Few legal issues in contemporary psychiatry are as controversial as what has come to be known as the Goldwater rule. That canon, incorporated into the American Psychiatric Association (APA)’s “Principles of Medical Ethics,” states that:
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.Footnote 1
Although the impetus for the rule stemmed from controversy surrounding a Fact magazine survey of psychiatrists’ attitudes regarding United States presidential candidate Barry M. Goldwater in 1964, the original version of the rule was not formally adopted by the APA until 1973. At that time, Harvard’s Alan Stone was the only board member to vote against it.Footnote 2 Stone viewed the rule as “a denial of free speech and of every psychiatrist’s God-given right to make a fool of himself or herself.”Footnote 3 The rule differs from many other rules in professional ethics codes in that it is not designed to protect a physician’s own patients, but rather those explicitly outside of his care.
Supporters of the Goldwater rule argue that it protects the integrity of the profession and public confidence in psychiatrists, prevents the wrongful and injurious diagnoses of public figures, and prevents psychiatric opinions from being used as political weapons.Footnote 4 , Footnote 5 Opponents decry its impact on freedom of expression, political engagement, and the ability of those with professional experience to warn against insidious dangers.Footnote 6 Both sides in this debate often see the rule in terms of universal principles. But the Goldwater rule was the product of a particular political and social context designed to meet specific functional goals. Its prohibitions arose in a world where medical authority was more widely respected, sources of public information more limited, and psychiatric illness more stigmatized than today. This paper argues that the presidency of Donald Trump has, in effect, “broken” the Goldwater rule irreparably. The dramatic political events of the preceding 4 years have made the rule’s shortcomings more visible, while the controversy surrounding its effects has helped to render its restrictions both quaint and obsolete. Whatever the merits of the rule in an earlier era, it now undermines the very goals it was designed to uphold, and for practical reasons should be relegated to the ash heap of medical history.
Historical Context
The “Goldwater rule” arose out of a highly unusual set of circumstances. New York city-based journalists Ralph Ginzburg (1929–2006), the publisher of a fledgling magazine called Fact, produced a special issue in September/October 1964 titled “The Unconscious of a Conservative” that questioned the mental health of Senator Barry Goldwater, the Republican nominee in the upcoming presidential election. Ginzburg was already a controversial figure, known both for a disputed Harper’s interview with chess grandmaster Bobby Fischer (who vehemently denied its contents) and for federal obscenity charges stemming from his previous organ, Eros (for which he later served eight months in prison).Footnote 7 At the same time that he was preparing his philippic, he was suing unsuccessfully to have Goldwater excluded from the presidential ballots in New York State and California, claiming that the candidate’s birth in 1909 in Arizona Territory—not yet a state—made him ineligible for the presidency.Footnote 8
Ginzburg condemnation of Goldwater proved one sided and full-throated. In an introductory essay, he wrote, “Many people around Goldwater think he needs a psychiatrist—probably not because they realize how sick he is—but because of the daily symptoms of hostility he manifests.”Footnote 9 He discussed two brief “nervous breakdowns under pressure” that the candidate allegedly experienced during his 20s, quoting from another magazine profile that “the sound of cracking ice or the crunch of teeth into crisp toast can set him on edge.”Footnote 10 To Ginzburg, Goldwater appeared a “paranoid divorced from reality,” suffered an “inner conviction that everybody hates him,” was “addicted to obscenities dealing with scatology,” and had been “sadistic” since childhood; his psychological makeup merited several comparisons to Adolf Hitler.Footnote 11 Accompanying the essay were the results of a survey by managing editor Warren Boroson of members of the APA on whether Goldwater was “psychologically fit to serve as President of the United States.” According to Boroson, the 41 pages of excerpted responses constituted “the most intensive character analysis ever made of a living human being.”Footnote 12
