COMMENTARY

The Goldwater Rule and Presidential Mental Health: Pros and Cons

Nassir Ghaemi, MD, MPH

Disclosures

June 07, 2017

Does the Goldwater Rule Stigmatize Mental Illness?

I was the fourth speaker, and I made two initial points based on prior statements in the panel.

I made the initial point that emphasis on the need for consent and direct examination does not reflect current psychiatric diagnostic practice, as explained below. Rather, it reflects psychotherapy practice, which was central to psychiatry in the 1960s/1970s, and which continues to be important but differs from the process of psychiatric diagnosis.

Second, I argued that the claim that without the Goldwater Rule, there would be an anarchy of psychiatric opinions, entails certain relativistic/nihilistic assumptions about psychiatry. If we accept the perspective that we should say nothing in public because psychiatrists have different views (eg, bipolar vs attention-deficit disorder vs sociopathy vs narcissism), all of which could be wrong, in this case we must admit that psychiatrists just don't know what they're talking about and thus should say nothing.

The APA surely doesn't want to admit such complete ignorance. Were they to do so, they would essentially be accepting the basic critique of antipsychiatry groups—namely, that there is no truth to psychiatric diagnoses.

This postmodern perspective, if used as a basis for the complete and universal censorship of the Goldwater Rule, itself contradicts the ethics of science, which involves the free discussion of competing hypotheses in the marketplace of ideas, with the confidence that eventually the truth—which is corrected error—will emerge. Science involves refutation of false hypotheses, not censorship of them.

I then turned to my main remarks, which involved approaching the problem of the Goldwater Rule from two perspectives: (1) its claimed rationale in the March 2017 APA ethics committee statement, and (2) insights from the field of psychohistory.

The March 2017 APA statement claimed three reasons to support the Goldwater Rule: consent, standards of diagnosis, and stigma. The view that consent is part of standard clinical practice is undermined, I said, by common emergency department practice, where patients often are seen who are brought by the police, friends or family, or the public, often against their will. It is common for psychiatric evaluation and diagnosis to happen without the consent of the patient in the emergency department. So this is not an uncommon practice, contrary to the Goldwater Rule.

Regarding standards of diagnosis, a direct examination of the patient commonly is not required or useful in psychiatric practice. In schizophrenia and mania, one half of patients deny their symptoms. In hypomania, it's even worse: Two thirds deny their symptoms. This lack of insight is a central feature of the two most common serious psychiatric conditions: schizophrenia and bipolar illness.

In these settings, the direct examination is uninformative and is trumped by collateral information, from friends or family or others, just as is the case in evaluation of a public figure. Again, this aspect of standard psychiatric diagnosis is common and contradicts the Goldwater Rule. The nonspecificity of the mental status examination, in contrast to "direct" examination in the rest of medicine was emphasized also, and hence contradicts the claim that "direct examination" is essential to making a psychiatric diagnosis.

Regarding stigma, I discussed the positive benefits of mania and depression, proven in several scientific studies, with mania enhancing creativity and resilience, and depression enhancing empathy and realism. In A First-Rate Madness, I showed how these symptoms and leadership traits were present in some of our greatest political and military and business leaders. Thus, making a diagnosis in such persons does not stigmatize them; in fact, it's the reverse: It reduces stigma by showing benefits of some psychiatric conditions. The Goldwater Rule in fact is stigmatizing, because it assumes that psychiatric diagnosis is bad and harmful and pejorative. This may be what the culture believes, but psychiatrists and the APA should not feed into that stigmatizing culture and worsen this discrimination against mental illness, as we do with the Goldwater Rule.

Finally, I emphasized that public figures give up some privacy rights if they seek to be elected officials, such as presidents. In a democracy, a leader is elected on the basis of the consent of the governed. The governed cannot consent fully if they are uninformed or if key information about their leaders is hidden from them. This is accepted widely now regarding all medical diseases, except psychiatric conditions, because the Goldwater Rule is stigmatizing and contradicts the claims by many of wanting parity between medical and psychiatric illnesses. Woodrow Wilson had a stroke in office; it is accepted now that the public had a right to know, instead of its occultation, leading to de facto governance by the First Lady.

I described two other key cases with psychiatric aspects. John Kennedy had Addison disease, which was hidden from the public during his election campaigns and which produced severe depression at times and required steroid treatment. In A First-Rate Madness, I documented that Kennedy abused testosterone injections for two of his three presidential years—times when his leadership was erratic and his judgments often wrong. An intervention by the White House physician Admiral George Burkley led to massive reduction in Kennedy's steroid abuse, just before a possible near-nuclear war in the Cuban Missile Crisis.

Adolf Hitler, I believe, had bipolar illness, on the basis of documentation I provided. From 1937 until his death, he received intravenous amphetamine daily for his severe depressive states, which worsened his manic states. Dr Karl Bonhoeffer, chair of the main psychiatric hospital in Berlin and father of the great Nazi resistance leader Dietrich Bonhoeffer, plotted with generals in 1937 to arrest Hitler, declare him insane, and lock him in an asylum. Would Bonhoeffer's planned action have broken the Goldwater Rule? Is it unethical, equivalent to having sex with one's patients?

In sum, I stated that the public also has a right to know about the psychiatric conditions of their leaders, just as it does regarding medical illnesses, because psychiatric diagnoses do affect leadership, not just for ill but also for good. I argued for allowing discussion of public figures with scientifically valid diagnoses (such as bipolar illness in contrast to "narcissistic personality disorder") and without specific political intentions, but rather to contribute to public discussion in a scientifically sound and morally responsible manner.

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