Forty-four years ago, a now-defunct magazine called Fact published a survey of psychiatrists in which nearly half of the respondents said that Barry Goldwater was "unfit" to be president, with excerpts from comments that characterized the candidate as "immature,"" impulsive," "megalomaniac," "paranoid,"" rigid," and "narcissistic."

One psychiatrist speculated that Goldwater was "inwardly a frightened person who sees himself as weak and threatened by strong virile power around him—and that his call for aggressiveness and the need for individual strength and prerogatives is an attempt to defend himself against and to deny his feelings of weakness and danger."

The remarks were condemned by both APA and the AMA, and Goldwater brought a $2 million libel suit against Fact magazine.

The survey responses were not one of psychiatry's finer moments, and in 1973 APA drafted Section 7.3 of its Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, which became known as the Goldwater Rule:

"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."

Since then there have been few notable breaches of the code by psychiatrists, but the temptation to muse aloud about the psychology of powerful figures in the limelight—and the public appetite for such insights—remains potent and typically grows stronger during times of political campaigning.

Past APA President and former chair of the APA Ethics Appeals Board Paul Appelbaum, M.D., said the most egregious violations in recent years have generally been by other mental health professionals.

"Everyone, whether a psychiatrist, a postal worker, or a store clerk, has an opinion about major public figures and political candidates, and it is common for those opinions to be expressed in ordinary conversation," Appelbaum told Psychiatric News. "Psychiatrists can sometimes forget that their opinions as psychiatrists carry a different weight from the average person's view. Their opinion may be seen as some sort of authoritative insight and hence be more likely to be believed.

"I think we have a particular obligation that is spelled out in our ethics annotations not to comment publicly on the mental state of public figures, because our comments may be seen as clinically valid diagnoses when they are not."

Psychiatrist Richard Friedman, M.D., revisited the Goldwater Rule and its implications in an article in the September 17 Journal of the American Medical Association. Friedman told Psychiatric News he was motivated by publicity surrounding the resignation of New York Gov. Elliot Spitzer following revelations of his involvement with prostitutes.

"There were a lot of mental health professionals, mostly psychologists, theorizing and speculating about the motivations for [Spitzer's] behavior," Friedman said. "It caused me to think, What is the sensible and ethical thing for a psychiatrist to say publicly about public figures that he or she doesn't know?

"Often it just looks silly or ridiculous," he continued." On the other hand, just because you haven't examined someone doesn't mean you have to be quiet. You might have something valuable to say, and to withhold it would be a public disservice."

He is a professor of psychiatry at Weill Cornell Medical College.

Friedman illustrated the distinction in his JAMA article." [A] mental health professional commenting on former Gov. Spitzer's actions would be free to speak generally about psychological principles that help the public understand his behavior," Friedman wrote. "The psychiatrist only needs to indicate that he or she has no professional relationship with the public figure and is not making a diagnosis. Thus, it would be unethical for a psychiatrist to say that Spitzer had a narcissistic personality disorder, which is a diagnosis, but would be permissible to discuss the psychology and symptoms of narcissism in general; the public could then decide whether the information applies to the given individual."

The line is not a bright one. "I think it's kind of hazy," Friedman said. "But guidelines have to be somewhat inexact since you can't possibly think of every possibility, and it's better than having nothing at all."

"As in so many things, it's at the extremes that the line is brightest," said Appelbaum. "When you get to the gray zone in the middle, it gets a little fuzzier. I would agree with Dr. Friedman that it is entirely appropriate for psychiatrists to speak publicly about mental health disorders or personality traits and the effects these can have on behavior. What's important in those cases is to make clear one is not commenting on a particular person. It's all too easy for a general comment made in the context of a public figure's behavior to be seen as a comment on that case."

The distinction is made more difficult in the case of psychiatrists who have made the study of political leaders a scholarly endeavor.

"Whenever I have discussed the work I do that is at the core of my career, everyone agrees it is ethical and valuable," said Jerrold Post, M.D., a professor of psychiatry, political psychology, and international affairs at George Washington University. "But if you took very literally the language of APA's ethics code, it veers perilously close to being in violation."

Post has confined his work to psychological profiles of leaders of other countries and does not comment on American political figures. He is also the author of "Ethical Considerations in Psychiatric Profiling of Political Figures," which appeared in the September 2002 Psychiatric Clinics of North America in an issue themed "Ehics in Psychiatry."

It was Post who famously delivered Congressional testimony in the early 1990s profiling former Iraqi dictator Saddam Hussein as a malignant narcissist; he was criticized by some but has steadfastly maintained the value of his assessment.

"I am confident from the feedback I have had that my clarification was useful to Congress and to the public at large," he told Psychiatric News.

"In my own view, one does need to be careful and mindful of the reputation of American psychiatry and the potential influence such commentary can have on that reputation," Post said. "Having said that, I think there are occasions when our expertise can usefully contribute to public understanding. I worry that there are occasions when some of us who follow these matters closely may be inhibited at times when we might have something useful to contribute."

There is enough disagreement about where exactly to draw the line and how brightly to paint it that a Board of Trustees Task Force to Update the Ethics Annotation has discussed a revision. In part, the draft revision reads as follows: "For some in our profession, psychiatry can extend beyond the physician-patient relationship into the broader domain of public relations: in administration, politics, the courtroom, the media, and the Internet."

The draft also states, "In some circumstances, such as academic scholarship about figures of historical importance, provisional diagnostic evaluations may be made and should be subject to peer review and academic scrutiny based on relevant standards of scholarship."

Richard Milone, M.D., a member of the task force, emphasized that the revision is only in draft form and has no effective force without being approved by the Assembly and the Board. But he said he believes that, if passed, it would encompass the kind of work that Post does.

"It enlarges the Goldwater Rule by making allowance for individuals who are doing scholarly research and for true psycho-historians and psycho-biographers," he said.

Still, opinion about revising the code is sharply divided.

"It's fair to say there are members who feel strongly both that the provision should remain exactly as is and that it ought to be changed at the very least to allow more clearly for scholarly endeavors," said Appelbaum. "I lean toward the latter position, but I'm not sure it will be at all easy to find a formulation that would clearly define what is acceptable and what is not."

"Role of Physicians and Mental Health Professionals in Discussions of Public Figures" is posted at<http://jama.ama-assn.org/cgi/content/full/300/11/1348>.▪