Professional ethics, role of psychiatrists, and the Goldwater Rule
This post is one article in a series covering the Goldwater Rule and the debate surrounding its use. The views expressed in this article are those of the author.
The campaign and presidency of Donald J. Trump triggered a vigorous debate among psychiatrists about the Goldwater Rule. Set by the American Psychiatric Association (APA) in 1973, the rule establishes that it is “…unethical and irresponsible … to offer professional opinions on people who were not properly evaluated…” It has been criticized as an absolute gag order that prevents an activist group of psychiatrists from participating in the political process. The APA, like any other professional association, has the authority to establish and enforce ethical guidelines, but the time has come for rethinking and upgrading these principles. Psychiatrists, and all physicians, are obligated to abide by ethical guidelines in their professional work, but they should not be marginalized from participating in the political process.
The APA published the rule following the failed presidential campaign of Senator Barry Goldwater in 1964. Goldwater successfully sued the editor-publisher of Fact magazine, Ralph Ginzburg, for libel following the publication of an essay on the candidate’s psychological state. The essay purported to cite facts and survey results from 2417 respondents out of the total 12,356 psychiatrists queried if the candidate was fit to be president. The medical director of the APA alerted Ginzburg before the article’s publication that the responses were not valid absent a “thorough clinical examination” of Goldwater.
The Ethics Committee of the APA elaborated the basis of the rule again in 2017:
… offering a professional opinion or a diagnosis of someone they have not thoroughly examined compromises the integrity of the doctor and the profession and it has the potential to stigmatize those with mental illness. Furthermore, when a physician publicly gives a professional opinion on a public ﬁgure without consent, it violates the principle that a psychiatric evaluation must occur with consent or authorization.
Despite the APA’s continued embrace of the Goldwater Rule, much has changed since 1964 across society and medical practice. Psychiatrists and other mental health professionals engage today in much broader arrays of professional practices and have vastly expanded scientific knowledge and resources. Jonathan Moreno, Penn professor of medical ethics and health policy, has observed, sitting at his father’s knee, that the Goldwater Rule came about when psychoanalytic “theorizing was the dominant style in psychiatry. The profession of psychiatry was dominated for many decades by psychoanalysis and its offshoots. This is the era that gave rise to the young Woody Allen’s neurotic character… they had much to lose by being embarrassed by association with amateurish psychological assessments and poor political prognostication…”
In the subsequent decades, psychiatry progressed beyond amateurish thinking and jargon to incorporate more science and evidence into its practices. Jerrold Post helped develop the discipline of political and psychological profiling that undertakes exacting studies and careful sifting of evidence to produce comprehensive political and psychological profiles of world leaders. The profiles are constructed at a distance from a vast trove of publicly available information to help explain the influences of personality on political affairs. Post demonstrated that constructing a psychological profile of a political figure is not analogous to standard assessment and diagnosis that is appropriate in the clinical setting.
Over the years, an entire field within forensic psychiatry has emerged that is dedicated to assessing dangerousness and is used by courts for sentencing and recommending treatment. The concept of dangerousness has advanced with substantial research on risk assessment, clinical practice, and probabilistic thinking. In their individual practices, clinicians have been sensitized to warning potential victims of patients they treat by the 1976 Tarasoff decision. In 2019, forensic psychiatrist Bandy Lee and her colleagues referenced Tarasoff and invoked the “duty to warn” when publishing The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President. James Gilliland, a contributor to the book, argues that psychiatrists have a “need to identify the potential causes of injury and illness before they have harmed any given population of potential victims as severely or extensively as they would if allowed to go unchecked. In other words, we need to recognize the earliest signs of danger before they have expanded into a full-scale epidemic of lethal or life-threatening injury.” Lee and her colleagues have extended the clinician’s “duty to warn” that arises in treating individual patients to a broader obligation to alert the public about the harms a political figure may perpetrate. The reference to Tarasoff obfuscates the principle “duty to warn” and political activism by psychiatrists in circumstances of potential societal danger and harm.
It bears repeating that the practices of diagnosing and treating, including prescribing medications, are fundamental to the medical profession. Psychiatrists adhere to established procedures of interviewing, testing, reviewing relevant history, and observation to conduct assessments, formulate diagnosis, and prescribe treatments. Professional associations, training programs, medical schools, and regulating agencies have concurred substantially on the standards of care for clinical procedures and practices. That said, these professional practices must be situated within the broader roles and responsibilities of psychiatrists and physicians that are inextricably bound by political considerations.
