Goldwater Rule Still Stands Firm As Ethics Guideline for Psychiatrists

The Goldwater Rule has set the boundaries—more or less—for public discussion of public figures by psychiatrists for the last half century. Yet those boundaries have been dented in recent months as psychiatrists have publicly offered their views on the mental status of the 45th president.

“There’s been an increasing flurry of activity in both the lay and professional literature that suggested that APA’s position was unclear, and some felt it appropriate to comment professionally on public figures,” said 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.

The Goldwater Rule, officially known as Section 7.3 of The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, says that “psychiatrists may share expertise about psychiatric issues in general but that it is unethical for a psychiatrist to offer a professional opinion about an individual based on publicly available information without conducting an examination.”

A “professional opinion” is defined broadly. The term applies equally to offering a diagnosis or stating that a person does not have a mental illness, noted the detailed opinion regarding Section 7.3 issued by APA on March 16.

The rule originated in a thoroughly unscientific poll of U.S. psychiatrists conducted by the magazine Fact during the 1964 presidential campaign pitting Sen. Barry Goldwater against President Lyndon Johnson. The psychiatrists were asked if Goldwater was “psychologically fit” to be president. APA objected to the poll, and its publication led the senator to sue the magazine. He won in court, and APA eventually drafted the rule that now informally carries his name.

“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,” said APA President Maria A. Oquendo, M.D., Ph.D., in a statement announcing the updated rule. “We decided to clarify the ethical underpinnings of the principle and answer some of the common questions raised by our members. APA continues to support this ethics principle.”

Psychiatric evaluations must consider the need for consent and confidentiality, said Griffith. Basing a diagnosis of some political figure seen on television violates the way psychiatry should be practiced.

“There is no direct interaction, no consent, no confidentiality, no examination, and no access to collateral information,” he said. Opinions drawn from such circumstances are thus both unethical and factually uncertain.

The Ethics Committee’s opinion went into some detail to address arguments raised against the Goldwater Rule in recent years. It dismissed suggestions that the use of psychiatry in forensic proceedings invalidated the rule. Psychiatric opinions in such cases are possible because they are conducted under a court’s authorization, with controls on the use and dissemination of information gathered.

References to Tarasoff duties to warn or protect also miss the mark, because Tarasoff applies only to cases in which the psychiatrist has access to information from a patient that is not otherwise available to the public or law enforcement authorities, said Rebecca Brendel, M.D., J.D., an assistant professor of psychiatry at Harvard Medical School and a consultant to APA’s Ethics Committee.

Viewing the Goldwater Rule as an infringement of a psychiatrist’s First Amendment right to free speech is also a false interpretation.

“The psychiatrist, as a citizen, may speak as any other citizen,” the opinion continued. “He or she may observe the behavior and work of a public figure and support, oppose, and/or critique that public action. But the psychiatrist may not assume a professional role in voicing that critique in the form of a professional opinion [because of a] … lack of consent or other authorization and failure to conduct an evaluation.”

The American Psychological Association does not have a Goldwater Rule per se, but its code of ethics directs psychologists to take precautions to ensure that their 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.”

Psychiatrists should be cautious and thoughtful in choosing when to express a personal political opinion, clearly noting that it is based only on publicly available information and placing their comments in perspective, said Griffith. “We have to guard against oversimplification of our opinions in the media.”

Ultimately, the Goldwater Rule goes to the core of the profession.

“Psychiatry is a serious enterprise, and we have to be serious about making diagnoses [in public] that can hurt or stigmatize our patients,” said Brendel. ■