The Goldwater Rule, a ruling within the professional guidance published by the American Psychiatric Association (APA), discourages psychiatrists from publicly engaging with personal comments on public figures in a professional psychiatric capacity. With the recent uptick in populism globally, a renewed energy, and indeed debate, has been given to the relevance of the Goldwater Rule among psychiatrists, healthcare professionals and the general public. This piece reviews the Goldwater Rule and then addresses whether or not medical professionals, in particular psychiatrists, are capable of forming opinions on public figures without consent. Finally, some of the ethical and professional elements of the Goldwater Rule are deliberated.

INTRODUCTION: What is the Goldwater Rule?

The Goldwater Rule was introduced into the APA guidance for psychiatrists in 1973, following the publication of a survey of psychiatrists’ views on the Republican presidential candidate Barry Goldwater in the 1964 Presidential election in the United States. The rule remains active in the APA and specifies that “On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention... In such circumstances, a psychiatrist may share ... [their] expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless [they have] conducted an examination...”1

The Goldwater Rule was controversial at the time, and now in a modern era of controversial political figures such as Mr Trump (and much public commentary made about his personality, character and behaviour) there has been a revival in the debate surrounding the need and the suitability of such a policy.2,3 Indeed, some psychiatrists insisted on defying the Goldwater Rule and commented on Mr Trump during his presidential campaign: “Mr. Trump’s speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions. His words and behaviour suggest a profound inability to empathize. Individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them.”3

These comments, published in the New York Times, by Dr. Dodes, a Harvard Professor of Psychiatry was co-signed by 34 other psychiatrists, psychologists and social workers. The letter declared that too much was at stake to be silent any longer: “Silence from the country’s mental health organizations has been due to a self-imposed dictum [The Goldwater Rule]. But this silence has resulted in a failure to lend our expertise to worried journalists... at this critical time.”3

The public debate raises the question of whether or not medical and psychiatric experts have a duty of care to use their clinical capabilities in an honourable manner, namely for both the greater good of society and prevention of a perceived threat to society. It also questions whether the need for the rule was in context of 1970’s America and if today, with readily accessible and ever-changing online news media, social media and post-truth politics, that need for the Goldwater Rule still exists.4

What constitutes an expert opinion and a medical examination?

In a modern context, debate around the Goldwater Rule highlights the need to clarify what exactly an examination entails. The modern psychiatrist can easily access video footage of a public figure and thus form a view from their speech, engagement and behaviour. Even taking candidate preparation ahead of formal speeches and speaking events into account, one might assume that more candid footage of most public figures is available. As a result, indirect observation of public figures is readily available, and while the majority of psychiatrists will never meet with the current President of the United States, video evidence of his behaviour is readily available. However, would this count as enough evidence to justify a psychiatric evaluation and possible diagnosis, if pathology were even to be present?

Irish case law has a number of interesting cases that touch upon the question of what satisfies the requirements for a medical examination, and thus the procedure by which a medical professional can come to a diagnosis. Does a clinical examination include simply observing a patient from afar? Does it require the verbal interaction, or eye-contact?

The notion that assessing a patient by a medical examination, or a psychiatric examination has been tested in both MZ v. Khattak and XY v. Clinical Director of SPUH.5,6 Together they posit that we must at least consider that thorough investigation and observation of informal actions of Mr Trump in person, from a short distance, or indeed from video footage, might be enough to draw medical conclusions.

In MZ v. Khattak, a registered medical practitioner, Dr W, was called to a Garda station to examine MZ, who was taken to the station under Section 12 of the Mental Health Act 2001. The patient MZ was outside the rear of the station, and Dr W joined him “for a smoke”, and lasted “for as long as it took to smoke our cigarettes”. The ‘interview’ was not held in the station, or in an interview room. Dr W said that after “his ‘chat’ with the applicant outside the [rear] of the station he was satisfied that he should be in hospital since he was not taking his medication, was elated and paranoid.”5 The definition of examination in the Mental Health Act was addressed: “Examination; in relation to a recommendation, an admission order or a renewal order, means a personal examination carried out by a registered medical practitioner or a consultant psychiatrist of the process and content of thought, the mood and the behaviour of the person concerned.”5

However, Mr Justice Peart was very cautious about the examination he views “the manner in which he conducted his examination with some disquiet”. He questions if it was “too informal”, but concluded also that “Dr W’s thirty years’ experience... enables him to reach the necessary conclusions.”5 It should be noted also that there were failings in this case for the medical practitioner to fully describe the procedures of the Mental Health Act and indeed explain what a Mental State Examination was, but, in spite of this, the ruling remains.

