Follow the Conversation
James L. Knoll IV, MD
Contemplating the Goldwater Rule
Alan D. Blotcky, PhD, Ronald W. Pies, MD, H. Steven Moffic, MD
How can we better define, clarify, and expand the Goldwater Rule for ethical and effective use in today's society?
The principle commonly known as the “Goldwater Rule” has been a part of the American Psychiatric Association’s (APA’s) Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry since 1973.1 Known as “Annotation 7.3,” the Goldwater Rule prohibits psychiatrists from proffering diagnoses of current public and political figures who have not been professionally examined.2 More precisely, the annotation states, “… 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.”1
James L. Knoll IV, MD
Contemplating the Goldwater Rule
Alan D. Blotcky, PhD, Ronald W. Pies, MD, H. Steven Moffic, MD
It is a seemingly straightforward statement that has not been substantially modified since its inception. However, in 2017 and 2018—in response to some psychiatrists’ concerns about the mental health of then-President Donald Trump—the APA Ethics Committee reaffirmed and tightened Annotation 7.3 by clarifying what is meant by “a professional opinion.”3
Making a diagnosis, for example, would be rendering a professional opinion. However, a diagnosis is not required for an opinion to be professional. Instead, 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. Thus, saying that a person does not have an illness is also a professional opinion.4
Since 1973, the Goldwater Rule has served its original purpose of keeping psychiatrists and other mental health professionals from making flippant, speculative, and/or unverifiable inferences about the mental health of (living) public and political figures. In our view, the Goldwater Rule’s basic rationale is correct. However, ethical guidelines are not meant to remain static and fixed. Over years or decades, provisions may need to be revised or at least further delineated. Such is the case, in our opinion, with respect to the Goldwater Rule.
According to the APA’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”1 Accordingly, there needs to be acceptable and ethical ways for psychiatrists and other mental health professionals to opine about political and public figures on behalf of the public’s well-being and society’s greater good. Serving society and the public health does not occur in a clinician’s office—it often requires reaching out to the public via the media. And because of explosive advances in technology, the media now include cable television, radio, print, internet websites, audio recordings, video recordings, tweets, podcasts, and so many more platforms. It is through these various media outlets that psychiatrists and other mental health experts can responsibly influence and improve the community and public health.
The Times, They Are A-Changin’
Back in 1973, when Annotation 7.3 was adopted, only a handful of media outlets were available. Today, the media are vast and ever-present, and an expert’s opinions can be seen and heard almost instantaneously throughout the world. Having a clear understanding of what is ethically acceptable will make interacting with the media more comfortable and effective.
The public is bombarded with mountains of information and opinions on a minute-by-minute basis. Unfortunately, much of the material is inaccurate and even harmful. Misinformation and disinformation regarding mental health and mental illness now abound. Who better to provide accurate and helpful knowledge than mental health experts, whose education, training, knowledge, and expertise can be brought to bear on the prevailing public and social issues of the day?
Refining the Goldwater Rule
By necessity, then, the Goldwater Rule needs to be better defined, clarified, and expanded so that it provides a clear direction for psychiatrists who want to interact ethically with the media. Building on a 2016 article by Pies,5 we propose that the following 5 categories of professional discussion and opinion be deemed ethical and specifically incorporated into a revised Goldwater Rule.
A professional opinion may explain the positive and negative effects of a specific mental disorder in a hypothetical public or political figure. For example, psychiatrists could explain how antisocial or narcissistic personality disorder might manifest in a hypothetical elected public official.
A provisional diagnosis or professional opinion regarding a (deceased) historical figure may teach us something about current public or political figures. An example would be a discussion of Abraham Lincoln’s depression or Richard Nixon’s well-documented alcohol abuse and paranoia.6,7
A professional discussion regarding a living public or political figure may focus exclusively on publicly observable behaviors or behavior patterns that, in principle, might affect the person’s ability to perform their duties. This type of discussion would not proffer a diagnosis or reach a conclusion regarding the person’s fitness for duty, dangerousness, or ability to serve in a specific capacity. To illustrate, we offer 1 inappropriate and 1 appropriate response to a typical media- generated question:
“Senator Brown” has been observed, on several occasions, walking unsteadily in public and slurring his speech. There are persistent rumors in the lay press that Senator Brown has a drinking problem. A mental health professional is asked by a television news reporter, “Doctor, can you comment on Senator Brown’s abnormal behavior? Do you think he is an alcoholic? Is he fit to do his job?”
Inappropriate response: “Based on his unsteady gait and slurred speech, it is my professional judgment that Senator Brown likely has a serious drinking problem. This could well impair his ability to carry out his functions as a senator and lead to some dangerous behaviors.”
Appropriate response: “I have not evaluated Senator Brown, so I do not want to speculate on his condition or mental capabilities. Certainly, when someone shows gait instability and slurred speech, I would want to have that person evaluated medically. The problem could be some type of intoxication, involving alcohol or some other substance. But these reported behaviors could also be consistent with a metabolic or neurologic disorder of some sort. For example, hypoglycemia and various postictal (ie, following a seizure) states may be mistaken for alcohol intoxication.8 Whether the senator’s condition—whatever it may be—would impair his ability to carry out his duties or cause dangerous behaviors would require a careful neuropsychiatric examination.”
