Mental Health Experts Urge Revision of the Goldwater Rule
Psychiatrists formally propose revising a highly divisive rule.
Posted Jun 28, 2018
The Goldwater rule, Section 7.3 of the American Psychiatric Association’s ethical code (APA, 2013), started with a quiet history. Already considered somewhat obsolete by the time it entered into the books in 1973, the rule prohibiting the diagnosis of public figures without a personal examination was largely ignored in the professional literature (Pouncey, 2018).
When discussions arose, many considered whether the APA should abolish the rule, especially since science and diagnosing practices were veering in the opposite direction, based less exclusively on a personal interview and more on observable behavior. Others proposed calling it more a matter of etiquette than a rule of ethics (Martin-Joy, 2017). Few scholars specialized in it, and not many psychiatrists had even heard of it. All that changed with the presidency of Donald Trump.
On March 16, 2017, after a number of psychiatrists were already speaking publicly about the dangers the president exhibited (Dodes, Schachter, et al., 2017; Greene, 2016; Herman and Lifton, 2017), the APA ethics committee issued a “reaffirmation” of the Goldwater rule that went beyond the original rule in scope and elevated the status of the rule beyond anything it had been before (APA, 2017). Many psychiatrists have called the new interpretation a “gag order.” The hitherto amicable agreement around the Goldwater rule, as an obscure rule that held less importance than other guidelines, dissolved; protests erupted within the professional group.
Following a debate at the American College of Psychiatrists’ annual meeting, the audience was provided with four options: retain the Goldwater rule, abandon the Goldwater rule, modify the Goldwater rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options (Bosworth, 2018). Dr. Steven Sharfstein, a past president of the APA and a paragon of ethics in resisting governmental pressure during the Iraq War to modify ethical guidelines to allow for torture, as the American Psychological Association had done (Ackerman, 2015), was in that majority. A poll by Psychiatric Times specifically addressing the instance of Trump yielded tenuous support for the APA’s position at best (Moffic, 2018).
More than two dozen mental health experts tried to address this issue in a public service book (with all royalties going into a public fund), The Dangerous Case of Donald Trump, which I edited and to which Dr. Thomas Singer contributed. The book arose out of an ethics conference at Yale, with Drs. Robert Jay Lifton, Judith Herman, and James Gilligan, also co-authors, as its principal speakers (Milligan, 2017).
The authors of The Dangerous Case have now decided to help clarify the contentious points around the Goldwater rule by releasing a white paper that would support their own position as well as allow for those who feel ethically obligated to keep the stricter, “new” Goldwater rule to do so. Under the initiative of Dr. Leonard Glass, a former distinguished life member of the APA, it is being released to the public at the same time as its submission to the APA by Dr. Lifton, internationally renowned for his groundbreaking research on Nazi and Soviet physician collaborators, and Dr. Herman, renowned expert on trauma, who are both distinguished life members, on behalf of 22 of us.
A committee consisting of authors of The Dangerous Case and members of the National Coalition of Concerned Mental Health Experts (dangerouscase.org) worked on the wording, and authors of The Dangerous Case overwhelmingly voted to release it in its name. The proposal asks that the APA recognize the importance of psychiatrists’ social responsibility to warn the public when they discern danger to its well-being that arises from the mental state of an official who is in a position to cause great harm. As such, it is important that they identify themselves as psychiatrists with training and experience and make clear that they are not doing so casually or from personal bias.
It is an important contribution to our profession in that it offers a thoughtful consideration of the role of the Goldwater rule in its current form. Intensive back-and-forth discussion among the contributors to The Dangerous Case of Donald Trump was devoted to the issue of the Goldwater rule prohibiting diagnosis without a personal interview, and a consensus position was reached. This reflected full consideration of the range of concerns raised by the Working Group and the Leadership among the authors. The Goldwater rule revision statement can be found below.
Co-authored with Thomas Singer
Revising the Goldwater Rule
“On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, 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” (emphasis added). American Psychiatric Association’s (APA) Principles of Medical Ethics, Section 7.3
This is the American Psychiatric Association's ‘Goldwater Rule’ which constrains the public statements of psychiatrists and most other mental health professionals because many other national mental health organizations have embraced it.
We, the authors of various chapters in the book, The Dangerous Case of Donald Trump, believe it is necessary that the Goldwater Rule be substantially revised and updated to reflect current research and evolving social awareness.
We call on the American Psychiatric Association (APA) and all other mental health associations that have adopted or follow the APA's Goldwater Rule, to significantly revise and amend it in accordance with the following points:
1) Formally recognize an affirmative responsibility for mental health professionals to publicly address mental health issues discerned in public figures when there is a clear and present danger to the public’s health and well-being.
