Thoughts on "The Goldwater Rule"

Should psychiatrists make comments regarding the mental health of public figures?

The candidacy and first Presidency of Donald Trump reinvigorated a debate within psychiatry that began half-a-century earlier, during the 1964 presidential campaign between Democratic candidate Lyndon Johnson and Republican candidate Barry Goldwater. The upcoming 2024 election brings the old debate into even sharper focus, now that both leading candidates—Joe Biden and Donald Trump—have been the subject of incessant speculation and accusations regarding their fitness to serve as president. Trump’s critics describe him as, among other things, narcissistic, psychopathic, impulsive, and various other terms that are, in essence, meant to signify “I think this man has a personality disorder and is too dangerous to be president”. Biden’s critics claim he is senile, demented, or otherwise cognitively impaired to the point that he can’t effectively do his job, relying instead on handlers to guide and manipulate him.

Obviously, the public has a legitimate interest in assuring the mental fitness of our presidents. Being President of the United States is one of the most demanding jobs in the world, and having the necessary physical stamina, sound judgment, and control of one’s cognitive faculties—i.e. mens sana in corpore sano—are indispensable for competently discharging one’s duties.

Psychiatrists are, on occasion, asked for their professional opinions on public figures, with some volunteering said opinions without solicitation.

The basic question is this:

May a psychiatrist give an opinion about an individual in the public eye when the psychiatrist, in good faith, believes that the individual poses a threat to the country or national security?

The non-psychiatrist may find this question confusing. Why shouldn’t psychiatrists be able to give their opinions on public figures whom they believe to be dangerous? After all, everyone else can. And, wouldn’t psychiatrists be particularly well-suited to warn the public about leaders who may be mentally unstable or unfit for office?

These are good questions that deserve nuanced answers. Let’s first take a brief look at the history of, and justification for, the rule. For the rest of this piece I will use presidential politics as the example, although what follows is generally applicable to any public figure.

From the American Psychiatric Association's website on The Goldwater Rule:

“Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” the editors of Fact magazine asked 12,356 psychiatrists during the 1964 presidential campaign between Goldwater and Lyndon Johnson…

…Fact published numerous comments questioning Sen. Barry Goldwater’s psychological capacity for office, which ultimately led to the creation of APA’s “Goldwater Rule” in 1973

Approximately 20% of those surveyed responded, and of the respondents, around 50% said he was “unfit”. The APA continues:

A look at the original episode reveals as much about psychiatry’s changes over the last half century as it does about politics then or now.

The harshly negative responses by people who had never even met Goldwater seem astonishing by today’s standards, as a sampling suggests:

“I believe Goldwater to be suffering from a chronic psychosis,” wrote one.

“A megalomaniacal, grandiose omnipotence appears to pervade Mr. Goldwater’s personality giving further evidence of his denial and lack of recognition of his own feelings of insecurity and ineffectiveness,” wrote another.

“From his published statements I get the impression that Goldwater is basically a paranoid schizophrenic who decompensates from time to time. … He resembles Mao Tse-tung,” said a third.

Not wanting to exclude other relevant 20th-century tyrants, another claimed, “I believe Goldwater has the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders.”

Anyone familiar with psychiatric diagnosis, including its history and practice, should cringe at the above comments. Not only are these “professional observations” incorrect—no one with schizophrenia could possibly serve in the military and government as Goldwater did if he actually suffered from such ailments—but they reveal how easy it is for those with certain kinds of authority to make potentially damning and even defamatory proclamations about people they have never met. (For those not familiar with Barry Goldwater, the idea that his psychology resembled that of Mao Tse-tung, Hitler, Stalin, etc, is patently absurd, regardless of whether you agree with his conservative politics.)

Goldwater’s 1964 campaign bumper sticker. Au = Gold, H2O = well, you get the idea.

Johnson’s less creative (and somewhat creepier?) bumper sticker.

Thankfully, not all psychiatrists gave in to the temptation to diagnose their political opponents in effigy.

Others pushed back. In reality, Goldwater had worked in his family’s business, then served as a transport pilot in World War II, and retained a commission in the Air Force Reserve for many years. He was twice elected senator before the 1964 presidential race and would be again in 1968, 1974, and 1980.

It was difficult, said one psychiatrist quoted in Fact, to believe that a man who was “psychotic” or “schizophrenic” would have managed all that.

“I served as a flight surgeon in the USAF,” wrote Wilbert Lyons, M.D., of Sellersville, Pa. “I speak with authority when I say that Sen. Goldwater could not be a jet pilot if he were emotionally unstable.”

