COMMENTARY

Kanye West, Elon Musk, and the Complexities of Armchair Psychiatry

Jeffrey A. Lieberman, MD

Disclosures

November 05, 2018

Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape. My comments can be [summed up as,] "Psychiatrists commenting on public figures: What is right and what is wrong?"

I thought that I had said my last words about President Trump's mental health and the ethics of psychiatrists opining on the mental states of political figures. However, my colleague, Dr Nassir Ghaemi, posted a blog on Medscape regarding this, which involves a reference to the 25th Amendment, and I really feel compelled to respond.[1]

Nassir, who's a good friend and colleague, very intelligent, capable, has stated that he believes that psychiatrists in general, and the American Psychiatric Association in particular, are shirking their civic duty by being constrained by the Goldwater Rule, and that they should look to modify it to enable psychiatrists organizationally or individually to be able to speak out in such situations.

I disagree with this. I don't think we're shirking our duty and I don't think that the Goldwater Rule as stated and adhered to should be modified or loosened. And the reason is because every US citizen is entitled to expression of their opinions, no matter how scurrilous or how favorable they are. But when you invoke your professional title as a physician, as a psychiatrist, and claim that that gives you a more valid opinion that should be accepted by the audience it's intended for, that is problematic because you don't have complete information. And when it's used in the context of government figures, it takes on not an expression of a medical evaluation out of the concern for the individual and serving their interests; it takes on the role of being a partisan political comment.

The rightful way for the psychiatrist to become involved is through the already established Constitutional mechanisms. If we have a bad leader, for whatever reasons, there are elections, there is impeachment. There is also, for infirmity or illness, annual medical exams, which should examine somebody from the neck up in addition to the rest of their body. And there is the 25th Amendment.

The 25th Amendment basically says that if a President is not able to execute responsibilities and duties of office, then there is a means to replace them in a defined, orderly way. The fourth clause of the 25th Amendment is the one that pertains here, and it's the only one of the four clauses that has never been invoked. It reads as follows[2]:

Whenever the Vice President and majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.

Thereafter, when the President transmits to the President pro tempore of the Senate and the Speaker of the House of Representatives his written declaration that no inability exists, the President can resume the powers and duties of his office unless the Vice President and a majority of either the principal officers of the executive department or of such other body as Congress may by law provide, transmit within four days to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office. Thereupon Congress shall decide the issue, assembling within 48 hours for that purpose if not in session. If the Congress, within 21 days after receipt of the latter written declaration, or, if Congress is not in session, within 21 days after Congress is required to assemble, determines by two-thirds vote of both Houses that the President is unable to discharge the powers and duties of his office, the Vice President shall continue to discharge the same as Acting President; otherwise, the President shall resume the powers and duties of his office.

The Constitutional mechanism here requires the government to invoke this amendment. Should that happen for reasons of infirmity—medical or psychiatric—then physicians and psychiatrists would obviously need to be involved, and that's where we would come in. I wrote about this in an article that was posted on Vice over a year ago, and it was really just a simulation of what steps would need to be taken should such an action be done.[3] The reason for that is because although I've just read to you the entirety of the fourth clause, it doesn't provide for how these determinations of competence or not, due to whatever infirmity, would be made. If it is suspected to be medical, then presumably physicians would be involved; and if it has to with mental function, that's where our role comes in as psychiatrists.

We are not shirking our responsibility. It's the government that's shirking their responsibility. If so many questions have been raised about President Trump's behavior, they should act. Now, whether they are not acting because they generally don't believe that or because of other partisan political reasons because they hold on to power, I can't say. But it's not ours to initiate it; it's ours to serve when we are called.

This raises another question. More broadly speaking, what is the role of psychiatry and psychiatrists in calling attention to people who appear to be in need of mental health care? The reason I mention this is that, recently, I was criticized because I tweeted out a statement about Elon Musk, stating that his behavior of late was of concern and I hope that he got the appropriate help. The criticism was that if we have the Goldwater Rule, why doesn't it apply to a figure like Elon Musk, and I understand that.

However, the reason why I did that is wholly different from the reasons why opinions are being expressed about President Trump. My motivation was because [Elon Musk], who was enormously successful, was doing things that were clearly unusual. He conducted an interview on the radio for a podcast while he was drinking whiskey and smoking pot. He had gone without sleeping for many days and then he slept on the floor of his office. There were reports in the media about things that were clearly abnormal and presumably uncharacteristic. It really was an expression of concern about public figures who, in full sight of the public, were exhibiting symptoms or behaviors that suggested that they were in trouble.

If you're sitting in a theater, a restaurant, or at work and you see somebody fainting, choking, or doubling up in pain, your initial reaction is to help, to go over and see if you can do something, or call 911. The fact that this is less commonly the reaction to when people see someone who is acting weird or, too often, intoxicated, is really because of the fact that there's stigma about mental illness and there's also confusion over what to do. But it's really the same situation.

What about somebody who is in full public view through the media and is acting in a similar way—they are in distress for behavioral reasons, and they don't seem to be getting help. Think of Lindsay Lohan, Britney Spears, Charlie Sheen, Robin Williams, and most recently, Kanye West. I'm not saying that we should be exhorting them to get into some kind of treatment, but when figures like that are in distress in full public view and they don't seem to be getting any help or getting any better, should we let them exhibit this continued, symptomatic, abnormal behavior in plain sight? Or is it appropriate to make expressions of concern?

That's what prompted me to do it. I can't say that it's safe to do in all cases and I don't know the boundaries of how extreme the behavior must be. If I was wrong in doing it with Elon Musk, I apologize. But the motivation for what was done in that case is wholly different from what has been done in terms of criticism or expressions of opinion that are critical of President Trump.

The bottom line is that violating the Goldwater Rule and expressing concern for celebrity figures are not the same. I believe that we should continue to adhere to the Goldwater Rule. As for whether we feel that it's our responsibility as psychiatrists, or just as human beings, to adopt the axiom now being advocated for terrorism purposes—"See something, say something"—we will have to determine.

Thank you for listening. This is Dr Jeffrey Lieberman, Columbia University, speaking to you today for Medscape.

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