The Goldwater Rule or Not, Our Country Needs Psychiatry

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COMMENTARY

Practicing psychiatry is both a pleasure and a privilege, and it should go beyond our patient interactions. In fact, the preamble to the American Psychiatric Association (APA) ethical principles, which are based on the American Medical Association principles, lists our secondary ethical priorities to be colleagues, self, and society.¹

Our training in deep listening with a “third ear” allows us to ascertain underlying meanings and is crucial to what we do. This training, it seems to me, makes it possible—albeit tricky—to apply our skills to support the wider society. For me, this aligns with the liberal Jewish concept of “tikkun olam,” our goal to try to heal the world. Healing patients accomplishes this ideal to some degree, but can we do more? Can we help heal what I have called the social psychopathologies, among them hate, anti-Semitism, Islamophobia, racism, sexism, ageism, burnout, loneliness, and cults?

A History Lesson in Finding the Best Leaders

Besides these social problems, what about addressing leadership? Did we—and do we—have knowledge that could be applied to understanding leaders, including the presidents of the United States?

This issue arose in the 1964 presidential race when conservative Barry Goldwater ran for office. Sigmund Freud, MD, had previously warned about “wild analysis,”² but when polled about Goldwater’s mental fitness for office, a majority of psychiatrists answered negatively and provided a variety of psychiatric diagnoses and considerations—some of which seemed “wild” indeed.

Lyndon B. Johnson won in a landslide, and Goldwater successfully sued the publication that had polled the psychiatrists. As a result, organized psychiatry seemed embarrassed. The American Psychiatric Association sent a letter to the publication, denouncing the published poll results and, in 1973, came out with the ethical guideline informally called the Goldwater Rule. The guideline stated that although psychiatrists can offer their expertise about psychiatric issues in general, it would be unethical to share opinions about individuals they had not examined and/or had not received permission for disclosure.³

The Goldwater Rule has remained controversial among psychiatrists and has sparked numerous debates.⁴ Interestingly, Jerrold Post, MD, was the approved exception to the rule. He provided psychological profiles of world leaders at the government’s request and took it upon himself to write books about living public leaders.⁵

A New Chapter: Considerations

Fast-forward to more modern days when former President Donald J. Trump first ran for office, and the Goldwater Rule became a matter of concern for many psychiatrists. Quite a few mental health clinicians apparently broke the rule by sharing their opinions on possible diagnoses, disclosing their concerns that Trump was dangerous.⁶ In response, the APA tightened the rule in March 2017, extending its application to any public psychiatric analysis of a public figure.⁷

I, too, have struggled with the rule and its risks. Alan Blotcky, PhD, and I wrote an article for Psychiatric Times in 2021 asking whether we should consider overruling the Goldwater Rule.⁸ We noted that absent psychiatry’s public involvement in discussing concerns, less knowledgeable political pundits would provide their less educated and less informed mental health opinions.

The Goldwater debate has again become an issue as the 2024 presidential election draws closer. This time, legal issues have impacted the discussions, as Trump’s role in the unprecedented insurrection at our Capitol on January 6, 2021, is being addressed. Some psychiatrists, such as Bandy X. Lee, MD, contend his activity is evidence of the risk to our society.

Affirming Psychiatry’s Place

Leading up to this presidential election, concerns have been brought regarding other candidates as well as Trump’s mental status. Over the summer, we heard concerns regarding President Joe Biden following an unexpectedly poor debate performance. Biden soon withdrew from the race, stating his love for his country and the need to do what is best for the US. Interestingly, I hardly read or heard anything from psychiatrists about Biden—nor, for that matter, about Trump.

I do not disagree with Dr Morehead’s recommended first step: “The first thing to do is calm ourselves and practice reflecting on these fraught matters with understanding and compassion for all.” But is that all we can and should do? Morehead goes further in the accompanying piece and says, “Nothing prevents psychiatrists from taking a full part in the political process or even the culture wars, as long as we do it outside of our roles as psychiatrists.”