In XY v. Clinical Director of SPUH, Dr B saw the patient, XY, in the car park. Dr B had “already formed the opinion from [his] previous assessment that the applicant had a major psychiatric illness... [He] did not speak to the applicant. [He] simply examined her through observations... [He] saw nothing... to change [his] mind from [his] previous assessment.”6 Mr Justice Hogan acknowledged that “an observation of the patient from a distance can - at least in some circumstances - also constitute a "personal examination" for this purpose” and that this is also supported by the fact that Dr B knew the patient XY already.6 It is worth noting that in SO v. Adelaide and Meath Hospital of Tallaght, it was shown that an examination does have to happen, and that before a recommendation is made under the Mental Health Act those signing the recommendation forms must be satisfied that a prior examination has been conducted.7

These cases highlight that a psychiatrist, or any medical doctor, does not necessarily need to exchange words to ‘examine’ the patient, or indeed spend a particular amount of time with them. While video footage is just a snapshot of a person in space and time, so too is a medical examination – and that can and must be considered when examining patients. Positive symptoms may not always be present and examination may be most appropriate on numerous occasions, at medical discretion. However, one might justifiably wonder if it would be sufficient to attend a meeting and observe Mr Trump, or merely watch him from a crowd, or indeed on television. If observation is sufficient to evaluate mental state in a clinical assessment, could that not justify accepting that a psychiatrist can genuinely, safely and professionally comment on public figures?

Why shouldn’t medical practitioners comment on public figures?

Medical professionalism relies on the three main ethical pillars of beneficence, non-maleficence and autonomy. Other principles of justice, fairness, confidentiality and informed consent also play essential roles in fostering positive empowering healthcare for patients.10 The crux of the Goldwater Rule is the use of medical knowledge unethically. Medical information and diagnoses are the knowledge of the patient and the medical professionals treating them (excluding exceptional circumstances; i.e. notifiable diseases, self-harm, or court-requested disclosures). Medical professionals do, however, have the honour and privilege of treating patients which grants them a significant power.11

The Goldwater Rule interacts variably with these ethical principles. One might ask if breaching the Goldwater Rule is beneficent. Assuming you can refer to a public-figure as a patient, is it really in the patient’s best interest? Is it non-maleficent? Perhaps not, because most often commenting on someone’s personality traits, character, behaviour, or suggesting a diagnosis is disclosure of medical information, but also puts them at risk of being stigmatised. Finally, speaking about a patient without their permission is in direct contrast to their autonomy.

The principles and pillars of medical ethics pertain to one’s own patient, with whom one has a doctor-patient relationship. If one was the treating doctor of a public figure, their opinion may be justified, but the breach of confidentiality, trust and the doctor-patient relationship is very much at stake. Furthermore, the risk to the profession is greater again as it creates a sense of fear and distrust amongst those that might seek care from mental health services.12

Kroll and Pouncey argue that psychiatrists have a duty to protect the privacy of their patients, but that they do not have an obligation to protect “public perceptions of the psychiatric profession”. By dictating to psychiatrists, they suggest that the Goldwater Rule confuses the interests of the patients and individual psychiatrists, with the interests of the profession as a whole. Instead they argue that the Goldwater Rule should be a standard of etiquette instead of a code of ethics. The distinction here is the difference between professionalism and professional ethics, which “are related but not identical”, and more importantly where violations of ethics are sanctionable, violations of etiquette are not.13

Allowing psychiatrists to professionally comment on public figures’ personalities or behaviours is commenting on a non-patient, and is difficult to justify under the main pillars of medical ethics. In the case of Barry Goldwater, psychiatrists’ opinions were being used to smear him, cost him votes and eventually the election; utterly non- beneficent, maleficent and indeed very much countering Goldwater’s autonomous freedom to pursue a free and fair election.14

While most of the literature suggests that the Goldwater Rule was created to protect the psychiatric profession,13 Appelbaum believes that comments harm the targeted public figure and dissuade others from seeking psychiatric care.12 In both of these outcomes the patient cohort and the public figure are harmed, and this contravenes both pillars of beneficence and non-maleficence. The greater harm is to the medical profession, in particular regarding psychiatric services which results in a lack of faith in psychiatric support services when they are most needed.13