Several prominent psychiatrists and former APA presidents have argued that any judgments about sitting political figures should be deferred to the political process. But the history is complicated. The trials of the Nazi doctors at Nuremberg codified that physicians had accountability for crimes against humanity as well as crimes against persons in the practice of medicine and medical research. The cases against the Nazi doctors were compelling as the evidence unfolded, revealing research that unquestionably endangered the lives of the subjects.
As important the accounts of the Nazi doctors are, the obligation to protect patients and communities from harm has historical precedence. For centuries and up to the present day, physicians have felt motivated and duty bound to engage in the political and social issues affecting them. One of those issues is interrogation and torture.
As an outspoken opponent of torture, I have observed in many nations the risks health professionals and their colleagues have taken to protect their communities from cruel, inhuman, and degrading treatment. The psychiatrists and physicians I have met feel that social and political responsibilities at times of grave danger and urgency compel them to speak out in their societies as independent agents. These men and women are forced to calculate and balance the risks of identification as opponents of established governments and institutions, the harm caused by their governments, and the impact on their clinical practices and personal welfare.
In this country, the activities and clinical practices of psychiatrists are subject to the rules and guidelines of multiple agencies and regulatory bodies that can be mobilized against proponents openly engaged in political processes. Generally considered professional associations, the American Psychiatric Association (APA), the American Psychological Association (APA), and the American Medical Association (AMA) are guilds that promote the trade (clinical practice) of their membership. Other agencies and boards regulate licensure, specialty certification, accreditation of medical schools and training programs, and graduate education. The agencies and boards are nominally independent but closely linked. The leadership and membership of the organizations often overlap and share common purposes and missions. The closely entwined activities of the boards blur nominal distinctions and obscure considerations regarding ethics of practice, standards of care, and financial incentives and interests. The professional associations lobby the president and Congress, the very individuals who have unquestioned authority and power to regulate practice and set guidelines for payment of services. The professional associations have obvious overlapping ethical, financial, and political interests.
I endorse the fundamental ethical principle of the Goldwater Rule that proscribes diagnosing or rendering a professional opinion on public figures without conducting an appropriate examination. Nonetheless, much has changed since 1964 that enables psychiatrists and other mental health professionals to engage politically in ways that do not violate standard clinical practice. Tools and methods have been developed to inform the public about the actions and mentality of public figures other than standard diagnosis and assessment. Vastly more information is available to the public that was often concealed decades ago. The media and current social practices expose public figures to much greater scrutiny and commentary than is available to psychiatrists and other professionals.
As in Nazi Germany and many other countries, individual physicians and psychiatrists face predicaments of speaking out and acting when they see danger and disaster on the horizon. Many psychiatrists and physicians believe that they have a responsibility to engage in the political process and exercise free speech at important times. There never have been easy choices for those physicians who feel an overriding obligation to the overall health and welfare of the people they serve. Many have risked their lives and livelihoods, as I have observed in my travels. We have seen the challenges in our country over the past year in speaking out publicly as the saga of the COVID pandemic has unfolded. In contrast to the advocacy of Bandy Lee and her colleagues on warning the public about dangers, we witnessed prominent physicians in high positions seemingly endorse policies and practices that were widely criticized as not scientifically based or sound. Some of these prominent physicians could have resigned, ending their careers and influence, but did not for unknown reasons. We suspect that they would have been subjects of political and professional fallout. They chose not to act when on the national stage but, ironically, they are now publicly speaking against the policies and programs enacted during their tenures.
The Goldwater Rule requires update and clarification on its application and the perception that it suppresses political activity by psychiatrists. It places psychiatrists in the dilemma of subscribing to standards of good clinical practice, using other tools and methods to speak about public figures, or acting on their political convictions. Plainly speaking, psychiatrists must decide whether to (1) not speak out without a proper clinical examination, (2) speak out on the basis of acceptable tools and methods, or (3) speak out and risk political and financial fallout. There are no easy choices, and all choices have consequences.
My view has been that psychiatrists and physicians have a responsibility to engage in the political process and exercise free speech at important times, as I did in penning this op-ed on the candidate Donald Trump and his attitudes about torture and PTSD.
Stephen Xenakis, M.D., Brigadier General (Ret.), U.S. Army, is a psychiatrist and an anti-torture advisor for Physicians for Human Rights. He is a member of CERL’s Executive Board. Twitter: @SteveXen
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