An Interview With Myself: Trump and the Goldwater Rule

Why a psychiatrist is concerned about the effect of the APA's Ethics Rule.

Posted Oct 08, 2020

Q: You are the author of Diagnosing from a Distance (Cambridge University Press, 2020). From what I can gather, your book is about the ethical problems of diagnosing presidents with narcissism. Isn’t it a bit narcissistic for an author to write an interview with himself?

A: Probably.

Q: Then why do it?

A: I admit that authors are not generally known for their modesty. In my case, I’ve mostly spent my career attending to patients, and waited until I was 58 years old to publish a book. But it seemed to me that in the age of Donald Trump, important issues were at stake that justified an exploration in public and at book length—not to mention at blog length.

Q: I see that you’ve been blogging on Psychology Today.

A: There is a presidential election coming up, as you may have noticed.

Q: Yes. What concerns you about the election?

Q: A number of things. But I became particularly puzzled—and then quite troubled—by the American Psychiatric Association’s Goldwater Rule and the effect it's having in the Trump era.

Q: What's the rule again?

A: The APA adopted the Goldwater Rule in 1973. In its current form, it says that it’s unethical for psychiatrists to comment on the mental health of public figures, unless they’ve conducted a personal interview and obtained consent from the public figure. Yet oddly, it introduces this central ethical principle in a discussion of situations where psychiatrists are asked for comment in the media.

At first I couldn’t really understand what the APA meant by this ban. Was it a general ban on psychiatric comment from a distance? The psychoanalyst Erik Erikson had contributed much psychoanalytic insight into the course of individual lives considered in historical context. I loved Erikson’s book Young Man Luther. My teacher, the psychiatrist Robert Coles, had been a student of Erikson and spoke of him in very admiring terms. In the 1970s, as it formulated the Rule, even the APA described Erikson’s book on Gandhi as a masterpiece.

Q: It’s been a while, but I remember Erikson as a very powerful writer. He wrote about Hitler, didn’t he?

A: He did. So, for example: Does the APA’s Rule prohibit morally important work in the tradition of Erikson’s psychohistory? If the Rule is indeed a general ban, then why is it phrased in the ethics code as a ban on talking to reporters? Why is its language so seemingly absolute, yet framed (as it were) contingently?

The whole thing seemed to me to be both confusing and at odds with the profession’s usual approach to difficult ethical questions, which is to encourage psychiatrists to be thoughtful, to acknowledge to weigh competing ethics principles, and then to make their best available choice under the circumstances.

Q: Hmm. Can you give me an example?

A: Sure. Confidentiality is a central principle of the profession. But when a patient is about to harm herself or someone else, psychiatrists have to intervene, break confidentiality, and get the patient to an emergency room.

Q: I see. That’s true.

A: Eventually I realized that in order to really understand what was going on, I had to learn about the APA’s history, consult its Ethics Committee opinions, and interview its officials and its critics. As it turned out, the APA itself was very cooperative in my effort.

Q: Wouldn’t you get more headlines if you just said that Trump is a narcissist?

A: Yes.

Q: So why didn’t you?

A: (Sighs) Well, for one thing, I am a longstanding member of the APA. I admire much of what the organization stands for and has done. And my membership means I am bound to respect the Goldwater Rule.

But I’m also not an expert in political profiling. And speaking for myself, I ultimately do believe that before I reach any conclusions about the mental health of a public figure, I would want to interview that person and obtain their consent. There is, I believe, an important element of respect in that stance. 

Q: Sounds like you actually agree with the Goldwater Rule.

A: As it turns out, I don't.

Q: I’m confused.

A: Yes, I can see that. The thing is, I discovered several problems with the Rule.

First, as I mentioned, its language is confusing. It sounds simple, but it’s not. For example, is scholarly comment acceptable, or is it just talking to the media that’s the problem? What about CIA profiling of foreign leaders? That activity has been going on for decades, and nobody is asking Vladimir Putin for his consent. Is that kind of profiling legitimate? What about forensic psychiatry? In a court setting, it often happens that a defendant refuses to participate in a court-ordered evaluation. Is it ethical for a forensic psychiatrist to give the court an opinion?