Meredith Levine explores the ethical angle of journalism and finds heavily in favour of keeping the Goldwater Rule to both protect the psychiatric profession and the public from what she describes as an “incalculable harm” in the modern viral digital media world. She urges psychiatrists that are keen to educate the public on mental health that this must be done carefully and without malice, and that the information must be “accurate and verified”.4

Robert Pies, while agreeing that the "ethical core of the Goldwater Rule is sound", suggests a more precise version of the rule where the type of remark made is categorised, and consequently, it is decided whether or not it breaches the rule.15 Most notably he provides a difference between commenting on a public figure by way of characterising their behaviour, versus suggesting differential diagnoses, versus clinically diagnosing them.15 He also suggests that psychiatrists can and should be very mindful of cloaking personal opinion in a professional tone. Others suggest the need for training schemes to discuss the Goldwater Rule as a didactic way of addressing the ethical and professional debate.16

CONCLUSION

The underlying issue in the modern debate surrounding the Goldwater Rule suggests that: for psychiatrists, or any physician, to propose a diagnosis at a distance of a figure that is not their patient fosters only distrust from the public, and
is both intellectually insincere and professionally damaging. While the rule itself may be questioned, and- particularly considering the challenges of the modern era- should be refined, it unquestionably serves to protect the trusted position that medical professionals have and need to conduct their work, and to nurture the doctor-patient relationship.

1. American Psychiatric Association. The principles of medical ethics with annotations especially applicable
to psychiatry. Am J Psychiatry. 1973;130(9):1058–64.

2. Frances A. An Eminent Psychiatrist Demurs on Trump’s Mental State. New York Times [Internet]. 2017 Feb 14; Available from: https://nyti.ms/2lMJ0xw

3. Dodes L. Mental Health Professionals Warn About Trump. New York Times [Internet]. 2017 Feb 13; Available from: https://nyti.ms/2kDc21k

4. Levine MA. Journalism ethics and the goldwater rule in a “post-truth” media world. J Am Acad Psychiatry Law. 2017;45(2):241–8.

5. High Court of Ireland. MZ -v- Khattak & Anor [2008] IEHC 262 High Court Record Number: 2008 No. 1038 SS 28/07/2008, Ireland [Internet]. 2008. Available from: http://www.bailii.org/ie/cases/IEHC/2008/ H262.html

6. High Court of Ireland. X.Y -v- Clinical Director of St Patricks University Hospital & Anor [2012] IEHC 224 (08 June 2012) 2012. Available from: http://www. bailii.org/ie/cases/IEHC/2012/H224.html

7. High Court of Ireland. S.O. v. Adelaide and Meath Hospital of Tallaght, [2013] IEHC 132 High Court Record Number: 2013 No. 495 SS 03/25/2013. 2013. Available from: http://www.courts.ie/Judgments. nsf/0/FFB24B69BC83E42480257B4B005314F9

8. Lee BX. The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a president. The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a president. St. Martin’s Press. New York; 2017.

9. Pouncey C. President Trump’s Mental Health — Is It Morally Permissible
for Psychiatrists to Comment? N Engl J Med. 2018;378(5):405–7. Available from: https://www.nejm.org/doi/full/10.1056/ NEJMp1714828

10. Jonsen A, Siegler M, Winslade W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th Edition by (1998). 7th ed. Hill, McGraw; 2010.

11. Davis NJ. Questioning the Goldwater Rule: Commentary on Lilienfeld, Miller and Lynam Nick. Perspect Psychol Sci. 2017.

12. Appelbaum PS. Reflections on the Goldwater Rule. J Am Acad Psychiatry Law. 2017;45(2):228–32.

13. Kroll J, Pouncey C. The Ethics of APA’s Goldwater Rule. J Am Acad Psychiatry Law. 2016;44(2):226–35.

14. Lilienfeld SO, Miller JD, Lynam DR. The Goldwater Rule: Perspectives From, and Implications for, Psychological Science. Perspect Psychol Sci. 2018;13(1):3–27.

15. Pies RW. Deconstructing (and reconstructing) the Goldwater Rule. Psychiatr Times 2016;1–4.

16. Armontrout JA, Vijapura S. A “Trans- Dyadic” Perspective on the Goldwater Rule. J Am Acad Psychiatry Law 2017;45(2):249–52.