History of Goldwater Rule Recalled as Media Try to Diagnose Trump

What began as one of the strangest presidential campaigns in living memory became even stranger in August when columnists and op-ed writers decided en masse to diagnose one of the candidates with mental illness.

AP Photo/Henry Burroughs

On the same day in the Washington Post, Robert Kagan referred to the Republican nominee as “a man with a disordered personality,” and Eugene Robinson said, “I am convinced that he’s just plain crazy.”

Keith Olbermann, writing in Vanity Fair, hauled a bit of science into the arena, using the Hare Psychopathology Checklist to rate Donald Trump. He awarded the candidate 32 out of a possible 40 points, clearly above the 30-point cutoff for certifiable psychopathy. (Olbermann did not complete a checklist for Trump’s Democratic opponent, or anyone else, as a control.)

Charles Krauthammer, who at least trained as a psychiatrist, referred to Donald Trump’s “hypersensitivity and unedited, untampered Pavlovian responses” and concluded: “This is beyond narcissism.”

Maureen Dowd of the New York Times went so far as to fantasize the Republican candidate waking up on Inauguration Day 2017, marveling at his new surroundings until, in the last paragraph, she reveals him as being not in the White House, but being escorted down the hall by two white-coated orderlies for his “impulse-control/delusion-reduction therapy.”

Not to be outdone by mere pundits, Trump himself called Hillary Clinton “unbalanced” and “a totally unhinged person.”

“Honestly, I don’t think she’s all there,” he said.

With all these amateur (or semi-professional) mental health experts weighing in, why shouldn’t practicing psychiatrists add their finely tuned wisdom to the discussion?

Because it’s unethical, at least for APA members, with reasoning going back half a century, when Sen. Barry Goldwater (R-Ariz.) was the Republican nominee for president in the 1964 election.

Back then, Fact magazine asked 12,000 U.S. psychiatrists if they thought Goldwater was “psychologically fit” to be president.

Only 2,417 responded, with half saying “no,” mostly employing the dominant psychoanalytic language of the day. The rest thought Goldwater was as qualified as anyone, and many objected to the poll itself. Goldwater later sued the magazine and won.

“This large, very public ethical misstep by a significant number of psychiatrists violated the spirit of the ethical code that we live by as physicians and could very well have eroded public confidence in psychiatry,” said current APA President Maria A. Oquendo, M.D., in a recent blog post on APA’s website.

Despite that misstep and the reaction to it, accusations of mental disability are never far from political campaigns, said former APA President Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and Law and director of the Division of Law, Ethics, and Psychiatry at Columbia University.

“If you look back over the last 50 years since the Goldwater incident, it seems that there has been some public discussion of the mental health of candidates in almost every election,” said Appelbaum. “At the moment, that discussion may be more intense, but its recurrence shouldn’t surprise anyone.”

In 1973, APA responded with the creation of Section 7.3 in the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, informally known as the Goldwater Rule.

“Simply put, breaking the Goldwater Rule is irresponsible, potentially stigmatizing, and definitely unethical,” wrote Oquendo.

The Goldwater Rule remains relevant, said Appelbaum. A diagnosis made at a distance is likely to be inaccurate and simply reflect the commenting psychiatrist’s political views, he said. As a result, the candidate may be unfairly hurt in the eyes of the public. Goldwater felt personally aggrieved by the Fact episode.

“It’s important to be circumspect and be sure that people understand what you’re claiming and what you’re not claiming,” added Ezra Griffith, M.D., a professor emeritus and senior research scientist in psychiatry at Yale University School of Medicine and chair of APA’s Ethics Committee. “It’s difficult to make claims about someone you’ve never examined and about whose background you have limited knowledge, or if you haven’t interviewed any collateral witnesses. The scandal following the Goldwater incident occurred because psychiatrists were making statements without being mindful of an ethics-based practice that guides a professional’s behavior.”

Accusations of mental deficiencies exploit the heightened stigma attached to mental illness. Much has been written about the current candidates’ hair, for example, said Griffith, but no one has asked dermatologists for their professional opinions.

Appelbaum also worries that people who could benefit from psychiatric treatment would look at psychiatrists who assessed candidates based on television reports as being incapable of rendering a scientifically sound diagnosis.

However, other psychiatrists believe that perhaps APA’s rule should not be so rigid. In a recent article in the Journal of the American Academy of Psychiatry and the Law (which Griffith edits), Jerome Kroll, M.D., and Claire Pouncey, M.D., Ph.D., challenge elements of the Goldwater Rule, which, they wrote, “denies an individual psychiatrist’s responsibility to speak up about political leaders’ behaviors that strongly suggest psychopathology. … The Goldwater Rule cannot distinguish between thoughtful and well-researched psychiatric commentary on public figures and the flippant sound bites about celebrities and politicians [that] make each day’s headlines.”

This view may be at odds with APA’s official position, but Griffith believes such arguments are legitimate in ethics discussions. “It’s important not to close debate,” he said. “When encountering ethics dilemmas, disagreeing parties in the debate are motivated by different interests, different points of view, and different approaches.”

Ultimately, each voter’s own assessment of the candidates is what counts.

“Sometimes people are not crazy; sometimes people are just acting badly,” said Appelbaum. “How they act and what they say tell us more about their likely future behavior than any psychiatric speculation.” ■