How is it that a supposedly central ethics principle has required so much clarification over the years?

Q: This is getting complicated.

A: It sure is. In my research, I discovered that the APA Ethics Committee has had to address each of these questions because its members have been so confused by the wording of the Rule.

When you sort this all out, it turns out that for the APA, psychiatric comment without an interview and without the subject’s consent is perfectly acceptable—if it’s done by the CIA, if it’s done in a court-ordered or emergency room setting, if it’s done in an insurance company, or if it involves a “curbside consultation” with a colleague who has never met the patient. All of that troubled me.

Q: How so?

A: The intent of the Goldwater Rule, I concluded, is not actually to ban all comment in the absence of an interview and consent. From the beginning, its intent has been to prevent an individual psychiatrist from talking in the media about a president or candidate, including in circumstances where the psychiatrist believes the candidate poses a risk to the country.

The APA views the Goldwater Rule as a bedrock of psychiatric ethics. But to me, it seems to involve a double standard. Under the Rule, comment is just fine if it's done by the government, a court, or a major institution, but it's unethical and outrageous if done by an individual psychiatrist of conscience.

Q: Ah. What effect has the double standard, if it is that, had on the field?

A: I think the effect has been clear: The Rule has in effect given a green light to CIA profiling, which is often conducted as part of a war effort, but it treats some very distinguished and thoughtful APA members as ethical violators: those who are sincerely concerned about the safety of their country. Psychiatrist and psychoanalyst Leonard Glass, for example, felt compelled to speak out about Donald Trump’s mental state—and could not get the APA to reconsider the Rule. He ultimately resigned.

Q: That seems unfair to him.

A: I agree. Judith Herman and Robert Jay Lifton are two other examples of very distinguished, thoughtful psychiatrists who have much moral credibility. Yet each has been placed in a position of breaking the Rule in order to satisfy his or her conscience about the risks they believe Trump poses to the country.

Q: That’s most unfortunate. Is there any alternative to the Goldwater Rule?

A: Yes. I think individual psychiatrists should be allowed to weigh competing ethics principles and then decide for themselves. This respectful stance is similar to the one adopted by the American Psychoanalytic Association, of which I am also a member.

Q: Hmm. Now that President Trump has COVID-19, do you find that you have any empathy for him?

A: Yes.

Q: Doesn't that change your opinion on the Goldwater Rule?

A: No.

Q: I see. How’s the book doing?

A: Thank you for asking. It just got a very positive review in the Journal of the American Psychoanalytic Association, and there was a thoughtful article in the New Statesman in the UK—

Q: I’m afraid that’s all the time we have for today.

A: (Sigh)

References

American Psychiatric Association (2013). The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, 2013 Edition. Accessed on September 27, 2020 at https://www.psychiatry.org/psychiatrists/practice/ethics. The text of the Goldwater Rule (its informal name) appears as section 7.3.

American Psychiatric Association (2020). Opinions of the Ethics Committee on the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, 2020 Edition. Accessed on September 27, 2020 at https://www.psychiatry.org/psychiatrists/practice/ethics.

Martin-Joy, John (2020a). In Age of Trump, Let Psychiatrists Judge the Mental Health of Public Figures. Washington Post. Posted on January 30, 2020. Available at https://www.washingtonpost.com/outlook/2020/01/30/age-trump-let-psychiatrists-judge-mental-health-public-figures/. Makes many of points discussed in this blog entry, but in op-ed form.

Martin-Joy, John (2020b). Diagnosing from a Distance: Debates over Libel Law, Media, and Psychiatric Ethics from Barry Goldwater to Donald Trump. Cambridge: Cambridge University Press. 

Percy, Walker (1977). Questions They Never Asked Me. Reprinted in Walker Percy, Signposts in a Strange Land, ed. Patrick Samway (New York: Farrar, Straus, and Giroux, 1991). A mock self-interview that inspired this blog entry and that still makes lively reading more than 40 years after it first appeared.