Of the 2,417 psychiatrists who responded, 1,189 stated that they believed Goldwater unfit; another 657 thought him fit, whereas 571 offered no opinion.Footnote 13 The most negative of these quotations have been quoted widely in the literature. They include Chester W. Johnson’s Jr.’s opinion that “Goldwater had the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders,” an anonymous claim that he was a “megalomanic…inflamed by fantasies of world domination” and G. Templeton’s belief that a victorious Goldwater would send his critics to “concentration camps.”Footnote 14 He was diagnosed as being “suicidal” and “narcissistic,” having “chronic psychosis” and qualifying as a “paranoid schizophrenic.”Footnote 15 (One of the most ironic condemnations came from Renatus Hartogs, who described Goldwater as “emotionally unstable, immature, volatile, unpredictable, hostile, and a menace to society”—and was later described in similar terms when on trial for sexually abusing his own patients.Footnote 16 , Footnote 17) None of these individuals had ever examined Goldwater in person. In fact, the one respondent who reported knowing Goldwater personally did not offer such a critique or diagnosis. Ten months after the election, Goldwater sued Ginzburg and Boroson for defamation and was ultimately awarded $75,001. According to the court, there was evidence “to indicate alteration of responses from the psychiatrists” including “occasions when two responses were published as one reply,” “one letter [in which] the words were changed and rewritten,” “two occasions [when] qualifying paragraphs in a response were omitted when published” and of similar liberties.Footnote 18 After his electoral defeat in 1964, Goldwater served two more decades as a distinguished—if fiercely conservative—senator without any public revelations of psychiatric illness. Four years later, Ginzburg allegedly sent out a similar survey regarding President Lyndon Johnson, but Johnson did not seek reelection, and if any results were obtained, they went unpublished.Footnote 19
What must be emphasized is that the Ginzburg’s attack on Goldwater was an extraordinary occurrence. In fact, many of his respondents objected to his methodology, criticizing colleagues who offered an opinion of the candidate as practicing medicine through a “crystal ball” or even proposing tongue-in-cheek to set up an intake appointment so that Goldwater could be properly examined in order to render an opinion.Footnote 20 The APA’s imposition of the Goldwater rule 9 years later might be thought to reflect the legal adage—its present meaning often associated with Justice Oliver Wendell Holmes Jr.—that “Great cases like hard cases make bad law…because of some accident of immediate overwhelming interest which appeals to the feelings and distorts the judgment.”Footnote 21 Alan Stone, the lone original dissenter, offered an additional explanation: The American Medical Association (AMA) was “furious” that “the defeat of Goldwater undermined their lobbying clout in Washington, and psychiatrists had rubbed salt in their wounds. They pressured the APA to discipline their members.”Footnote 22
Objections to the constraints of the rule simmered intermittently through the ensuing decades, but psychiatrists largely avoided embroilment in politics.Footnote 23 One area of particular dispute were psychiatric profiles of international political leaders, such as Jerald W. Post’s characterizations of Iraqi dictator Saddam Hussein during Congressional testimony in 1991.Footnote 24 A well-known defender of the rule, Richard Friedman, suggested there might be room for an exception in such cases: If “it is deemed vital to public safety or national security,” he wrote, “one could reasonably defend it even if it violates the profession’s code of ethics and is personally damaging to that individual.”Footnote 25 Both Post and Friedman invoked a Tarasoff-like principle (i.e., the duty to breach confidentiality to warn of imminent dangers) to permit such profiles.Footnote 26 But Friedman emphasized that while commentary on the metal health of Libyan strongman Muammar el-Qaddafi “might well be in the national interest because it could help guide how we deal with this difficult figure,” that did not justify psychiatric comment upon figures like former New York Governor Elliot Spitzer or ex-IMF director Dominique Strauss-Kahn, both the subjects of such speculation after being exposed in sex scandals.Footnote 27 , Footnote 28 “Despite what some of us might believe,” Friedman wrote in the New York Times 5 years before the Trump candidacy, “none of our celebrities or politicians is likely to rise to the level of a national threat that justifies violation of the Goldwater rule.”Footnote 29 The APA Ethics Committee revised the rule in 1985 to emphasize that “a psychiatrist may share with the public his/her expertise about psychiatric issues in general” when addressing the mental health of a public figure.Footnote 30
Opposition to the Goldwater rule might have remained relatively muted if not for the election of President Donald J. Trump in 2016. Concerns about the Republican candidate and future president’s mental health drew increasing commentary from critics. As early as 2015, Vanity Fair ran an article titled “Is Donald Trump Actually A Narcissist? Therapists Weigh In!” Leading psychologists including Howard Gardner, Ben Michaelis and George Simon—not bound by the Goldwater rule—did weigh in critically.Footnote 31 In contrast, psychiatrist Robert Klitzman pointed out that he and his colleagues could not comment “on an individual’s mental state without examining him personally and having the patient’s consent to make such comments.”Footnote 32 Maria A. Oquendo, president of the APA, echoed this sentiment in the Washington Post: “The unique atmosphere of this year’s election cycle may lead some to want to psychoanalyze the candidates, but to do so would not only be unethical, it would be irresponsible.”Footnote 33 But this warning met with opposition. In April 2017, Yale psychiatrist Bandy X. Lee hosted a “Duty to Warn Conference” that