Time to revisit the Goldwater rule?

ASKED by a news magazine to comment on the mental health of a certain US presidential candidate, psychiatrists detailed his “grandiose manner” and “godlike self-image”, describing him as “paranoid” and a “counterfeit figure of a masculine man”.

If you think I’m talking about 2016, you’ll need to wind back the clock.

The Republican presidential candidate in question was Senator Barry Goldwater and the year was 1964.

Fact magazine, employing some pretty loose journalistic ethics, had published a special issue devoted to the candidate’s mental health, or rather alleged lack of it.

The magazine’s case rested in part on a survey of 12 356 psychiatrists, which asked whether Goldwater was psychologically fit to be president.

Of the 2417 who responded – most of them anonymously – 1189 said that Goldwater was unfit, 657 answered fit, and 571 said they did not know enough about him to answer the question.

Some offered specific diagnoses of mental illness or comments like the ones quoted above.

After the defeat of his presidential bid, Goldwater successfully sued for libel over the publication.

The ripple effects of the affair continue today. The magazine’s survey led to a rewriting of the American Psychiatric Association’s (APA) ethical guidelines.

Clause 7.3, the so-called Goldwater rule, states, among other things, that it is “unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination”, thereby precluding comments on the mental health or otherwise of public figures.

The APA has felt the need to restate the rule in recent times as a result of the diagnostic frenzy surrounding President Donald Trump.

“Simply put, breaking the Goldwater rule is irresponsible, potentially stigmatising, and definitely unethical,” wrote APA president Dr Maria Oquendo in the lead-up to the 2016 election.

Among those who had offered a diagnosis was former dean of the Harvard Medical School, Professor Jeffrey Flier, who tweeted back in July 2016: “Narcissistic personality disorder. Trump doesn’t just have it, he defines it.”

Professor Flier is not a psychiatrist, but three prominent members of that profession tried to tread a fine line when they publicly raised concerns about the president elect’s mental health in a letter to President Barack Obama late in 2016.

The professors, from Harvard Medical School and the University of California, acknowledged that their professional standards did not allow them to venture a diagnosis for a public figure who they had not examined personally.

“Nevertheless, his widely reported symptoms of mental instability – including grandiosity, impulsivity, hypersensitivity to slights or criticism, and an apparent inability to distinguish between fantasy and reality – lead us to question his fitness for the immense responsibilities of the office,” they wrote.

The three professors urged Obama to order “a full medical and neuropsychiatric evaluation” of the president elect before he assumed office, though they did not explain just how they thought an outgoing president might require such an examination of his replacement.

Meanwhile, Dr Allen Frances, the psychiatrist who wrote the criteria for narcissistic personality disorder, weighed into the debate, declaring the widespread diagnosis of the new president by both professionals and amateurs to be inaccurate and misguided.

While President Trump might exhibit some or all of the symptoms of the disorder, Dr Frances said he did not meet the requirement – “crucial in defining all mental disorders” – of clinically significant distress or impairment.

“Trump is clearly a man singularly without distress and his behaviors consistently reap him fame, fortune, women, and now political power… Dismissing Trump as simply mad paradoxically reduces our ability to deal with his actions,” Dr Frances wrote.

You could argue, I suppose, that Dr Frances himself broke the Goldwater rule by saying a public figure did not have a particular condition.

In any case, even before the current brouhaha, some were arguing the rule was overly prescriptive.

In an article published in 2016, American authors described it as an excessive response to what was admittedly an embarrassing moment in American psychiatry.

Mental health experts, they argued, should not be prevented from “voicing psychiatric concerns as matters of conscience”.

Time for a more nuanced view, perhaps?

Jane McCredie is a Sydney-based science and medicine writer, editor and publisher.

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