It’s hard to keep up with the flurry of books, articles, op-eds and letters addressing the issue of President Trump’s mental state, many written by well-known psychiatrists 1-5. Reaction to these writings has sometimes been extreme, including reported “death threats” in response to one recent book about the President’s alleged “dangerousness.”5
In an op-ed piece in the Boston Globe, the editor and one contributor to this book argued that they are not “diagnosing” Mr. Trump—which would violate psychiatry’s now famous “Goldwater Rule”—but rather, focusing “squarely on Trump’s dangerousness.” Furthermore, they argue that “dangerousness” can be “reliably established from public records” and “does not require a face-to-face interview.” They go on to depict their portrayal of Mr. Trump as nothing more than “expert commentary,” provided “… for the purpose of enhancing the public’s understanding, awareness, health and safety.” 5
We don’t doubt the good intentions of these colleagues, and we recognize that opinion among psychiatrists is often sharply divided, as regards the Goldwater Rule. Nevertheless, we find the above claims regarding “dangerousness” deeply problematic. When psychiatric terms of art are used capriciously to label a public figure, this stigmatizes not only the person labeled but also those with genuine mental illness. This impedes our ability to provide vitally important psychiatric care and diminishes the credibility of our profession.
Accordingly, in this essay, we attempt to (1) update readers’ understanding of the “Goldwater Rule” in its latest incarnation; (2) describe what the term “dangerousness” ordinarily means in clinical psychiatry, and how it is properly ascertained; (3) examine the claim that a psychiatrist can determine a public figure’s “dangerousness” without having evaluated the person clinically; and (4) discuss the psychiatrist’s ethical responsibilities and legitimate options when he or she believes a public figure is “dangerous,” absent a clinical evaluation of that individual.
First, a quick update regarding two recent clarifications (or modifications) of the Goldwater Rule (GR) from the American Psychiatric Association. (One of us (RP) discussed and critiqued earlier formulations of the GR in a piece published on this website in October, 2016).6
In March, 2017, then APA President Maria Oquendo MD, PhD, issued this statement:
…APA’s Ethics Committee asserts that while it is perfectly fine for a psychiatrist to share their expertise about psychiatric issues in general, it is unethical to offer a professional opinion about an individual without conducting an examination. The committee clarified that the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.7
The Ethics Committee defined the term “professional opinion” as follows: “…when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.”8
These clarifications (or modifications) of the GR stimulated a robust “pro and con” exchange in Psychiatric Times between psychiatrists Leonard Glass, MD, and Rebecca Brendel, MD, JD.9,10
1. Lee B (editor). The Dangerous Case of Donald Trump. 27 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books, 2017.
2. Pouncey C. President Trump's Mental Health—Is It Morally Permissible for Psychiatrists to Comment? N Engl J Med. Dec. 27, 2017.
3. Lieberman J. The Dangerous Case of Psychiatrists Writing About the POTUS's Mental Health. Psychiatric News. Nov. 15, 2017. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.11b13.
4. Frances A. We must not confuse Trump's bad behavior with mental illness. The BMJ Opinion. August 25, 2017. http://blogs.bmj.com/bmj/2017/08/25/allen-frances-we-must-not-confuse-trumps-bad-behavior-with-mental-illness/
5. Glass LL, Lee BX. We aren't diagnosing Trump. We're sounding an alarm. Boston Globe. January 10, 2018. http://www.bostonglobe.com/opinion/2018/01/10/aren-diagnosing-trump-sounding-alarm/Kx995paa5Wv7Ns6UEOdErO/story.html?event=event12.
6. Pies RW. Deconstructing and reconstructing the Goldwater Rule. Psychiatric Times. October 7, 2016. http://www.psychiatrictimes.com/blogs/deconstructing-and-reconstructing-goldwater-rule
7. Oquendo MA. APA Remains Committed to Supporting Goldwater Rule. American Psychiatric Association. March 16, 2017. https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/03/apa-remains-committed-to-supporting-goldwater-rule.
8. American Psychiatric Association Ethics Committee Opinion. March 15, 2017. https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/03/apa-remains-committed-to-supporting-goldwater-rule.
9. Glass LL. Dealing with American Psychiatry's Gag Rule. Psychiatric Times. July 20, 2017 http://www.psychiatrictimes.com/blogs/couch-crisis/dealing-american-psychiatrys-gag-rule.
10. Brendel R. The Goldwater Rule Is Still Relevant. Psychiatric Times. July 20, 2017. http://www.psychiatrictimes.com/blogs/goldwater-rule-still-relevant.
11. APA Calls for End to "Armchair" Psychiatry. January 9, 2018. https://www.psychiatry.org/newsroom/news-releases/apa-calls-for-end-to-armchair-psychiatry.
12. Simon RI, Shuman DW. Clinical Manual of Psychiatry and the Law. American Psychiatric Publishing, 2007.
13. Pinals DA, Mossman, D. Civil Commitment. In: The Encyclopedia of Clinical Psychology. Robin L. Cautin (Editor), Scott O. Lilienfeld (Editor). Wiley-Blackwell, 2015.
14. American Psychiatric Association Code of Ethics. 2013 edition. https://www.psychiatry.org/psychiatrists/practice/ethics.
15. AMA Adopts Guidance for Ethical Physician Conduct in the Media. November 14, 2017. https://www.ama-assn.org/ama-adopts-guidance-ethical-physician-conduct-media.
16. Summergrad P, Xenakis SN. Congress is AWOL on the 25th Amendment. Boston Globe. January 12, 2018. https://www.bostonglobe.com/opinion/2018/01/12/congress-awol-amendment/IsjnwJuVbmWOni8m6gUXON/story.html.
17. Ginzburg R. Goldwater, the man and the menace. Fact Vol. 1, Issue 5. 1964. https://www.scribd.com/document/322479204/Fact-Magazine-Goldwater-1964.
18. APA Criticizes Tax Bill as Unnecessary Attack on Nation's Health Care. Psychiatric News. Dec. 20, 2017. http://alert.psychnews.org/2017/12/apa-criticizes-tax-bill-as-unnecessary.html.