Goldwater certainly held very conservative political views and expressed them forcefully. Many of the respondents who declared him “unfit” were likely expressing their own political biases in psychiatric terms. Tellingly, many of them asked that their names be withheld from publication, perhaps hinting at some guilt feelings over their cavalier, remote diagnoses of the candidate.

Dr. Stach, in my opinion, gives the appropriate reply:

“Your inquiry for a professional opinion regarding Sen. Barry Goldwater’s general mental stability is an insult to me,” wrote Thomas Stach, M.D., in 1964. “An inquiry of this type regarding any individual can only be based on ignorance of the field of psychiatry.”

Stach demanded an apology from the editors to all the psychiatrists who had received the survey.

“It was astounding to me when the survey first came out,” Stach, now retired in Willowbrook, Ill., told Psychiatric News. “It was impossible for a psychiatrist to come to a conclusion like that without a personal examination. The psychiatrists who were baited into giving responses were imprudent.”

One of the results of this embarrassing fiasco was the creation of “The Goldwater Rule” in 1973:

APA member psychiatrists have abided by the Goldwater Rule since it was implemented in 1973. It is so named because of a controversy that emerged during the 1964 presidential election, when Fact magazine published the results of a survey in which 12,356 psychiatrists were asked whether Sen. Barry Goldwater, the GOP nominee, was psychologically fit for the presidency. Out of 2,417 total responses to the survey, 1,189 said that Goldwater was unfit for office. Goldwater eventually won a defamation suit against Fact.

What is The Goldwater Rule? And, aside from the desire to avoid lawsuits and public embarrassment, how is the rule justified? The APA announced its continued support for The Goldwater Rule in 2017—

Section 7.3 of The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (sometimes called “The Goldwater Rule”) explicitly states that psychiatrists may share expertise about psychiatric issues in general but that it is unethical for a psychiatrist to offer a professional opinion about an individual based on publicly available information without conducting an examination. Making a diagnosis, for example, would be rendering a professional opinion. However, a diagnosis is not required for an opinion to be professional. Instead, when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one. Thus, saying that a person does not have an illness is also a professional opinion.

The APA gives three overarching reasons for the rule. They are, roughly—

1. Barring special circumstances such as forensic evaluations or involuntary commitment, undergoing a psychiatric evaluation is a voluntary procedure and requires the consent of the person being evaluated. It is therefore unethical for a psychiatrist to evaluate someone without (1) his consent or (2) appropriate legal authorization.

2. A proper psychiatric evaluation cannot be performed without actually meeting the patient, taking a thorough history, performing an exam, and obtaining any necessary collateral information, eg. from family or friends. Any clinical judgment based on an insufficient evaluation is inherently suspect and represents, at best, an educated guess or hunch. Educated guesses and hunches may be good enough for government work (or may even be better than government work…), but it isn’t good enough for a thoughtful, responsible physician making public statements on issues of national importance. Acting otherwise tarnishes one’s own character, trivializes the work we do, and impugns the integrity of our profession.

3. Patients may, with good reason, be skeptical of a psychiatrist who offers professional opinions on those he has never properly evaluated. For example, if a psychiatrist publicly states “I think such-and-such candidate is a paranoid schizophrenic who resembles Mao Tse-tung”, might patients who actually have schizophrenia be a bit put off by this? Further, if a psychiatrist is willing to diagnose public figures based on such shoddy methods, how much can I trust the work he does with me? And, might he also blab about my diagnoses and potential similarity to Chairman Mao?

I agree with these three justifications. Below I will briefly outline how I think psychiatrists can intelligently and responsibly comment on public figures without violating the spirit of The Goldwater Rule. But first, here are a few more justifications for the rule that I find fairly persuasive.

4. Psychiatrists’ opinions on public figures are of limited use because severe mental illness is extremely difficult to conceal forever. In other words, if a public figure is seriously disturbed, it usually doesn’t take a bunch of psychiatrists to clue everyone else in on that fact. Consider how apparent it is when a celebrity is going through some kind of public mental health crisis: we may not know exactly what is going in a psychiatric sense, but it is usually clear enough even to the casual observer that this person is going through something bad and isn’t in a normal state of mind. In this respect, psychiatrists’ input becomes at best superfluous.

