COMMENTARY

The Goldwater Rule and Presidential Mental Health: Pros and Cons

Nassir Ghaemi, MD, MPH

Disclosures

June 07, 2017

Arbitrating Morality

It should be noted that in March 2017, the APA ethics committee put out an elaboration on the Goldwater Rule—mainly as a result of growing concern about the current US president—in which an exception was provided for political profiling under the authorization of the government, as in Dr Post's work. An exception was provided also for forensic profiling with a court order, and for psychohistory of deceased public figures.

The APA claimed, though, that these scenarios were exceptional and uncommon and did not change the main basis for the Goldwater Rule—namely, that in the majority of cases, psychiatrists need to directly examine a patient and obtain that patient's consent before offering a professional opinion. Furthermore, the March 2017 statement expanded the limitation of the Goldwater Rule beyond making an actual diagnosis; it stated that any kind of professional opinion—just commenting on the behavior of another person, even without making a diagnostic judgment, was impermissible.

The third speaker, Dr Claire Pouncey, took up some of these specific claims of the APA ethics committee. Dr Pouncey is immediate past president of the Association for the Advancement of Philosophy and Psychiatry. She is a practicing psychiatrist in Philadelphia and has a PhD in philosophy as well. In 2016 Dr Pouncey published, along with fellow psychiatrist Dr Jerome Kroll, an article in the Journal of the American Academy of Psychiatry and the Law critiquing the Goldwater Rule from an ethical perspective. She expanded on that analysis in her talk.

A central point she made is that ethics is not just about "rules"; it is not about do's and don'ts. Sometimes this is the case. It is accepted that it is and should be a rule that psychiatrists should not have sex with their patients. But that kind of red-line unethical controversy is uncommon. Most ethical decisions are nuanced; they involve contrasting values, differing outcomes, and conflicting opinions. There is rarely a clear right or wrong decision.

In the most cases, human beings have to make ethical judgments in a complex way. A simple rule doesn't work. This is called "moral agency." The members of the APA are psychiatrists who have spent many years studying human behavior; they are licensed physicians who have been certified to treat mentally ill persons; they are bound by many ethical restrictions and laws to which, in the vast majority of cases, they live up conscientiously.

Dr Pouncey argued that the psychiatrist members of the APA deserve some respect and trust from their main professional organization. They should be allowed to exert their moral agency, and make their own judgments about whether, how, and on what grounds to comment on public figures. The claim that any commentary on public figures is unethical is questionable on moral grounds, because ethics doesn't work that way.

Instead of telling psychiatrists what they can and cannot do on this matter, it would make more sense to talk about the moral aspects of the problem, when one can or should discuss public figures, and for what purposes. This approach would be more respectful of the moral agency of psychiatrists, rather than setting the APA up as the sole arbiter of morality. It is understandable that some behavior is reprehensible and deserves clear prohibition—for example, sex with patients. But a psychiatric discussion of public figures is not a behavior of that ilk.

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