featured mental health luminaries Charles Dike, Judith Lewis Herman, James Gilligan, and Robert Jay Lifton addressing the merits of speaking out regarding the president’s mental health, which Lee described as an “elephant in the room.”Footnote 34 In discussing the Goldwater rule, Gilligan—a psychiatrist—noted that “German Psychiatric Association…does not deserve any honor or praise for having remained silent during Hitler’s rise to power.”Footnote 35 Although Lee did not offer her own opinion at the conference, she subsequently became a highly vocal critic of the President’s mental health. Soliciting essays from 26 fellow mental health professionals, she edited The Dangerous Case of Donald Trump (2017), a New York Times bestseller that warned the public regarding the President’s psychiatric wellbeing. Lee argued that she and her colleagues did not violate the Goldwater rule, which she claimed to support, by offering a “diagnosis from afar” and actually “took pains not to diagnose the president in the book.”Footnote 36 Rather, she argues that the APA was using Goldwater as a “gag rule” to “prohibit any commenting on the mental health of a public figure.” Footnote 37
The APA had in fact responded to the Trump controversy with a spirited defense of the rule. Its Ethics Committee reaffirmed and refined the policy on March 15, 2017, making clear that offering comments on the mental health of public figures—even without diagnoses—was unacceptable.Footnote 38 Then APA-President Maria A. Oquendo stated: “It was unethical and irresponsible back in 1964 to offer professional opinions on people who were not properly evaluated and it is unethical and irresponsible today…. In the past year, we have received numerous inquiries from member psychiatrists, the press and the public about the Goldwater Rule….APA continues to support these ethical principles.”Footnote 39 The AMA also adopted a policy (“Ethical Physician Conduct in the Media”) in 2017 that required members to “[r]efrain from making clinical diagnoses about individuals (e.g., public officials, celebrities, and persons in the news) they have not had the opportunity to personally examine.”Footnote 40
Prominent psychiatrist including Paul Appelbaum,Footnote 41 Allen Frances,Footnote 42 and Jeffrey Lieberman came out in continued support of the ruleFootnote 43; so did former Presidential candidate Michael Dukakis, himself the subject of unsubstantiated innuendo during his 1988 campaign.Footnote 44 In the Journal of the American Academy of Psychiatry and the Law, Michael J. Redinger, Tyler S. Gibb, and Peter L. Longstreet argued that “The APA’s Goldwater Rule exemplifies a necessary and justifiable professional norm that is intended to temper the potentially imprudent and self-indulgent motivations of psychiatrists to use the cloak of their profession to further a particular political ideology and neutralizes a fallacious appeal to their own authority.”Footnote 45
Others have argued for jettisoning the policy entirely. In the Journal of the American Academy of Psychiatry and the Law, James Kroll and Claire Pouncey wrote, “[t]he real purpose of the Goldwater Rule is to prevent individual psychiatrists from misrepresenting or embarrassing the psychiatric profession, possibly at the expense of personal, professional, or social values. We find this to be unreasonable.”Footnote 46 As Kroll and Pouncey see it, [p]rudence can too easily slide into complicit silence….[T]he possible but transient harm that nonadherence to the Goldwater Rule might cause may be infinitesimal compared with the overall harm that an elected public official who has mental illness might produce.”Footnote 47 Psychiatrist Judith Vida resigned from the APA after facing investigation by the Southern California Psychiatric for joining other experts in signing a New York Times letter raising questions about Trump’s psyche.Footnote 48 Leonard Glass of Harvard, an APA Distinguished Life Fellow, did the same, writing in Psychiatric Times, “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.”Footnote 49
Whether or not the Goldwater rule ought to have been adopted in 1973 is a philosophical and increasingly historical question that has been well-debated elsewhere. What has become increasingly clear is that the rule is dysfunctional. Rather than protecting the integrity of the psychiatric profession, debate around the rule does for modern day mental health what David Rosenhan’s “On Being Sane in Insane Places”—also published in 1973—did to psychiatric diagnosis: namely, unmask the lack of consensus within the profession. The rule has also proven unenforceable. Moreover, the disconnect between adherence to the rule and widespread perceptions of public figures undermines psychiatrist’s credibility. Arguably, the most significant consequence of the rule has been its impact upon subjects outside the political arena entirely: mentally ill individuals who have allegedly perpetrated high-profile crimes while psychotic, and find themselves subjected to a barrage of uninformed, disparaging commentary by nonprofessionals in the media that psychiatric professionals are not permitted to rebut. Finally, multiple alternate remedies are now available to anyone who feels unjustly diagnosed without examination. Each of these functional challenges with the rule is discussed below.
