On the face of it, the statement by Maria A. Oquendo, MD, President of the American Psychiatric Association (APA), could not have been clearer: “Simply put, breaking the Goldwater Rule is irresponsible, potentially stigmatizing, and definitely unethical.”1 I completely agree with Dr. Oquendo, in so far as the general principle goes. Ah, but it is far from clear that the Goldwater Rule itself can be “simply put” or that its language is easily transferable to the complex ethical issues that arise when psychiatrists express opinions about figures who are “in the light of public attention.” Indeed, at least 2 recent reviews suggest that the Goldwater Rule is in need of substantial revision—or, more radically, that the rule itself may sometimes be unethical!2,3
Here I argue that—while fundamentally sound—the Goldwater Rule requires more precise and limited language. I propose a reformulation of the rule that allows for greater leeway in some circumstances, while retaining its core ethical principle.
The APA’s Principles of Medical Ethics: Section 7
The Goldwater Rule is published as an annotation in Section 7.3 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. It states:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her 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
As is widely known, the Goldwater Rule was a reaction to the debacle that occurred during the US presidential election of 1964, when a large group of psychiatrists, responding to a magazine survey, declared Senator Barry Goldwater psychologically unfit to be president. As Dr. Oquendo noted, “. . . some responding doctors even issued specific diagnoses without ever having examined [Goldwater] personally.”1 I share Dr. Oquendo’s view that such “diagnoses” are fundamentally unethical, not to mention scientifically dubious. But wait—the Goldwater Rule as written does not use the term “diagnosis.” It refers to offering “a professional opinion.” (The rule also did not specifically distinguish living versus non-living subjects who are “in the light of public attention,” though it seemed clearly intended to limit psychiatrists’ comments about living persons.)
I would argue that not all “professional opinions” proffered by psychiatrists constitute specific diagnoses, nor should all such opinions be deemed unethical, when properly limited in scope. I would distinguish 4 types of comments or claims regarding public figures, although these categories are not exhaustive.
• First, there are historical inferences as to likely diagnosis, as applied to persons no longer living: for example, when historians (or psychiatrists) examine the psychology of figures such as Abraham Lincoln or Winston Churchill.5,6
• Second, there are non-diagnostic professional opinions regarding living persons, as when a psychiatrist might comment broadly about the clinical significance of a pattern of behavior, without proffering a specific “clinical diagnosis” of the person in question.
• Third, there are professional comments that offer a differential diagnosis of a symptomatic or behavioral pattern in a living person—again, without providing a clinical diagnosis of the particular person in question.
• Finally, there are comments that amount to a clinical diagnosis of a living person—and here is where the Goldwater Rule emerges as useful and necessary.
Dr Pies is Professor of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of Psychiatric Times. He reports no conflicts of interest concerning the subject matter of this article.
1. Oquendo MA. The Goldwater Rule: why breaking it is unethical and irresponsible. https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2016/08/the-goldwater-rule. Accessed August 24, 2016.
2. Ghaemi N. Is psychoanalyzing our politicians fair game? Medscape. August 15, 2016. http://www.medscape.com/viewarticle/867320. Accessed August 24, 2016.
3. Kroll J, Pouncey C. The ethics of APA’s Goldwater Rule. J Am Acad Psychiatry Law. 2016;44:226-235.
4. American Psychiatric Association. The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry. https://www.psychiatry.org/psychiatrists/practice/ethics. Accessed August 24, 2016.
5. Shenk JW. Lincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness. New York: Houghton Mifflin Company; 2005.
6. Ghaemi N. A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness. New York: Penguin Books; 2012.
7. Online Etymology Dictionary. http://www.etymonline.com/index.php?term=clinic. Accessed August 24, 2016.
8. Pies R. Misunderstanding psychiatry (and philosophy) at the highest level. Psychiatric Times. September 8, 2011. http://www.psychiatrictimes.com/articles/misunderstanding-psychiatry-and-philosophy-highest-level. Accessed August 24, 2016.
9. Moffic HS. The results of a psychiatric poll on presidential candidates. Psychiatric Times. August 18, 2016. http://www.psychiatrictimes.com/blogs/couch-crisis/results-psychiatric-poll-presidential-candidates. Accessed August 24, 2016.
10. Friedman RA. Role of physicians and mental health professionals in discussions of public figures. JAMA. 2008;300:1348-1350.