COMMENTARY

25th Amendment Debate Raises Tough Questions for Psychiatry

Nassir Ghaemi, MD, MPH

Disclosures

October 04, 2018

A year ago, there was much debate about whether Donald Trump was "mentally fit" to be president. That concept of mental fitness wasn't very clear, but the debate persisted.

The American Psychiatric Association (APA) has come out strongly against any involvement of psychiatrists in politics. Beginning with the so-called "Goldwater Rule," a term derived from a 1964 magazine article in which over 1000 psychiatrists endorsed the idea that conservative Republican Barry Goldwater was mentally unfit to be president, the APA has held the view for decades that it is unethical for psychiatrists to express professional views about a public figure. After the 2016 election, many psychiatrists pushed back on this prohibition, both in the scientific literature and at professional meetings. This ferment has not led to any appreciable change in APA policy; in fact, the APA hardened its stance.

This standoff seems to have been reflected in the larger culture. Major media often discuss the question of Trump's mental fitness, but the Goldwater Rule has prevented most psychiatrists from going on television or writing in newspapers. Since non-MD mental health professionals, such as psychologists, are not limited by the Goldwater Rule (which is a policy by and for psychiatrists), commentators in the media were limited mostly to non-psychiatrists. Yet many psychologists also avoided giving professional judgments about the president.

A substantial minority of mental health professionals have opposed Trump vocally, though they too have tended to avoid directly breaking the Goldwater Rule, usually by not making an explicit diagnosis.

Even if the letter of the Goldwater Rule is not broken, many mental health professionals have felt able and willing to criticize the president on psychological grounds, such as "dangerousness," "narcissism," or other concerned psychopathological concepts. Whether such considerations reach the standard of being "mentally unfit" for office remains unclear.

Revived Questions About the 25th Amendment

The concept of fitness relates directly to the 25th Amendment to the United States Constitution, which was created mostly with non-psychiatric illness in mind. The classic case that would meet the standards of the 25th Amendment is the massive stroke that afflicted President Woodrow Wilson during his second term in office. Such massive physical disability is obvious. The complex impact of psychiatric illness is not as easily interpretable by the standards of the 25th Amendment.

It has been observed that if psychiatric illness was considered relevant to the 25th Amendment, much would depend on whether the president himself was capable of resisting removal. This issue relates to the psychopathological phenomenon of "lack of insight." In some serious psychiatric conditions, such as mania or delusions, a person can be unaware that he or she is psychiatrically ill. It often is part of the manic or delusional state that the person believes that he or she is not manic or delusional.

This fact produces a major problem for potential invocation of the 25th Amendment in that one could foresee a scenario where the vice president and cabinet may see a president as psychiatrically ill, whereas the president himself would not. This scenario is quite different from something more akin to Wilson's illness, where a president, if paralyzed by a stroke, might be unable to express his own opinion about his fitness.

A practical aspect to the limitations of the 25th Amendment also involves the fact that the vice president and cabinet would have to lead the process, in most readings of the language of the amendment, which appears to be unlikely at present.

This discussion returns us to the concept of "fitness." The 25th Amendment doesn't use medical language, but it has been seen by most observers as having a medical meaning. It was meant to apply to a president who was medically ill to the point of being unable to function. It wasn't meant to apply to someone who could function but who made decisions that concerned others. In a dangerous world characterized by nuclear weapons and constant warfare occurring somewhere, it might not be unreasonable to ask whether clearly dangerous decisions, made by someone with discernable psychopathology, reaches the standard of the 25th Amendment.

Like the Goldwater Rule, the role of psychiatrists in relation to the 25th Amendment has come to the fore, with many questions and few answers. The approach of the APA has been to remove psychiatrists from any public discussion in relation to presidential leadership. This abdication of any public role for psychiatry could be seen as prudent but perhaps excessive. Is there nothing psychiatry can offer?

Mental Health Debates Are Nothing New in Politics

I have previously described[1] that many great political leaders have had psychiatric conditions, particularly manic-depressive illness. My view has been that such leaders often were helped by having manic and depressive states, especially when those symptoms were mild. Those mood states help crisis leadership by enhancing creativity and resilience (which occur in mania more than in normal mental health) and by promoting realism and empathy (which are greater in depression than in normal mental health). On the other hand, sometimes those manic and depressive states are obviously harmful, especially when severe. Even delusions can occur in a minority of severe manic or depressive episodes.

Thus, we could have a manic-depressive president who would be excellent, especially in times of crisis—a president who was creative, resilient, realistic, and empathic. In fact, we have had at least depressive presidents (like Lincoln) and mildly manic ones (like Theodore and Franklin Roosevelt, and John Kennedy). It is not inconceivable to have a president with a psychiatric illness; it has happened already. It is possible, therefore, that we could have a manic or depressive president who could even become delusional.

The invocation of the 25th Amendment for psychiatric illness could be relevant under extreme circumstances. But to do so, psychiatrists would have to be involved in the public discussion about the benefits, and risks, of psychiatric conditions for public leadership. Such public discussion would help reduce stigma against psychiatric illness, as opposed to the current professional silence which only feeds into stigma. If major public leaders were diagnosed with psychiatric illnesses, it would help our culture to better accept, rather than fear, those conditions.

This has happened in the past. It began with Senator Thomas Eagleton, who probably had manic-depressive illness and had been treated with electroconvulsive therapy. In the 1972 election, Eagleton had to be dropped as the vice presidential nominee on the Democratic ticket due to the discriminatory reaction to his prior treatment. Eagleton went on to have a distinguished career as a senator for a decade longer. He would have been a fine vice president and even president.

As stigma weakened a bit in ensuing decades, other politicians opened up. In 1990, Lawton Chiles, who became governor in Florida, admitted taking Prozac for depression. Later, Congressman Patrick Kennedy opened up about his bipolar illness and substance abuse, and has remained a champion in the fight against discrimination against psychiatric illness. Major leaders of other countries were diagnosed and treated. Menachem Begin, the revered Prime Minister of Israel in the 1970s/'80s, was diagnosed with bipolar illness and treated with lithium. The same diagnosis and treatment was given to Hamid Karzai, the president of Afghanistan after the fall of the Taliban. Other contemporary political leaders probably have such conditions, but the news is kept secret, often until decades later when historians can access medical documents or other sources.

Almost 2 years into the Trump Administration, psychiatry still struggles with its role. Book after book continues to raise questions about the president's mental fitness, but a deep cultural discrimination against psychiatric illness persists and complicates social reaction to such questions.

The Goldwater Rule and the 25th Amendment aren't clear solutions. I would suggest that one thing is clear: Given the link between manic-depressive illness and political leadership, these questions aren't unique to the current president, and they aren't going away.

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