The psychiatrist’s dilemma: To comment on Donald Trump or not?
Columnist Irwin Stoolmacher (“A Progressive Perspective,” February 3) captures well the ethical dilemma faced by many psychiatrists in the age of Donald Trump.
With considerable historical and ethical nuance, Stoolmacher reviews the history of debates over the appropriateness of psychiatrists commenting in the media on the mental health of public figures—including the American Psychiatric Association’s (APA) Goldwater Rule. Adopted in 1973 in the wake of the scandal caused by Fact magazine’s attack on 1964 presidential candidate Barry Goldwater, the Rule prohibits such comment.
“In theory,” Stoolmacher says, “I agree with the “Goldwater rule” as I believe it is probably impossible to accurately psychologically evaluate a person one has not personally examined.”
Obtaining a personal interview and consent before evaluation is, in fact, a foundation of psychiatric ethics. Personal observations make possible accurate conclusions. And a surgeon, no matter how skilled, would not operate unless she had consent from the patient—unless she was prepared for trouble.
I recently interviewed two of the APA’s top officials about the Goldwater Rule and heard versions of this central argument. Saul Levin, the APA’s medical director, strongly supported the group’s longstanding ethical rule. To Levin, it is a matter of “protecting the art and science of psychiatry— that we don’t do armchair psychiatry.” Rebecca Brendel, the head of the APA’s ethics committee, told me that the values and methods of the profession must be respected.
Ad hominem media attacks, she emphasized, will not do.
Yet there is another side to the story. As Stoolmacher puts it, “I am convinced that there is something mentally wrong with President Trump and believe with all my heart and soul that Americans have a moral responsibility to do everything within their power to ensure he is not re-elected.”
What’s an ethical psychiatrist to do? Whether Democrat or Republican, concerned psychiatrists have choices.
Voting against Trump or fighting his policies in public is one option. No one, including the APA, would deny that psychiatrists have a right to do so. In fact, the APA itself has issued many vigorous public statements against such Trump policies as the separation of children from parents at the southern border and changes in the Affordable Care Act. Says Brendel: “Nobody is arguing that psychiatrists should not be speaking out.”
A second approach countenanced by the APA is for a psychiatrist to provide the public with education about psychiatric conditions in general. If one thinks Trump has narcissistic personality disorder, one can describe publicly the nature, diagnostic criteria, treatment, and impact of that disorder— without saying Trump has it. Not many find this alternative satisfying, but it is ethical.
Being available to Congress for consultation is also an option, though a more rarified one. The 25th Amendment to the Constitution allows a president to be removed from office if he or she is unable to discharge the duties of the office. The process requires the Vice President and majority of the cabinet to certify to Congress the president’s disability, a step that has never been taken. But it is not impossible.
Former APA president Jeffrey Lieberman objects to public psychiatric comment on a president’s mental health. But he believes it is appropriate for a psychiatrist to “assist in the process” if removal from office is initiated under these Constitutionally specified mechanisms. In other words, expert opinion may have a role here. The option of assisting is perhaps most realistic if the psychiatrist happens to be nationally prominent, to practice in Washington, D.C., or to specialize in forensic psychiatry.
That leaves the most controversial option. A psychiatrist can take a deep breath and proceed with psychiatric comment on Trump.
There are risks to this approach. At least one APA member was investigated by a local branch after speaking out, and others have resigned.
But Robert Jay Lifton and Judith Herman, both respected APA members, have drawn on their study of German psychiatrists under Hitler and of trauma to argue that in some circumstances, psychiatric comment without interview or consent is morally justified.
Lifton’s notion of a psychiatrist as a “witnessing professional” aims to integrate professional ethics with what he learned in his research on the erosion of professional integrity under Nazism. When a tyrant shifts social norms, asserts Lifton with his colleagues Herman and Bandy Lee, a professional organization can either stay silent or can protest against the new “malignant normality.” There’s no easy answer. My own view, based in part on the work of the late philosophers Jacques Maritain of Princeton and John Rawls of Harvard, is that a reasonable respect for the diversity of opinion within the APA matters. No one would argue that psychiatrists should be allowed to exploit their patients or participate in torture. But when psychiatrists of good faith disagree on speaking out about public figures during a crisis, exceptions to the Goldwater Rule may be philosophically and morally sound—and not an ethics violation at all.