Functional Shortcomings
Lack of Consensus
One of the primary goals of ethics codes promulgated by professional societies is to reflect and advance the consensus standards of conduct expected of members of that profession. Yet even at the time of Ginzburg’s poll, no clear consensus existed in the psychiatric profession regarding the sorts of conduct that the Goldwater rule prohibited. The AMS might condemn the survey as “an obviously scurrilous unscientific questionnaire” and the APA could describe it as “a low blow to all who would advance the treatment and care of the mentally ill in America,” but 13 percent of APA members (the field’s largest professional body) did respond to the poll—and the majority offered an opinion on the candidate.Footnote 50 , Footnote 51 , Footnote 52 Although the rule might in theory have commanded the support of a majority of APA (assuming that was the position of nonrespondents), it remained the subject of intermittent debate, rather than an accepted doctrine like the confidentiality of psychotherapy notes or prohibitions upon sexual contact with patients. Whatever majority the rule might have represented during its early decades has likely eroded even further during the Trump era. The actions of some of the rule’s most prominent supporters speak to this decline. For instance, Jeffrey Lieberman wrote on January 4, 2019, via Twitter: “Up till now I have strictly adhered to the Goldwater Rule not to use my expertise and credentials to express #clinical opinions about @POTUS, but…thinking that it may be time for the 25th amendment.”Footnote 53 Allen Frances tweeted on September 6, 2020, “I could not care less about the ‘Goldwater Rule’ against diagnosing politicians. Trump is so dangerous, its OK for psychs to speak up if they had something worth saying & people would listen. But neither is true & I do greatly object to confusing evil with mental illness”—questioning the rule itself, although, in fairness, Frances does not argue that Trump is mentally ill.Footnote 54
Even for those who claim to support the rule, they often implicitly advance exceptions and qualifications that swallow it whole cloth. Bandy X. Lee and Thomas Singer published a “white paper” in Psychology Today that nominally advocated for revising the rule, which they stated, “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.”Footnote 55 But to describe their proposal for modifying the rule as reform—rather than an outright reversal—requires Orwellian contortions. They sought to “[f]ormally 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,” and wrote, “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.”Footnote 56 To Alan Stone, Lee’s publication of The Dangerous Case of Donald Trump “obviously defies the Goldwater rule,” her own protestations to the contrary notwithstanding.Footnote 57 Other psychiatrists, without arguing explicitly for reform, have offered their own extraordinarily broad interpretations. For instance, even while still fully supporting the rule in 2017, Lieberman gathered together a group of experts who offered of the President a “diagnosis that seemed most plausible,” namely “incipient dementia (possibly Alzheimer’s, Fronto-Temporal, or less likely, cerebrovascular).”Footnote 58 The line between proposing a “diagnosis” and a “most plausible diagnosis” might strike a layperson as rather thin. Do not all clinicians offer a “most plausible diagnosis,” even when evaluating their own patients? Richard Friedman, who objects to diagnosing American political figures, is comfortable stating that a foreign leader’s conduct “suggest[s] a severe personality disorder called malignant narcissism.” Why Qaddafi and not Trump? Because, Friedman writes, Qaddafi’s diagnosis might “well be in the national interest because it could help guide how we deal with this difficult figure.”Footnote 59 Of course, critics of the American leader offered nearly identical justifications for diagnosing Trump. Meanwhile, C. Ray Lake raises the possibility of another exception for the “diagnoses of psychotic rampage killers” in the hope that this might reduce such tragedies.Footnote 60
The Goldwater rule curtails physician autonomy—the right of psychiatrists to express themselves—in the name of professional welfare. Such a draconian approach might prove persuasive if it had nearly universal buy-in among practitioners. The reality is that some leading psychiatrists have rejected the rule entirely, others violate it with impunity while calling for reform and still others finesse their interpretations in ways that render the original doctrine unrecognizable. In the absence of such consensus, the canon carries little moral suasion and actually makes the psychiatric profession appear uncertain regarding its own ethical moorings.