This is where I disagree. Not only does that approach limit our influence, but I contend acting outside of our psychiatric identity is largely impossible. Our training and expertise infuse our psyche and cannot be ignored, even if we try to be ordinary citizens. Interestingly, even Morehead falls into that trap, indirectly and perhaps inadvertently, sharing proposed diagnoses: “Trump has been publicly diagnosed with dementia, psychopathy, narcissism, psychosis, and bipolar.” Granted, he is noting diagnoses made by other people, but if he wanted to stay true to his concerns, he could have omitted them.

Exploring the Ethical Quandaries

The complex discussions about the Goldwater Rule have made me wonder whether it was the best or only possible follow-up to the 1964 election. There is no possible answer because we cannot do a double-blind study comparing 2 nominees who become president at the same time. But is it possible that Goldwater was relatively more dangerous in his ideas and beliefs than his opponent? Because Goldwater lost in a landslide, most likely the survey of psychiatrists did not determine the election. In uncertainty, perhaps it is ethically better to side with safety, as we often do as physicians. Safety, in this case, was to express our concerns.

I believe that not completely participating in these public concerns is an abdication of our responsibilities, as is clearly stated in the AMA Principles of Medical Ethics, the same section under which the Goldwater Rule falls⁹:

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

Fortunately, there are ways to comment publicly without violating the Goldwater principles.

This may include the following:

• Commenting on the environmental policies of Trump’s administration, as discussed in the expanded edition of Lee’s book¹⁰
• Educating the public about the tight narcissistic bonds between followers and leaders
• Forming an ad hoc expert task force that the media could call upon to discuss political concerns
• Establishing a position such as psychiatrist assistant surgeon general
• Analyzing the presence and risks of alternative facts, cultish thinking, and psychological warfare

Where I Would Try Going Further

Historically, it seems that picking leaders has been a hit-or-miss process, with some successes and some disasters. If given the chance, could our expertise potentially help reduce the failures and increase the success rate? If psychiatrists were consulted, could (or should) we prevent a potential dictator?

We also must remember that there are public figures in fields besides politics, such as entertainment, sports, business, religions, and cults, and these individuals also have influence on the well-being of a country and its citizens. Although there may be harm in commenting and doing too much, Hippocratic harm can be done by not saying or doing enough. If we love psychiatry and our psychiatrist colleagues, as both Morehead and I do, and respect our organizational ethics, as we both do, I conclude that we must slowly, but affirmatively, take our patient healing as ethically far as practically possible into the realm of society.

Dr Moffic (he/him/his) is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and refirement as a private pro bono community psychiatrist. He was chosen to receive the 2024 Abraham L. Halpern Humanitarian Award from the American Association for Social Psychiatry. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He recently coedited the final book in a 4-volume series on religions and psychiatry, Eastern Religions, Spirituality, and Psychiatry. He serves on the Editorial Board of Psychiatric Times.

References

1. American Psychiatric Association. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. 2013 ed. Accessed September 9, 2024. https://www.psychiatry.org/getmedia/3fe5eae9-3df9-4561-a070-84a009c6c4a6/2013-APA-Principles-of-Medical-Ethics.pdf

2. Freud S. Wild Analysis. Penguin Classic; 2002.

3. Levin A. Goldwater Rule’s origins based on long-ago controversy. Psychiatr News. 2016:51(17).

4. McLoughlin A. The Goldwater Rule: a bastion of a bygone era? Hist Psychiatry. 2022;33(1):87-94.

5. Post J. The Psychological Assessment of Political Leaders: With Profiles of Saddam Hussein and Bill Clinton. University of Michigan Press; 2005.

6. Lee B, ed. The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books; 2017.

7. Levin A. Goldwater Rule still stands firm as ethics guidelines for psychiatrists. Psychiatr News. 2017;52(7).

8. Blotcky AD, Moffic HS. Overruling the Goldwater Rule? Psychiatric Times. October 29, 2021. Accessed September 9, 2024. https://www.psychiatrictimes.com/view/overruling-the-goldwater-rule

9. AMA Principles of Medical Ethics. American Medical Association. Updated June 2001. Accessed September 9, 2024. https://code-medical-ethics.ama-assn.org/principles

10. Van Susteren L, Moffic HS. The age of Thanatos: environmental consequences of the Trump presidency. In: Lee B, ed. The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books; 2019.