AT THE COLLEGE 2018
TAMPA, FLA. (FRONTLINE MEDICAL NEWS) – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD , who argued for no change, and Steven S. Sharfstein, MD , who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD , chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.