Lack of Enforcement
The second challenge the Goldwater rule faces is a lack of any credible enforcement mechanism. The APA is an entirely voluntary organization—the psychiatric version of the Benevolent and Protective Order of Elks or the Knights of Columbus. Membership is not required for either state licensing or hospital privileges. Nothing stops members who disagree with the Goldwater rule from leaving the organization—as Vida and Glass have done. In fact, this has been the choice historically for those who wished to comment on public figures. For instance, George Washington University’s Justin Frank quit the APA before writing Bush on the Couch and Obama on the Couch, and the rule did nothing to prevent him from publishing the psychiatric analysis, Trump on the Couch, a volume endorsed by none other than Bandy Lee as a “great public service—critical for our time.”Footnote 61 Lee herself is not an APA member, reportedly having resigned prior to the Goldwater controversy “over her concerns the organization was too beholden to pharmaceutical interests.”Footnote 62 Not being a member has apparently done little to impede her career and she remains affiliated with one of the nation’s top medical schools. In fact, it does not appear that anyone has ever been expelled from the APA for violating the Goldwater rule. Kroll and Pouncey note the case of Fox News psychiatrist Kenneth Ablow who speculated on New Gingrich’s fitness for the presidency on his blog in 2012, but was not referred by the APA “to his district branch for investigation of misconduct.”Footnote 63 Psychiatrist David Abrahamsen published a damning psychiatric assessment of former President Richard Nixon in 1977 without significant professional backlash.Footnote 64 Psychiatric historian John Martin-Joy notes that only eight complaints were filed between 1950 and 1980 under the section of the code that ultimately included the rule and “little information is available on to what extend the APA has enforced this rule since 1973.”Footnote 65 He reports that “in the early years some members were sanctioned or warned in connection with the Goldwater Rule,” but according to Alan Stone (APA President from 1979 to 1980) concerns for “due process led the APA to abandon the issue of sanction.”Footnote 66 Of course, the possibility exists that psychiatrists have been removed—or pressured to resign—but in a manner than has not become public. Undoubtedly, this occurs regarding other ethics violations. However, the probability seems low because unlike violators of other norms, transgressors of the Goldwater rule likely do not view themselves as having done anything wrong, so they have no rationale for not addressing such an expulsion (if it has ever occurred) in the public forum. On the contrary, they have all the incentive to do so.
The APA could, of course, aggressively pursue Goldwater violations. In practice, it seems highly unlikely that the political will exists to do so—especially as many leading members have already, to use a conservative assessment, skirted the rule’s boundaries. Enforcement would inevitably lead to more resignations and less power for the organization. Unlike other ethical norms—such as those regarding sexual boundaries, confidentiality, financial probity, and so forth—the Goldwater rule is not mirrored in state laws or licensing codes, nor has it served as the basis for civil liability, so enforcement is largely toothless. Other organizations of subspecialists such as the American Academy of Psychiatry and the Law do require APA membership to join, but it is even harder to imagine these smaller organizations expelling prominent members for violating a controversial ethics rule in another organization’s code.
Although the occasional resignations and transgressions of the pre-Trump era may have done little to undermine the rule, the widespread breaches since 2016 have largely rendered the Goldwater rule impotent. More concerning, an unenforced policy deters some speakers and not others, skewing public debate in favor of transgressors over those concerned with the rule of law. Conservative commentator Roger Kimball has even argued that its nonenforcement favors those who support Democratic rather than Republican candidates.Footnote 67 An ethics code that is so honored in the breach certainly does not protect the profession’s public image.