A professional discussion may focus on the differential diagnosis of publicly observed behaviors or behavior patterns in relation to a current public or political figure. As in the previous example, a discussion could be provided by a mental health professional without diagnosing the person in question or opining on the person’s job fitness or dangerousness. Again, we provide an inappropriate and an appropriate professional response:
“Congresswoman Young” is running for president of the United States. Over the past 6 months, reports in the media have raised the question of manic-depressive illness or bipolar disorder. Reports in the lay press have cited Congresswoman Young’s extreme mood swings and intervals of abnormal speech and erratic, impulsive behaviors that have lasted for 2 to 3 days. A psychiatrist is asked by a newspaper reporter, “Doctor, can you comment on Congresswoman Young’s mood swings and erratic, impulsive behaviors? Could she have bipolar disorder, and would this render her unfit for the presidency?”
Inappropriate response: “In my professional opinion, Congresswoman Young’s obvious and extreme mood swings; emotional lability; rapid, pressured speech; and periods of irritability all point to a diagnosis of bipolar disorder. This condition, if left untreated, could well impair her ability to function in the role of US president.”
Appropriate response: “I have not evaluated Congresswoman Young, so I do not want to speculate on her condition or mental capabilities. When psychiatrists evaluate the behaviors you are describing, we consider a number of neuropsychiatric disorders in our differential diagnosis. For example, bipolar disorder can, indeed, be characterized by significant mood swings; emotional lability; rapid, pressured speech; and periods of irritability. But similar symptoms may be seen in several substance use disorders, such as methamphetamine use disorder, or in borderline personality disorder.9 Endocrine disturbances, such as abnormal thyroid function, or the periodic use of corticosteroids can also produce signs and symptoms that may be mistaken for a mood disorder. Only a professional evaluation can determine what is actually going on with a particular person and what degree of impairment exists.”
A discussion of specific behaviors or behavior patterns attributed to a current public figure may be related to general categories of mental disorders. For example, the constellation of repeated lying; multiple legal infractions or arrests; interpersonal manipulativeness; and lack of empathy and concern for the rights of others could be discussed in relation to certain personality disorders (eg, narcissistic personality disorder, antisocial personality disorder). Absent a professional evaluation, care must be taken to avoid implying that the public figure in question fits one of these categories. Again, mental health professionals should refrain from making a diagnosis or speculating on the job fitness or dangerousness of a living public figure.
As can be seen, there are at least 5 ways in which psychiatrists and other mental health professionals can educate, inform, and provide guidance regarding public or political figures without violating the intent and spirit of the Goldwater Rule. To better understand and implement Annotation 7.3, it would be helpful for examples of the type we have provided to be presented and discussed in the revised annotation. Once revised, the Goldwater Rule could serve as a roadmap for psychiatrists and others who have a responsibility to improve the community and better the public health as they avoid the pitfalls of “armchair diagnosis.”
Finally, it must be emphasized that the Goldwater Rule does not limit psychiatrists or other mental health professionals as private citizens from expressing political views concerning a current situation, policy, or political figure. Health care professionals may always offer their opinions as concerned citizens without characterizing their views as professional judgments.10 Indeed, our representative democracy functions best when all its citizens are active, vocal, and assertive.
Dr Blotcky is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He is also clinical associate professor in the Department of Psychology at the University of Alabama at Birmingham. Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University. He is also clinical professor of psychiatry at Tufts University School of Medicine and Editor-in-Chief Emeritus of Psychiatric TimesTM. 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.
1. American Psychiatric Association. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Section 7. American Psychiatric Association; 2013. Accessed November 15, 2021.
2. Levin A. Goldwater Rule’s origins based on long-ago controversy. Psychiatric News. August 25, 2016. Accessed November 15, 2021.
3. APA reaffirms support for Goldwater Rule. American Psychiatric Association. March 16, 2017. Accessed November 15, 2021.
4. American Psychiatric Association Ethics Committee Opinion. American Psychiatric Association. March 15, 2017. Accessed December 2, 2021.
5. Pies RW. Deconstructing and reconstructing the “Goldwater Rule.” Psychiatric Times. October 7, 3016. Accessed November 27, 2021.
6. Chakrabarti M. Do some leaders have ‘first-rate madness’? WBUR Radio Boston. August 25, 2011. Accessed November 15, 2021.
7. Latest Nixon biography portrays an isolated leader. NPR. May 30, 2007. Accessed November 15, 2021.
8. Bennett J, Fairbrother H. Alcohol intoxication mimics: ED DDx + approach to management. emDocs. August 30, 2017. Accessed November 15, 2021.
9. Mackinnon DF, Pies R. Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 2006;8(1):1-14.
10. Knoll JL IV, Pies RW. Psychiatry, “dangerousness,” and the president. Psychiatric Times. February 16, 2018. Accessed December 2, 2021. ❒