Raquel Raclette/Unsplash
Source: Raquel Raclette/Unsplash

“Mental illness of such a severe nature that a person cannot distinguish fantasy from reality,… or is subject to uncontrollable impulsive behavior” (legal definition of insanity).

Not so distant history tells us about the tragedy of professional silence.  In early twentieth-century Germany, sociologist Max Weber argued that intellectuals should not utter any political opinions or say anything that could remotely be regarded as partisan.  As we know, under Nazism, not only psychiatrists but most German clergymen, professors, lawyers, doctors, and other leading thinkers became passive enablers of some of the worst atrocities under a dangerous political leader who led their country into the worst disaster in its history.  The World Medical Association issued its 1948 Declaration of Geneva (World Medical Association, 2017) after the recognition that either silence or active collusion with a destructive regime runs contrary to the humanitarian goals of medicine.

We are living under circumstances where the norms and standards of medical practice would require that we speak out in order to protect society’s health and safety.  A major political leader is impaired enough to meet, apparently, the legal definition of insanity.  For all the powers he holds, he ought to be deemed dangerous until proven otherwise—through thorough neuropsychiatric testing.  Yet only a “smoke and mirrors” ten-minute screen was performed to avoid a real examination.  For the responsible psychiatrist, these ploys raise greater alarms, as they themselves indicate pathology, if not an extreme attempt by those around him to mask pathology.

A nonprofit book intended as a public service (Lee, 2017) predicted, ten months ago, just when the nation believed that its new president was settling into his office, that his condition was going to grow worse over time ultimately to involve the danger of nuclear weapons.  Months later, repeated threats to use the nuclear arsenal began.  Now, the Department of Defense has subtly ended the “no first strike” policy and advocates the use of smaller (as large as those that eliminated Hiroshima and Nagasaki) nuclear weapons (U.S. Department of Defense, 2018).  There are attempts to undermine the self-initiated diplomatic efforts on the Korean peninsula to make war inevitable.  Some expert observers believe that war preparations are underway with Iran.  The Bulletin of the Atomic Scientists’ “Doomsday Clock” is currently as close as it has ever been to symbolic apocalypse.

So why are psychiatrists so hung up on the so-called “Goldwater rule”?  They are not.  As a world famous psychologist put it, when a reporter asked about the psychologist’s version of the rule: “I don’t care.”  As one psychiatrist has said: “The preamble to the code of ethics of the American Psychiatric Association says that my responsibility first and foremost is to my patients as well as to society,… not to a public figure [and] not to the American Psychiatric Association” (Brave New Films, 2018).  Many psychiatrists had not even heard of the rule before this administration.  In short, it was an obscure rule on its way out, contradicted by science and evolving practice—until it gained political expediency.

What needs to be discussed is why the American Psychiatric Association (APA) felt the need to turn an obsolete rule into an absolute decree that serves as a silencing mechanism, without members’ input and against their protest, in ways that run counter to medical ethics.  In this case, it forces the adherent to go against the ethical principle it falls under, not to mention against the Declaration of Geneva, the preamble of the APA code of ethics, the code of the American Medical Association, and the Hippocratic oath.  Many worry that this post-inauguration modification is politically-motivated in unethical and possibly illegal ways, and dozens of members have resigned, now including high-ranking officers of the APA.

The new “Goldwater rule” is likely invoked because, medically, there is no argument.  Very few disagree on a medical basis, and thousands of professionals have come forth in the belief that we should speak out about the danger, in ways that are unprecedented in American history.  Thus, the only way to shift the discourse is to argue how “unethical” those who speak their concerns are.  Merely bringing up what one sees as indicators of concern and the need for further evaluation becomes “diagnosing”.  Speaking about objective, medical issues that simply happen to fall within the political realm turns into “politicizing psychiatry.”

Perhaps it takes a forensic psychiatrist to distinguish between offering psychiatric expertise to legal and political systems, as ethical guidelines themselves instruct us to do in public service, and using psychiatry to political ends.  Recognizing the limits of lay analysis, court systems have long ago set up routine procedures for receiving input from “expert witnesses.”  This does not mean the experts make legal decisions for them, but it means that we assist the legal and political bodies to make informed decisions based on the evidence we provide.  Without expert input, there is a danger of underestimating not just the severity but the scope of the problem.

Applying psychiatric knowledge to the political realm can not only be done responsibly but may help answer difficult quandaries.  As scientific fields describing natural phenomena, medicine and psychiatry have the ability to serve as neutralizing grounds for politics.  Politics might do well to modernize to become more evidence-based, focusing on problems and proven solutions, which can help mitigate the excessive emphasis on power or partisan struggles.  Unfortunately, there has been a conflation of this with the politicization of psychiatry—even though the field itself makes a clear distinction—promulgated mostly by a past president of the APA, who should have been denounced as ignorant and self-serving but instead has been backed by the APA itself.

Silencing a profession, meanwhile, has already had a chilling effect.  By planting in the public’s mind that mental health professionals are not to be heard from, or that what is currently happening is not psychiatric, the psychiatric establishment has effectively “normalized” pathology.  Furthermore, by generating an impression of a lack of consensus in the field, when in fact the agreement on the medical side is overwhelming, it has undermined the credibility of those who have chosen to speak.  In the same way that the most lethal violence is structural and inconspicuous (Lee, 2016), the greatest harm consists not of overt manifestations but of silent shifts in the culture.  We must remember how the American Psychological Association, during the Iraq War, went against member protests to modify its own ethical guidelines under political pressure, allowing for psychologists to design and implement torture—and how momentary expediency resulted in scandals.

References

American Medical Association (2016).  AMA Code of Medical Ethics.  Chicago, IL: American Medical Association.  Retrievable at: https://www.ama-assn.org/sites/default/files/media-browser/principles-of-medical-ethics.pdf

American Psychiatric Association (2013).  Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.  Washington, DC: American Psychiatric Association.  Retrievable at: https://www.psychiatry.org/psychiatrists/practice/ethics

Brave New Films (2018).  Mental Health Experts on Donald Trump.  Los Angeles, CA: Brave New Films.  Retrievable at: https://www.bravenewfilms.org/trumpmentalhealth

Lee, B. X. (2016).  Causes and cures VII: Structural violence.  Aggression and Violent Behavior, 28(3), 109-114.

Lee, B. X. (2017).  The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President.  New York, NY: Macmillan.

U.S. Department of Defense (2018).  Nuclear Posture Review.  Arlington, VA: U.S. Department of Defense.  Retrievable at: https://media.defense.gov/2018/Feb/02/2001872886/-1/-1/1/2018-NUCLEAR-POSTURE-REVIEW-FINAL-REPORT.PDF

World Medical Association (2017).  WMA Declaration of Geneva.  Ferney-Voltaire, France: World Medical Association.  Retrievable at: https://www.wma.net/policies-post/wma-declaration-of-geneva/

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