5. Even for patients evaluated properly, psychiatrists don’t always agree on diagnoses. Psychiatric diagnosis is not like diagnosing influenza, glioblastoma, or a broken femur, because most psychiatric illnesses are not (as we currently understand them) “natural kinds”. Rather, they are our best current attempt to categorize syndromes with sometimes highly variable presentations, symptoms, signs, and natural histories, into something coherent. To take one example among many: patients presenting with impulsivity, erratic and self-destructive behavior, suicidality, frequent drug use, depression, and anxiety are often diagnosed as having Borderline Personality Disorder. Or, they may be diagnosed with Bipolar Disorder. Or something else entirely. They may have a few additional diagnoses thrown in for good measure as well (some ADHD perhaps? PTSD? The list goes on). The point is that diagnostic uncertainty and disagreement occurs frequently in psychiatry even among competent clinicians. This should only increase skepticism that diagnoses-in-absentia are reliable.

6. It is so unbelievably easy to convince yourself that your pet diagnosis is correct because it perfectly aligns with everything you think you know to be evil about a particular politician. One of the very good reasons psychiatrists are not supposed to evaluate people they already know is that we will be too biased by the pre-existing relationship and thereby risk sacrificing our objectivity. So, even if a psychiatrist has never met a political candidate, the constant exposure to that candidate through the media will, of course, bias one’s judgment and render dispassionate clinical reasoning very difficult if not impossible.

7. The link between psychopathology and a person’s ability to function at a job isn’t always clear, and psychiatrists aren’t necessarily or always the best people to make that judgment. Consider an admittedly bizarre hypothetical: a presidential candidate publicly admits to having schizophrenia, or severe bipolar disorder with frequent episodes of psychosis and catatonia. The first thing to say is that such a revelation would not require psychiatrists piling on in order to immediately torpedo the candidacy. Anyone who knows anything about mental illness knows that such a candidate obviously couldn’t manage the presidency. But what about less dramatic diagnoses? Does, say, ADHD or narcissistic personality disorder necessarily disqualify someone from leadership? Perhaps the ADHD candidate shows a particular talent for jumping effectively from crisis to crisis, even if he sacrifices some patience and thoroughness? Perhaps narcissism too is adaptive and advantageous in certain circumstances? And, by the way, how can we be sure if someone “truly” has narcissistic personality disorder vs just having some narcissistic traits, or what some people call “character flaws”? The difficulties raised by these questions should give us pause when making blanket statements such as “so-and-so is XYZ-type of person, and therefore shouldn’t do such-and-such job”.

In sum: aside from the APA’s core justifications for The Goldwater Rule, it is a sound guideline because (1) severe mental illness is often noticed easily enough without psychiatric input, (2) there is still significant disagreement about diagnosis within the psychiatric community, (3) the risk of political bias is simply too great, and (4) making a diagnosis can, but doesn’t necessarily, imply unfitness for a particular job, the details of which a psychiatrist may be mostly ignorant.

Since around 2016, some psychiatrists have written against The Goldwater Rule for various reasons. I’m not going to go through them here mostly for the sake of space, but also because I think the arguments are generally thoughtless and wrong and have been implicitly dealt with already. But one objection I’ve heard bears mentioning: what about Tarasoff? “Tarasoff” refers to the 1976 Supreme Court ruling in Tarasoff v. Regents of the University of California which held that mental health professionals have a duty to take action to warn/protect a person whom their patient has threatened to physically harm. Doesn’t a psychiatrist, the reasoning goes, thereby have an even more pressing duty to warn when the entire country may be at stake? The answer, it turns out, is no. First, the Tarasoff rule applies in the context of psychiatric treatment with a particular patient making specific threats against a particular person or people. It does not apply to just to anyone the psychiatrist happens to believe is a dangerous person. Second, when the Tarasoff principle is operative in a particular situation, the psychiatrist has specific and privileged knowledge and must take concrete steps to ensure safety based on that knowledge, eg. alerting the police and (if possible) notifying the target of the threats. There is no Tarasoff-equivalent for potentially dangerous public figures. After all, the psychiatrist doesn’t have privileged knowledge of the situation, no clear or concrete threats, and has no one to alert (other than “everyone”). Personally, I think any psychiatrist criticizing a public figure under the guise of “duty to warn” has come down with an unfortunate case of grandiose-hero-savior-syndrome.

