Is Donald Trump “crazy”?
His antics have certainly prompted speculation about his sanity in the public and media. Over the past year, the physician community–and particularly the psychiatric community– has also been weighing in, in defiance of the “Goldwater” rule. And that concerns me deeply.
Section 7.3 of the American Psychiatric Association Principles of Medical Ethics—Goldwater’s formal name—states that it is unethical for a psychiatrist to publicly offer a professional opinion on the mental health of an individual if they have not formally examined that person and received consent to release their impressions. The rule is named after Barry Goldwater, who successfully sued Fact magazine for defamation after it published a poll of 1,189 psychiatrists suggesting Goldwater was unfit to be president of the U.S. ahead of his 1964 run. (In Canada, the Canadian Psychiatric Association provides similar advice in a position statement on courtroom testimony: “Whenever possible, psychiatrists should testify… as to the mental state of a particular person only if they have examined that person or made significant attempts to do so.”)
But since Trump has taken office, certain quarters of the American psychiatric community have been arguing that a “moral duty to warn” should override Goldwater. This past fall, a movement of mental health professionals formed with the goal of removing Trump from office under the U.S. Constitution’s 25th Amendment, on the basis that he is “psychologically unfit to serve.” A subsequent book has attracted much attention, both in popular media and academically, notably in a New England Journal of Medicine op-ed which argues that “standards of professional ethics and professionalism change with time and circumstance.” Their message is clear: Unusual times require physicians to speak up in defiance of Goldwater.
For my part, I’m no fan of Trump and find many of the things he says abhorrent and disconcerting. But is that really a justification for offering a sidewalk diagnosis?
A public health perspective
My support for Goldwater is based on three pillars. First, while it might seem that the rule arose in response to a lawsuit, it’s a good reminder of the principle of “no examination, no diagnosis,” which is not unique to psychiatry but fundamental to medical practice and the sanctity of the doctor-patient relationship. This principle dictates why one cannot ethically treat family members (because one can’t objectively examine them) and also why transport regulators across North America require that reports of a patient being medically unfit to drive be based on formal examinations as opposed to what the doc might have seen on the drive home.
Second, choosing to ignore the Goldwater rule in this one instance invites the question: Why not others? Indeed, it could be argued that the mental health of many politicians, both current and historic, might warrant public scrutiny and even intervention. Consider alternate realities where public psychiatric discourse might have forced JFK out of office due to sex addiction, or Lincoln due to severe depression, or Churchill—in the middle of the war effort—for supposed bipolar disorder. Allowing psychiatrists to present such opinions about political leaders sans exam turns medical expertise into a political lever, one that could potentially create chaos and threaten peace, order, and good government. Not to mention that the decision to selectively overturn Goldwater could fuel perceptions of psychiatrists and the entire medical community as being partisan.
Which leads to my third reason for supporting the Goldwater rule. As a public health physician, my work aims to protect, promote, and optimize the health of the community through population-level interventions. These efforts require me to be seen as objective and impartial, providing recommendations that are based on data and evidence. Attempts by my psychiatric colleagues to offer professional opinions about the mental health of a public figure that they have not examined undermine public health’s efforts to stand objectively against poor policy and programming decisions.
We’re all in this together
Recently, I raised my concerns about ignoring Goldwater with a colleague in mental health. The colleague not only disagreed, but further suggested that I wasn’t in a position to call the matter into question, given that I am not trained and don’t practise in the field.
I couldn’t disagree more.
Fundamental standards exist across specialties. “No exam, no diagnosis” is one of these, and the Goldwater rule suggests that psychiatry is no exception. While psychiatrists are certainly the specialists, mental health considerations apply across specialties; family doctors likely diagnose mental illness more frequently than psychiatrists, and physicians of all stripes assess competence every single day. And it is important to remember that a mental illness diagnosis does not automatically signify incompetence. Individuals who experience mental illness may still be fully capable of making rational decisions.
Additionally, professional colleagues have a duty to question one another, especially where things are not clear-cut. If a family physician gets a referral back from a specialist that they don’t understand or agree with, they are within their rights to ask questions rather than tacitly accept direction. Psychiatrists would do well to remember that any dialogue around overturning Goldwater reflects on all physicians. For the populations I serve, and for all of us in the medical field, I feel I have a duty to question my colleagues around any position that might impact the standing of all physicians.
This work represents his views and not those of the organization he is affiliated with.