Goldwater redux: Shifting rationales for ethical noncompliance

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “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.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.