Lack of Credibility
The third challenge that Donald Trump raised for the Goldwater rule relates to the credibility of the psychiatric community’s insistence upon nondiagnosis. Although Mary Trump, the President’s estranged niece and herself a clinical psychologist, argues against the rule on the grounds that the “American public is inadequately educated about mental health” and that by sidelining psychiatrists, the public is left in the dark, she also acknowledges that her uncle’s “disordered, impulsive, self-defeating and destructive behavior, which are unlikely to present themselves in a clinical setting, have been extensively recorded.”Footnote 68 The American people have watched President Trump day after day for the past 4 years; many have formed their own conclusions regarding his mental state. When professional organizations refuse their members the ability to comment on what is readily apparent to large segments of the population, this does not make the professionals look neutral or protect their reputations. Rather, the approach makes them appear out-of-touch and almost laughable in their attachment to what are increasingly perceived as self-serving optics.
The stance of the APA, and more recently the AMA, places the medical profession at odds with other mental health organizations. By comparison, the American Psychological Association’s Ethics Code allows for “public advice or comment via print, Internet, or other electronic transmission” if members “take precautions to ensure that statements…are based on their professional knowledge, training, or experience in accord with appropriate psychological literature and practice” and “do not indicate that a professional relationship has been established with the recipient.”Footnote 69 Social workers are not bound by any such rules at all.Footnote 70 (Nor, incidentally, are journalists, attorneys, the clergy, or politicians themselves.) The result is that rather than mental health professionals avoiding comment on the psyches of public figures, only a subset of mental health professionals do so. There is no reason to believe that psychologists are any less gifted—or inept—at diagnosing from a distance than their medically trained peers. But if the purpose of the rule is to prevent such commentary, then only applying it to MDs and not PhDs does not actually achieve a rational public policy objective. At best, psychiatrists sacrifice their autonomy in favor of irrelevance. More likely, the public interprets their silence in the face of obvious data as willful abandonment of civic responsibility and common sense.
Inadvertent Consequences
The debate over the Goldwater rule has largely focused on political figures like Goldwater and Trump, but these controversies may draw attention away from the areas where the rule inflicts the most damage. Ordinary Americans can use their common sense to speculate about candidates for office whose conduct can be compared against historic norms and widespread social mores. In contrast, the public has little mechanism for gauging or evaluating the conduct of perpetrators of violent crimes whose culpability may have been compromised by psychiatric illness.
When James Holmes killed twelve and injured seventy shooting up an Aurora, Colorado, theater in 2012, President Obama described the act as “evil” and Speaker of the House John Boehner denounced it as “evil we cannot comprehend.”Footnote 71 A year earlier, at his arraignment for killing six people including a federal judge and severely injuring Arizona Congresswoman Gabrielle Giffords, the New York Post described perpetrator Jared Lee Loughner as looking “every bit the face of evil yesterday—grinning like a maniac as he appeared before a federal judge for the first time since Saturday’s massacre.”Footnote 72 A decade earlier, Post columnist Andrea Peyser described Andrea Yates, accused of drowning her five children in a bathtub, as “a snapshot of pure evil” deserving a “just end of a lethal injection.”Footnote 73 To many psychiatric professionals watching from afar, all three of these individuals appeared profoundly ill. (Holmes was ultimately convicted of first degree murder; Loughner pled guilty and received multiple life sentences; Yates was initially convicted and sentenced to life in prison, but found not guilty by reason of insanity on retrial after an appeal.) All three defendants were, of course, entitled to present psychiatric testimony in the courtroom regarding their mental states. However, in each of these cases, the public discourse was largely shaped by the commentary of politicians and the media. Why? Because mental health professions were hamstrung in their ability to comment. The recent modifications to the Goldwater rule make offering such wisdom even more difficult. Under the current rule, one cannot say that Holmes or Loughner appears psychotic. The result does not just shape discourse around their particular cases, but inevitably around public perceptions of mentally ill killers more broadly, yielding the public forum to the ignorant and the bloodthirsty.
