The Goldwater Rule Paradox: Does psychiatry as a profession risk losing the public’s respect by its silence in the face of Donald Trump’s declining mental health and fitness to lead the country?

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Anti-Goldwater campaign button, 1964

The so-called Goldwater Rule was added to psychiatry’s code of ethics to preserve the integrity and reputation of the profession. Ironically, it may end up damaging that reputation because of the collective failure of the profession to try to protect us from the harm done by a dangerously mentally ill president. The psychiatric profession should make known its collective opinion on the president’s mental fitness through its professional association, the American Psychiatric Association, before it is too late.

Individual psychiatrists and other mental health professionals (who are not bound by anything comparable to the Goldwater Rule) made early attempts to warn us about the dangers posed by a president with narcissistic personality disorder of the type exhibited by Trump. In 2017, 27 psychiatrists and psychologists co-authored The Dangerous Case of Donald Trump, in which they stated that “anyone as mentally unstable as Mr. Trump simply should not be entrusted with the life-and-death powers of the presidency.”

The book was revised in 2019, adding ten co-authors and the observation that Trump had become even more erratic and dangerous. In December 2019, a group of 350 psychiatrists and other mental health professionals submitted a petition to Congress stating that Trump’s mental health was rapidly deteriorating under the pressure of impeachment. Things got even worse when Trump was required to manage the federal response to the COVID-19 pandemic, a task for which he is by nature especially unsuited.

Dr. Justin Frank is a former clinical professor of psychiatry at the George Washington University Medical Center with more than 40 years of experience in psychoanalysis, and the author of Trump on the Couch: Inside the Mind of the President. In July, he told Salon:

“Through his public behavior Trump has repeatedly shown that he is mentally unwell. His apparent pathologies include malignant narcissism, delusions of grandeur, an attraction to violence, sadism, a lack of impulse control, utter disregard for rules and norms, and a pathological tendency to lie. In sum, our president can be reasonably described as a psychopath or a sociopath.”

And of course, Trump’s own niece, Mary Trump, has added her voice to the chorus. Ms. Trump is a clinical psychologist, and in her recent book, Too Much and Never Enough: How My Family Created the World’s Most Dangerous Man, had this to say about her uncle:

“I have no problem calling Donald a narcissist — he meets all nine criteria. But the label gets us only so far. A case could be made that he also meets the criteria for antisocial personality disorder, which in its most severe forms is generally considered sociopathy but can also refer to chronic criminality, arrogance, and disregard for the rights of others…. Donald may also meet some of the criteria for dependent personality disorder, the hallmarks of which include an inability to make decisions or take responsibility, discomfort with being alone, and going to excessive lengths to obtain support from others.”

She also stated that she believes that Trump has a “long-undiagnosed learning disability that for decades interfered with his ability to process information.” (Former Secretary of State Rex Tillerson thought that Trump was just a “fucking moron,” but then again Tillerson does not have a Ph.D. in clinical psychology like Ms. Trump.)

So, individual mental health professionals, including psychiatrists, have spoken up. The Goldwater Rule, however, has tended to keep discussion of Trump’s mental health in the background. Certainly, it has precluded the American Psychiatric Association (APA) from lending its weight to the concerns about Trump.

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The Goldwater Rule is an ethical canon precluding psychiatrists from offering professional opinions in the media about public figures whom they have not examined. It was named for former senator and presidential candidate Barry Goldwater, who successfully sued Fact magazine for a 1964 article questioning his mental fitness to be president that contained derogatory comments from psychiatrists on Goldwater’s mental health.

Of the 2,417 psychiatrists who responded to a survey by the magazine, 1,189 said Goldwater was unfit. None of the psychiatrists had examined Goldwater, and the comments disparaging Goldwater’s mental health were widely discredited as politically motivated. Most psychiatrists believed that the embarrassing episode damaged the credibility of their profession and were determined that nothing similar would happen in the future. The Goldwater Rule was the result.

The psychiatric establishment, led by Dr. Jeffrey Lieberman, chairman of the department of psychiatry at Columbia University College of Physicians and Surgeons and a former president of the American Psychiatric Association (APA), responded sharply to the publication of The Dangerous Case of Donald Trump. Dr. Bandy X. Lee and her co-authors were castigated by Lieberman for allegedly violating the Goldwater Rule.

The Goldwater Rule has been criticized as a bureaucratic overreaction to a single unfortunate situation and potentially dangerous; as lawyers say, “hard cases make bad law.” In my opinion, there simply has to be an exception applicable to the situation at hand, where psychiatrists have had years to listen to what Trump says and how he says it and to observe his behavior.

I would couch the issue as a question to Lieberman, who was virulent in his criticism of Lee and others for expressing their opinions on Trump:

“Dr. Lieberman, what the hell good is the psychiatric profession if it cannot at least try to protect society from someone like Donald Trump?”

It may or may not do any good, but I believe that the APA should step forward and take a formal position on how the mental condition of Donald Trump is affecting his ability to lead the country in a time of crisis. Dr. Lee supported the assessment by Trump’s niece that Trump is mentally incapable of leading the country, adding that “any honest and competent mental health professional has come to the same conclusion.” If that is the case, then why would the APA not want to put its credibility and prestige behind that conclusion?

The APA can take a position on the issue of Trump’s fitness to continue leading the country now, while its opinion still might influence the course of future events. Or it can wait until Trump kills more people by his indifference and incompetence and destroys our democratic institutions, and then the APA can forever make excuses for failing to stand up when it counted. In my opinion, the APA has a moral duty, if not an ethical one, to act now.

Retired lawyer, former prosecutor, former social worker, Army vet — former lots of things. Commentary published in Washington Post, Baltimore Sun and elsewhere.

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