2) Acknowledge our right to identify ourselves as mental health professionals when speaking out, as opposed to being constrained from identifying ourselves as such.
3) Recognize that our duty to use our professional knowledge to educate the public on matters that fall within our areas of expertise, like all other specialties, does not violate the confidentiality or privacy rights of patients because such constraints on speech do not apply in the absence of a bona fide doctor-patient relationship.
4) Affirm a duty to address the public in a manner that respects the limits of our knowledge and clearly acknowledges those limits in our public comments.
5) Refrain from speaking out as identified mental health professionals when motivated by personal or partisan preferences; only speak out identified as mental health professionals when indicated by our recognition of clear and present threat to the public’s well-being that arises from public figures in a dangerous position. (Clearly, this precludes commenting as professionals on others who are outside this narrow delineation.)
6) The Goldwater Rule’s insistence that it is unethical for a mental health professional to comment on a public figure’s psychological functioning without an interview is misguided and without scientific foundation. Forbidding any such commentary conflates a professional’s public speech with his/her taking care of a patient. In the former role, we, as citizen professionals, are addressing the welfare of the community; in the latter, we provide care for an individual and affirm our profession’s adherence to strict confidentiality. Further, since the Goldwater Rule was adopted (1973) there has been substantial multi-disciplinary research questioning the necessity of an in-person interview as the sole basis for assessment in all circumstances.
7) In calling for the adoption of the above points, we explicitly acknowledge the need to avoid stigmatizing individuals dealing with mental health problems through the ill-considered use of psychiatric terminology.
These changes are necessary because the Goldwater Rule, in its present form, is antiquated, illogical, without scientific foundation, and intrinsically undermining of mental health professionals’ efforts to protect the public’s well-being.
Revising Goldwater Working Group: Leonard Glass, Chair (other names are available upon request)
The Dangerous Case Leadership Group: Bandy Lee, Thomas Singer, Judith Herman, and Robert Jay Lifton
Ackerman, S. (2015). U.S. torture report: Psychologists should no longer aid military, group says. Guardian. Retrievable at: https://www.theguardian.com/us-news/2015/jul/11/cia-torture-doctors-psychologists-apa-prosecution
American Psychiatric Association (2013). Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association. Retrievable at: https://www.psychiatry.org/psychiatrists/practice/ethics
American Psychiatric Association (2017). APA Reaffirms Support for Goldwater Rule. Arlington, VA: American Psychiatric Association. Retrievable at: https://www.psychiatry.org/newsroom/news-releases/apa-reaffirms-support-for-goldwater-rule
Bosworth, T. (2018). Goldwater Rule should be modified, debate audience at the College agrees. MD Edge. Retrievable at: https://www.mdedge.com/psychiatry/article/159384/personality-disorders/goldwater-rule-should-be-modified-debate-audience
Dodes, L., Schachter, J., et al. (2017). Mental health professionals warn about Trump. New York Times. Retrievable at: https://www.nytimes.com/2017/02/13/opinion/mental-health-professionals-warn-about-trump.html
Greene, R. (2016). Is Donald Trump mentally ill? 3 professors of psychiatry ask President Obama to conduct ‘a full medical and neuropsychiatric evaluation.’ Huffington Post. Retrievable at: https://www.huffingtonpost.com/richard-greene/is-donald-trump-mentally_b_13693174.html
Herman, J. L., and Lifton, R. J. (2017). ‘Protect us from this dangerous president,’ 2 psychiatrists say. New York Times. Retrievable at: https://www.nytimes.com/2017/03/08/opinion/protect-us-from-this-dangerous-president-2-psychiatrists-say.html
Martin-Joy, J. (2017). Interpreting the Goldwater Rule. Journal of the American Academy of Psychiatry and the Law, 45(2), 233-240.
Milligan, S. (2017). An ethical dilemma: Donald Trump’s presidency has some in the mental health community re-evaluating their role. U.S. News and World Report. Retrievable at: https://www.usnews.com/news/the-report/articles/2017-04-21/mental-health-professionals-debate-ethics-in-the-age-of-trump
Moffic, H. S. (2018). What our Goldwater Rule poll may be telling us. Psychiatric Times. Retrievable at: http://www.psychiatrictimes.com/couch-crisis/what-our-goldwater-rule-poll-may-be-telling-us
Pouncey, C. (2018). President Trump’s mental health—Is it morally permissible for psychiatrists to comment? New England Journal of Medicine. Retrievable at: https://www.nejm.org/doi/full/10.1056/NEJMp1714828