The Trump presidency serves as a reminder of whom the Goldwater rule protects: political leaders, sports figures, and celebrities. Those with wealth, power and social capital. Ordinary individuals are highly unlikely to benefit from the protections of the doctrine—in part because they are much less likely to fall under “the light of public attention,” certainly not in a manner than would produce a public interest in an armchair diagnosis. The sorts of influential, well-heeled figures protected by the Goldwater rule are more than capable of defending their reputations without such a doctrine. In an earlier generation, accusations of psychiatric illness could derail ambitions for higher office—as they did in 1972 when venerable Missouri Senator Thomas Eagleton (1929–2007) was dropped as George McGovern’s running mate after revelations that he had previously undergone electroshock therapy. In 2020, in contrast, public discourse has been debased to the point where accusations of psychosis and senility were routinely exchanged between surrogates for the two major party presidential candidates. Protecting high profile politicians at the expense of individuals with mental illness facing long prison sentences, or even death, seems like a skewed priority. Without the Goldwater rule, the result would be a far more candid discussion of serious crimes committed by the mentally ill, possibly leading to both sympathy and treatment. That seems like a far better mission for the APA to pursue than protecting occupants of the White House from telescopic diagnoses.
Alternative Remedies
The legal system already offers a host of protections to ward off the behavior which the Goldwater rule is intended to forestall. Truth is arguably the most effective of these; all 50 states allow civil actions for libel and slander. Needless to say, the Goldwater rule did not protect Senator Goldwater himself; it did not exist when he was skewered by Ginzburg. However, the verdict in his defamation lawsuit—upheld by the United States Supreme Court—vindicated him publicly and decisively. Despite the perception that repeal of the Goldwater rule will lead to a Wild West of misdiagnoses, clinicians will still be constrained by facts. Those psychiatrists choosing to comment directly on public figures will have to qualify their assessments in such a way as to avoid speaking with certainty regarding matters in which their verdict is in doubt. Otherwise, they will face a jury of their peers—not in an APA hearing, but in court. The sorts of public figures most likely to be assessed in this open way are also most likely precisely those with the financial resources to pursue such claims. Fear of legal retribution should serve as a far greater deterrent against reckless commentary that any controversial professional code.
The other significant tool available today that was not at the disposal of earlier victims of misdiagnoses is a vastly expanded public forum. Social media platforms, a broader range of radio and television outlets, and a swath of communications technologies have transformed our society from one in which the ability to disseminate views was highly limited to one in which access to such opportunities is widespread, if not universal. One need not fear a helpless victim being disparaged by a phalanx of headshrinkers and not able to defend himself. When Donald Trump’s mental health was challenged by professionals, he did not sue. He responded on Twitter. In 2020, any other victim of an unjust assessment has an opportunity to do the same.
Conclusions
Discussing the merits of the Goldwater rule without accounting for the controversy of the Trump presidency is like assessing the attributes of the League of Nations without reference to the World War II. It is true that, to paraphrase Nixon, psychiatrists will not have Trump to kick around indefinitely, but the genie is already out of the bottle—the damage to the rule has already been rendered. The APA has demonstrated itself largely impotent with regard to widespread breaches of the rule, some defended by arguments too clever by half, unable to build a broad consensus of support or enforce with any effect. Even the very notion that a profession can speak with one voice is becoming increasingly antiquated in our fractured, multipolar worlds.
The reality is that Americans no longer live in 1964 or 1973. Nor do psychiatrists, try as they might to convince themselves otherwise. To pretend that medical professionals are above the political fray might have been a helpful fiction at one point, but no longer remains so at present. Trump, after all, was not Goldwater. And yet the APA continues to confront a 21st century challenge with 20th centuries niceties.
American society is already highly politicized, rife with false information, and disabused of any notion that psychiatrists cannot form opinions from afar. Allowing experts to weigh in on apparent psychiatric attributes of figures in the public eye, even in the absence of formal evaluation—to debate as adversaries in the public arena, as those with less insight do already—can only improve the value of information available to laypersons. Psychiatry as a field will appear engaged, rather than derelict. One of the legacies of the Trump era should be a psychiatric profession less afraid to engage in constructive public discourse.
