Dealing With American Psychiatry’s Gag Rule

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POINT

For the Counterpoint, see

The Goldwater Rule Is Still Relevant

Dr Glass is a psychoanalyst and Associate Professor of Psychiatry (Part-time) at Harvard Medical School and a Senior Attending Psychiatrist at McLean Hospital. He was a distinguished life fellow of the American Psychiatric Association until he resigned in protest in April 2017.

Since 1973, the American Psychiatric Association’s (APA) Code of Ethics has considered it “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.”¹ This measure, commonly referred to as “the Goldwater Rule,” was part of the fallout from psychiatrists offering their armchair diagnoses of Barry Goldwater for Fact magazine, which was successfully sued for libel by the losing presidential candidate. APA’s chastened leaders then acted to protect their professions’ reputation by including in their code of ethics a prohibition that was widely understood to prohibit future diagnosis of public figures.

This February, 33 psychiatrists signed a letter to the New York Times² that decried the silence from mental health professionals caused by the Goldwater Rule. While it refrained from diagnosis, the letter concluded the “grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.” Notably, none of us had interviewed the President nor had we obtained his permission to speak out.

The following day, the New York Times printed a letter from a supporter of the Goldwater Rule, Dr. Allen Frances, who “wrote the criteria that define(d) narcissistic personality disorder,” calling us to task for “psychiatric name-calling,” although no diagnosis had been asserted.³ This brought the conflict to a head in a very public way.

One month later, perhaps in response, the ethics committee of the APA issued a new interpretation of the Goldwater Rule. While the language of the underlying code remained unchanged, the committee’s new opinion made it clear that the prohibition was not restricted to making diagnoses, stating that it “applies to all professional opinions offered by psychiatrists, not just diagnoses.”⁴ The APA statement continues:

Making a diagnosis, for example, would be rendering a professional opinion. However, a diagnosis is not required for an opinion to be professional. Instead, when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one. Thus, saying that a person does not have an illness is also a professional opinion.

Thus any psychiatrist making a comment about the mental functioning of any public figure would be in violation of the profession’s code of ethics. Specifically, the new interpretation stated that comments about a public figure’s affect and behavior constituted an unethical professional opinion.

In this way, a significant shift was made from the decades-long common understanding that psychiatrists should refrain from making diagnoses or interpretations about the unobservable inner life of public figure to prohibiting all comments about easily observable phenomena. At the same time, the APA noted that psychiatrists were allowed to comment as citizens, as long as they didn’t identify themselves as psychiatrists; a statement that many found gratuitous and oddly self-defeating, insofar as it intentionally devalued psychiatric expertise.

My colleagues and I were shocked by what we felt was the APA’s “gag rule.” Since I had previously agreed to write an article that contained a more detailed delineation of the issues broached in the first Times letter, I wrote to the APA leadership, expressing my profound disagreement with the new interpretation and urging them to rescind it. I argued that the new, more literal application of the Goldwater Rule made a fundamental error conflating a “professional opinion” that one might provide in a clinical setting and be the basis for a treatment plan with the “opinion of a professional” who is making an observation in a non-clinical context, in the public domain.

There is no patient-doctor relationship in the latter instance and hence the standards that apply to clinical assessment (thorough history, mental status exam, interview with relevant members of the patient’s support system, etc; necessity for confidentiality and authorization from “the patient”) are not applicable. One might be interested in the “opinion of a professional” (which wouldn’t be the foundation for a plan of medical care) when selecting an investment, choosing a catering menu, or learning more about the Civil War.

I acknowledged that caution needs to be used when commenting on matters from afar. It is always appropriate in those circumstances to qualify one’s impressions in accordance with one’s methodology. I said, if the APA had advised its members to exercise such caution, I would have no objection. But I argued that to ordain a gag rule out of concern that fully trained professionals might misspeak privileged the protection of the profession’s public image over members’ rights to follow their consciences, even if it turned out that some persons spoke imprudently.