The solution to this entire issue is, I believe, the democratic process itself, along with a few safety mechanisms embedded in our form of government. One benefit of the modern presidential campaigning process is that it selects for people with drive, energy, and endurance. It would be difficult to conceal a candidate’s infirmity in the way that, say, Franklin Roosevelt’s declining health was minimized during the election of 1944. And, should such a candidate be removed from public view to conceal the infirmity, that action in today’s world would, in itself, rouse sufficient suspicion among voters, likely damaging the campaign. In the event such a candidate does reach high office, however, or if a sitting president develops some form of mental incapacity, Section 4 of the 25th Amendment to the Constitution may then be invoked. The Amendment stipulates—

Whenever the Vice President and a 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.

(For a president who engages in misconduct, impeachment is yet another available recourse.) My main contention is that at every step of the process, the psychiatrist’s professional opinion is likely to be either (1) superfluous, because people already suspect something is “going on” with a candidate’s mental health, or (2) too imprecise, inaccurate, and far-removed to be useful anyway. Generally speaking, the best people to decide whether a candidate is fit to serve are the citizens who cast their votes. For questions of fitness among sitting presidents, the Cabinet of the United States, along with other high ranking officials including Congress, both have regular exposure to the president as well as a far better working knowledge of the job than any psychiatrist, and are therefore much better suited to determine whether the chief executive is up to the task. The only formal role I see a psychiatrist playing would be to conduct a proper psychiatric evaluation of the candidate/president in question if agreed to by the prospective patient, or in cases where an evaluation is mandated by law.

Lastly, how can psychiatrists comment on public figures, especially ones they believe are particularly consequential, while preserving the integrity of the profession? There are, I believe, some ways of discussing the things people want to discuss without violating The Goldwater Rule. One way to do this is by keeping the conversation sufficiently general, as well as being very up front about the limitations of the comments one is about to make. If, for example, a psychiatrist is asked whether a candidate’s particular behaviors are indicative of a psychiatric illness, the psychiatrist would be prudent to state first that no diagnoses will be made (or ruled out), and that the following comments are based off of such-and-such observations, without formal evaluation, and will be kept as general as possible, etc, etc. It is a lot of hedging, but it is necessary. Boundaries are important. After the throat-clearing is finished, the psychiatrist could comment on the features of the (suspected) diagnosis in general terms, explaining how such a diagnosis might manifest itself in a hypothetical leader or in a typical person (I can’t comment on whether or not Congresswoman Jane Doe has histrionic personality disorder, as I have never evaluated her or even met her. So before jumping the gun on whether a particular person does or doesn’t have histrionic personality disorder, perhaps I could first flesh out what the diagnosis itself means and how a typical patient with this condition might appear…). One could also discuss how particular symptoms of a diagnosis might show themselves in everyday life or affect daily functioning, again without reference to the individual in question. (Leaving candidate Joe Schmoe’s particulars aside, it may be more helpful if we look at what the symptoms of kleptomania and transvestic disorder actually are, and what it is like to live with those symptoms…). One might use historical examples of public figures with known psychiatric diagnoses, although even here care must be exercised because histories may be contested, and the psychiatrist’s knowledge of the historical figure may be incomplete. I would not recommend using living, non-American leaders as examples for the same reasons we shouldn’t diagnose our own leaders; The Goldwater Rule should not respect national borders. The central message is: when commenting on public figures, use prudence and caution before bringing your psychiatric expertise to bear, and when in doubt, err on the side of saying less.

Psychiatrists do themselves, their profession, and the public a disservice when we insert ourselves into politics inappropriately. While psychiatrists might have pretty decent intuitions about people generally, we are, despite what the critics say and what our own egos tell us, merely human too, with all the attendant biases and blind spots, and are typically no wiser politically than our neighbors (trust me on this: psychiatrists as a whole have no better political insight or intuitions than anyone else). The truth is that the American people don’t need psychiatrists telling them that their politicians are crazy, unstable, or otherwise evil in this way or that (most people already suspect this anyway). And for those Americans who can’t or won’t see that their favored candidate is somehow mentally unfit, does anyone really think that some psychiatrist is going to convince them otherwise? Psychiatrists can participate in healthy political discourse like any other citizens, and should do so if they are so inclined, but let’s try to keep our professional opinions out of it. Otherwise, the most likely outcome will be little more than a growing public perception that psychiatrists are a politically captured constituency, with the field of psychiatry itself seen as yet another unofficial arm of political and social control, best ignored and probably not to be trusted. By exercising cautious and thoughtful judgment, we will be doing the next generation of psychiatrists, and more importantly their patients, a valuable service. As much as I despise the phrase, we would do well to stay in our lane.