Clarifying the Goldwater Rule and Other Ethical Principles

“A physician shall recognize a reasonability to participate in activities contributing to the improvement of the community and the betterment of public health.”

I greatly appreciate the point of view of David T. Springer, MD, in his article, “Why the Goldwater Rule Should Not be Changed.” Just as with James L. Knoll IV, MD’s, response, titled “Gilding the Goldwater Lily,” I assume many other psychiatrists would agree with both responders, though certainly not all psychiatrists. My responses to this second colleague will overlap a bit with those in my response to Dr Knoll, titled “The Moffic-Gold Rules,” but also cover other ethical ground. I am grateful to Dr Springer for this opportunity.

Having been the chair of numerous psychiatric ethics committees, I know from experience how common it is to forget or misinterpret some of our formal ethical principles and priorities. First of all, let us again clarify that the authors were not giving their own personal opinion about our responsibility regarding the “public’s well-being and society’s greater good,” but rather referring to 1 of 9 basic ethical principles in the American Psychiatric Association’s The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry.1 These basic principles are the same as those of the American Medical Association. The principle of Section 7, of which the so-called Goldwater Rule is only 1 of the annotations, is the following:

“A physician shall recognize a reasonability to participate in activities contributing to the improvement of the community and the betterment of public health.”1

This overriding Section 7 principle essentially means that the overall principle takes priority. One way to apply it is to follow the Goldwater Rule, but that is by no means the only way.

Since we are using a general medical set of principles, because I am a physician first and a psychiatrist specialist secondly, we also need to keep in mind how other physicians react as far as the “choice to speak out on public policies or political figures.” Clearly, many physicians of other specialties, especially infectious disease, have been speaking out about presidential and Centers for Disease Control and Prevention policies, as well as specifically our last 2 presidents. This does not make them or us political figures—just ethically responsible physicians. In fact, I would recommend that any presidential administration include a psychiatrist at the highest levels of their administration to help inform them of the psychological and mental health ramifications of policies. Clearly, the pandemic years have been associated with rising anxiety, depression, suicidality, and burnout. Who better than psychiatric experts in these areas to advise on those concerns? Even so, in that capacity, that person would be a psychiatrist first and a political figure secondly.

Yes, as Dr Springer claims, the public may assume that we are talking about public figures when we are talking about policy, but that can often also be erroneous. Many in government will be part of the policies that come out of any presidential administration. We should not make that same erroneous assumption.

We also need to remind ourselves that we are public and political servants. Politics influence the funding of our work and licensing. It is impossible to completely separate the professional from the political.

Finally, Dr Springer wonders about the silence of psychiatrists regarding President Biden’s mental status. Is that the Goldwater Rule’s influence and/or the sense that his mental status currently is not psychologically problematic? Nevertheless, let me go out on a limb here and comment about one of his administration’s policies. Recently, President Biden reminded the country that he promised to nominate a Black woman to the Supreme Court if the opportunity arose, and he is beginning to do so. Here is my psychiatric concern about that working policy. Yes, all other qualifications being relatively equal, a Black woman would be an appropriate and welcome addition because representation of such a large cultural group is important. It is akin to a Black woman patient having the possibility to see a Black woman psychiatrist if the need and preference arose. However, there are other cultural groups that also need representation on the Supreme Court. Readily, Asian-Americans come to mind—a large representative group in the country. And, for a smaller, but greatly oppressed group, how about Native Americans? If I am violating the Goldwater Rule, I would like to know how.

Dr Moffic is an award-winning psychiatrist who specializes in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is retired from his tenured professorship at the Medical College of Wisconsin.

Reference

1. American Psychiatric Association. The Principles of Medical Ethics, with Annotations Especially Applicable to Psychiatry, 2013 Edition. American Psychiatric Association Press; 2013.