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I said the APA confused the personal and necessarily private doctor-patient relationship with the right, some would say duty, of psychiatrists to publicly add their understanding of widely available but bewildering behavior of political leaders that is regularly and haphazardly analyzed by non-professionals. I was not advocating diagnosis, although that is frequently what is being objected to.

For example, recently Dr. Prudence Gouguechon assessed President Trump’s capacity for leadership using the US Army’s Field Manual 6-22 for Leadership Development (the criteria are trust, discipline and self-control, judgment and critical thinking, self-awareness, and empathy.)⁵ This non-diagnostic assessment by a psychiatrist and psychoanalyst was highly illuminating though contrary to the intent of the newly expanded interpretation of the Goldwater Rule.

I agreed that making diagnoses of public figures without interviewing them (as opposed to commenting of their widely available videotaped behaviors and remarks) is not relevant or helpful, as there have been many great leaders with diagnosable mental illness who functioned superbly (Abraham Lincoln and Winston Churchill to name two.)

In short, I found this new interpretation of the Goldwater Rule to be an unacceptable infringement on my right and duty to participate in public dialogue about issues that confuse the public and where the perspective of psychiatrists could be very relevant and enlightening. It unduly and misguidedly forced me to refrain from speaking in a manner I considered responsible or to do so under an unwarranted cloud of ethical doubt.

The APA’s response was to offer a dialogue with a colleague who was a consultant to the ethics committee with the hope that some common ground could be found. Over the next two weeks we had “a frank and cordial” conversation, ending in our agreeing on two points:

1. There is a respect-worthy moral foundation for both the decision to refrain from statements about the apparent impairments in psychological functioning of a public figure and for making them, as long as the statements are offered circumspectly and without offering a diagnosis.

2. As things currently stand, those APA members who feel compelled to speak out about such perceived impairments and act on their convictions will be in violation of the APA’s ethical code.

I concluded that the APA is trying to protect American psychiatry from looking bad by prohibiting its members from using their professional expertise and experience to comment on the readily observable behavior and remarks of public figures. The APA appears to have preemptively decided that its members cannot be allowed to exercise their own good judgment and self-restraint in these matters, but must be muzzled to protect the profession. This stance in and of itself devalues American psychiatrists and thus defeats its purpose. To my knowledge no other medical specialty is constrained in this manner.

Because I intend to continue to speak out in these manners and am unwilling to practice under a cloud of ethical suspicion cast by my own professional organization, I resigned in protest from the APA after 41 years of membership. I had hoped it would end differently, but, in retrospect, once the APA insisted its members couldn’t join the conversation in the public square and reference their professional experience and expertise, the outcome was preordained.

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References:

1. American Psychiatric Association. Ethics. https://www.psychiatry.org/psychiatrists/practice/ethics. Accessed July 14, 2017.

2. Mental Health Professionals Warn About Trump. New York Times. February 13, 2017. https://www.nytimes.com/2017/02/13/opinion/mental-health-professionals-warn-about-trump.html?_r=0. Accessed July 14, 2017.

3. Frances A. An Eminent Psychiatrist Demurs on Trumps Mental State. https://www.nytimes.com/2017/02/14/opinion/an-eminent-psychiatrist-demurs-on-trumps-mental-state.html?_r=0. Accessed July 17, 2017.

4. American Psychiatric Association. APA Remains Committed to Supporting Goldwater Rule. https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2017/03/apa-remains-committed-to-supporting-goldwater-rule. Accessed July 14, 2017.

5. Gourguechon PL. Op-Ed: Is Trump mentally fit to be president? Let’s consult the US Army’s field manual on leadership. Los Angeles Times. July 14, 2017. http://www.latimes.com/opinion/op-ed/la-oe-gourguechon-25th-amendment-leadership-mental-capacities-checklist-20170616-story.html. Accessed July 14, 2017.