The Dangers of Speculating About Trump's Mental Health

A Troubling Best Seller

Hello. This is Dr Jeffrey Lieberman of Columbia University in New York City, speaking to you for Medscape.

The title of this talk could be "The Dangers of Psychiatrists Writing About the President's Mental Health." What prompted this is the recent publication of a book called The Dangerous Case of Donald Trump, which arrived to great fanfare and is currently on the best-seller list. The book was edited by a Yale psychiatrist named Bandy Lee and is a compendium of 24 chapters authored by psychiatrists, psychologists, or therapists that offer a variety of clinical opinions of the president.

So that you understand where I am going with this, let me just say that this is not good. I can certainly understand how concerned citizens would react to Mr Trump's unconventional, often offensive, and seemingly unhinged behavior by expressing their discomfort and disapproval. However, I don't believe that it is acceptable for psychiatrists or physicians to publicly proclaim diagnoses and proffer clinical opinions of the president. Doing so violates a key principle of psychiatry and our professional ethics, and moreover, risks harming the reputation of our discipline.

In full disclosure, I was an advisor to Secretary Hillary Clinton's campaign for mental health policy and contributed to her mental health agenda that was released in August 2016 during the campaign. I was also present at the Javits Center on election night for what was expected to be a historic celebratory event. Seated next to the stage, I witnessed the euphoria of a throng that came to what they thought would be a celebratory event and which turned into a funereal experience as the results of the election poured in.

Since then, I have been among the many who are shocked and saddened by the president's behavior, and can well understand the impulse to speak out and become inclined toward activism. That is felt by increasing numbers of Americans, and in the case of Dr Lee and her colleagues, it prompted them, presumably, to formally express their opinions in this book.

However, as a physician and psychiatrist, I cannot condone—and must strongly criticize—these actions as unprofessional and irresponsible.

Threats to Psychiatry's Reputation

Let me state unequivocally that I embrace the First Amendment and fully subscribe to the famous quote, "I disapprove of what you say, but I will defend to the death your right to say it."

The matter of Donald Trump's mental status is different; it is not the Vietnam War, the Civil Rights movement, or abortion rights, issues on which physicians have historically expressed their strong support for social justice. However, in opining on the president's mental health, we are using our professional credentials to express a medical opinion when we have neither the right nor the evidence to do so.

Psychiatry possesses a greater capacity for abuse than other medical specialties because it can be exploited to bypass standard legal and governmental procedures for establishing guilt, innocence, or competence.

Physicians in general have to be wary of this, but psychiatrists in particular. Our history is marked by too many missteps in the past to allow itself to be drawn into an exercise of political partisanship, disguised as patriotism, that risks eroding the credibility of our profession after we have worked so hard to establish it. We have infamously been involved—unwittingly or knowingly—in human rights abuses in many instances when the definitions of mental disease were manipulated to include political dissidents and suppress civil disobedience. Among the most egregious were psychiatry's role in the eugenics policies of Nazi Germany and the political repression of dissidents in the former Soviet Union. We must be aware that psychiatry possesses a greater capacity for abuse than other medical specialties because it can be exploited to bypass standard legal and governmental procedures for establishing guilt, innocence, or competence, and ostensibly legitimizes political action, even incarceration, without need for due process and the odium ordinarily attached to such political conflicts.

Constitutional Course for Removing a President

The Constitution provides three mechanisms by which a sitting president can be removed from office: elections, impeachment, and the 25th Amendment.

Elections reflect the will of the people; impeachment applies when the president may have committed "crimes and misdemeanors"; and the 25th Amendment pertains to questions of presidential competence, which is what we're talking about here.

This amendment consists of four sections. Section 1 applies to when a president dies, resigns, or is impeached from office. In such cases, the vice president becomes president. The best-known example is Richard Nixon, who resigned when faced with impeachment for the Watergate crimes and was succeeded by his vice president, Gerald Ford.

Section 2 applies when the vice president dies or resigns, as Spiro Agnew did when faced with charges of corruption.

Section 3 is for a voluntary transfer of power by the president to the vice president when he/she is, or will be, incapacitated. This occurred when Ronald Reagan was shot and when other presidents underwent medical procedures involving general anesthesia, such as routine colonoscopies. When they regain capacity, presidential authority is transferred back to them.

Section 4 has never been invoked.It allows the vice president, together with a "majority of the principal officers of the executive departments and with the assent of Congress," to declare the president "unable to discharge the powers and duties of his office." To be enacted, a written declaration must then be submitted to the president pro tempore of the Senate and the Speaker of the House. In such instances, the vice president would become acting president.

Section 4 is needed when the president's incapacitation prevents him/her from discharging their duties, but if they don't see it that way or agree and are unable or unwilling to provide the written declaration for voluntary transfer of power as called for in Section 3, Congress has 21 days to decide the issue of competence and need for change.

What Role, if Any, for Medical Professionals?

It is in the context of this process being carried out that physicians, and particularly psychiatrists, must and should play a role. But our role and authority is not to initiate, which is done through the constitutional mechanisms just described, but rather to assist in the process as needed.

While we may be impatient for Congress to take action, it does not justify our taking clinical potshots and lobbing diagnostic grenades at the president through the media. To do so is nothing more than partisan tabloid psychiatry, which does not reflect well and actually harms our profession. Sadly, The Dangerous Case of Donald Trump is not a serious, scholarly, civic-minded work but simply tawdry, indulgent, fatuous, tabloid psychiatry.

All citizens, psychiatrists included, are entitled to express their opinions of the president as a First Amendment right. However, when we render a clinical diagnosis, drawing on our credentials as physicians, as reasons for removal from office outside of constitutionally defined mechanisms, we cross a boundary into an unprofessional and unethical realm. Even as we feel galvanized to action by political crisis, as described in Thomas Paine's immortal words, "These are the times that try men's souls," we should remember the rueful quote of Samuel Johnson some years earlier: "Patriotism is the last refuge of the scoundrel."

In such situations, as Americans or physicians, we must exercise discipline and forbearance. The three generals serving in the administration (Kelly, Mattis, McMaster) provide an instructive example that we should reflect. I cannot imagine that these extraordinary public servants of tremendous accomplishment approve of Trump's conduct. But they continue to serve and do not complain or criticize (at least publicly), because their duty to the country's professional code of conduct supersedes their personal feelings. I encourage us to reflect on this and emulate it as physicians, as professionals. It's our responsibility.

I thank you for listening to these comments. This is Dr Jeffrey Lieberman for Medscape.

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