The so-called Goldwater rule, an ethical guideline that prohibits diagnosing public figures without a personal examination, started with an unremarkable history. Based on one lawsuit and already considered outdated by the time it entered the books in 1973, scholars largely ignored it. Many psychiatrists had not even heard of it, and those who pondered it considered changing it to simple etiquette. Then came the turbulent presidency of Donald Trump.
We have a president with questionable decisional capacity who attended a summit with North Korea, a hostile nuclear power, unprepared and unaware of his deficiencies. He woke up one morning and decided to launch a trade war. He just threatened to quit NATO. Now he’s about to meet with Russian President Vladimir Putin, who attacked our 2016 elections.
Nominating a Supreme Court justice, or deciding to hold summits with rivals and enemies, are political decisions that presuppose certain basic mental capacities. Are we certain Trump possesses them? Some of the most renowned psychiatrists in the country have their doubts.
Barely two months into Trump’s term, responding to the psychiatrists who spoke up about signs of dangerous impairment, the American Psychiatric Association (APA) issued a “reaffirmation” of the Goldwater rule that was, according to many, the equivalent of a “gag order.” Members rose up in protest: Calls for a vote, demands for a commission to reexamine the rule, and scoresof resignations ensued.
One wonders what might have happened had the APA not gagged us.
Now 22 mental health professionals, all co-authors of “The Dangerous Case of Donald Trump,” have submitted a proposal for revising and clarifying the Goldwater rule. We ask that the association recognize our social responsibility to warn the public when there are signs of danger to its well-being due to the mental state of a public official, based on professional expertise. Medical neutrality — grounded in scientific evidence and clinical experience of actual defect patterns — allows professionals to identify abnormalities in a standardized way while eliminating bias.
Without diagnosing, we attempted through our public service book (none of the authors are taking royalties) to educate about what we are able to discern, applying our specialized training to widely available information. Our book was an instant bestseller. Immediately upon its release last year, Google searches putting together “Trump” and “danger” soared. Within three days of publication, the APA issued a public statement that a “duty to warn” does not apply outside the patient-provider relationship.
Maybe not, but there is no principle stating that there is no duty to warn in other domains. On the contrary, medical ethics clearly stipulate that we may not turn away but must treat any stranger as a patient in the case of an emergency — and danger is an emergency. Also, the APA’s own preamble to professional ethics says we have a duty to society as well as to patients, and the mental capacity of a public figure is very much a societal concern.
Instead of mental health issues being addressed for what they are, some members who spoke up about Trump received mysterious letters stating that they were investigated by the ethics committee and found not to be at fault — without previously being notified that they were under investigation and for what reason. Others did not venture to speak at all.
Last December, I consulted with a dozen Congress members about these concerns, at the invitation of former assistant U.S. attorney Sheila Nielsen. When I revealed the news in January, the APA issued a public statement stating that “armchair psychiatry” and “use of psychiatry as a political tool” were not allowed, even though I was following its own guidelines “to serve society by advising and consulting with the executive, legislative, and judicial branches of government.” It echoed the words of past APA president Dr. Jeffrey Lieberman, who speculated diagnoses but was not sanctioned. He also consistently misrepresented our book in multiple forums, including news shows I myself declined.
The APA also has not sanctioned prominent psychiatrist Dr. Allen Frances, even though he stated that the president does not have narcissistic personality disorder — which is tantamount to a diagnosis. Meanwhile, even though I resigned from the APA over a decade ago because of its growing pharmaceutical industry ties, and hence am outside its reach, the APA stated, “we urge all psychiatrists, regardless of membership, to abide by [our] guidance.”
When White House physician Dr. Ronny Jackson performed a 10-minute, inappropriate screen and declared the president “fit for duty” while calling our work “tabloid psychiatry,” he was using Dr. Lieberman’s words. Dr. Jackson was removed from his position as the president’s personal doctor, but not before falsely allaying a worried public.
What concerns me is that much harm is preventable through having correct information and responding accordingly. First, dangerousness is different from a diagnosis. Assessment requires consideration of the whole situation, including a person’s position. For instance, an individual with dizzy spells walking down a sidewalk is harmless. The same individual driving a car, however, has the potential to cause greater harm. In both cases, observations made outside of an interview can be more valuable for assessing danger.
A member of the public who recently messaged our website, dangerouscase.org, said our situation is like being on an ocean liner that is heading toward an iceberg, but passengers are not told that the captain is unqualified. The public, like these passengers, has the right to be informed in a responsible and professional manner.
We hope that our challenge to the Goldwater rule will allow more professionals to speak up, and for the authorities to respond. Our nation is suffering: population anxiety levels have soared according to multiple measures, and clarity, to start, can help bring relief. This, too, is a part of therapy.
Bandy X. Lee is a forensic psychiatrist at Yale School of Medicine and a project group leader for the World Health Organization Violence Prevention Alliance. Her views are solely her own.