The Goldwater rule exalts the doctor-patient relationship. But here’s rub: Unless the public figure in question happens to be your patient, there is no doctor-patient relationship. Across other branches of medicine, it is commonplace for physicians to offer insight when a public figure’s medical condition is in the news. Orthopedists weigh in on the star quarterback with a high ankle sprain; cardiologists on a political candidate who has a fainting spell. Everyone knows that the physician is not making a definitive diagnosis, but is instead helping the public understand the implications of a condition that is within the specialist’s domain.
This extension of the Goldwater rule gets into regulating not just psychiatrists’ clinical practice, but also what we’re permitted to do as citizens in the public sphere, as though psychiatrists don’t regularly voice opinions as teachers, researchers, writers, and expert witnesses. This narrow view, at odds with real life, precludes recognizing our responsibility to the community at large.
The APA’s assertion that it is unethical for a mental health professional to comment on a public figure’s psychological functioning without an interview rests on shaky scientific ground. In the 45 years since the Goldwater rule was adopted, substantial multidisciplinary research has cast serious doubt on the primacy and necessity of an in-person interview as the sole basis for assessment in all circumstances.
The Dangerous Case of Donald Trump challenges the APA position that a psychiatrist cannot know enough about a person she has not interviewed to formulate a diagnostic impression. Contrary to the APA, a physician who has not formally evaluated a patient is not making a diagnosis in the medical sense, but rather using diagnostic speculation and terminology informally, with the benefit of education. That characterization applies to the orthopedist or physical medicine specialist speculating on the knee injury of the football player limping off the field and the dermatologist wincing at a stranger’s melanoma in the grocery line as well as to the psychiatrist interpreting Trump’s public statements. Physicians don’t stop knowing what we know when we leave the clinic. Psychiatric terminology has become part of the common parlance, and the authors in Dangerous Case describe and define that terminology much better than, say, Ralph Northam. The question is whether psychiatrists are the ones we should hear it from.
These limited, practical revisions to the Goldwater rule would correct its most severe shortcomings and facilitate psychiatrists’ responsible engagement with our complex society.
Leonard L. Glass, M.D., is associate professor of psychiatry at Harvard Medical School and senior attending psychiatrist at McLean Hospital in Belmont, Mass. He resigned in protest from the American Psychiatric Association in April 2017.