologists. He is a Past President of the American Psychological Association, winner of that organization’s Gold Medal for a lifetime of significant contributions to psychological science and, I’ll note in passing, a graduate of Brooklyn College where I was on the faculty for 35 years.

There are two key elements in this reconsideration of the ethical standards of mental health practitioners and they need to be taken very seriously.

(a) Ultimately it is what a person does and says that forms the foundation for a psychiatric diagnosis. While a full, in-person assessment under informed consent is needed for an “official” diagnosis, a consistent pattern of irrational public behaviors and statements is sufficient for a “remote” consideration that the individual does, in fact, fulfill the standard criteria for a mental disorder.

(b) While the Goldwater Rule was designed to protect an individual from unethical attacks, in the case of Trump the rule goes out the window. It is not the individual (Trump) who needs protection from an unethical psychiatrist, it is the rest of the country (indeed, the world) that needs protection from the damage that an unstable, irrational person with immense power can wreck.

In short, the ethical argument is being flipped and the flip is gaining momentum. As of this writing over 30,000 mental health therapists have agreed that Trump is mentally unfit to hold the position of president of the United States — this is a remarkable number given the long-standing, inflexible adherence to the Goldwater Rule.

It’s important to understand that in the health care professions there are circumstances where the ethical guidelines may be set aside. For example, the doctor-patient confidentiality clause can (in fact must) be abrogated in the physician is convinced the patient is about to commit a felony. A doctor who is certain a patient is going to murder someone has a moral obligation to step outside the confidentiality clause and notify authorities.

In a sense, what Sword and Zimbardo (and many others) are arguing is that Trump poses a similar threat, one sufficiently severe that mental health practitioners are obligated to suspend the Goldwater Rule and make public their professional opinion that Trump suffers from a number of identifiable psychiatric disorders that threaten the country — a country that, ironically, recently elected him president.

Like almost everything else surrounding Trump since he announced his candidacy, we’ve not seen anything like this before.

Let me end with a warning. If this this shift in the position of the mental health professions reaches a genuine consensus among practitioners and the carrying out of this kind of “remote” diagnosis is accepted as legitimate by the electorate, care needs to be taken. It must not be seen as some sort of psychiatric precedent but as a procedure only to be used in extreme cases such as the one presented by Trump. It should not become a cudgel to wield against a political adversary simply because his/her positions and actions are ones a clinician does not agree with.