Abstract
Journalists often turn to psychiatrists for analysis of medical, social, political, and cultural events that involve human behavior and illness. Once journalists seek their expertise, psychiatrists often rush to be helpful, which can lead to ineffective performance and to statements that may run afoul of principles of professional ethics. In this article, we discuss the bases on which the professionalism of psychiatrists may be impugned when they commit errors in their media presentations. Found within the Principles of Medical Ethics with Special Annotations Especially Applicable to Psychiatry, the Goldwater Rule prohibits certain behaviors when psychiatrists share professional opinions with the public. We first discuss the Goldwater Rule, highlighting the events that led to its development and the professional response to its enactment. We then present a method to guide psychiatrists in their interaction with the media that will help them avoid violating ethics principles or the law. The method encourages knowledge of a framework of ethics principles that in turn guide the psychiatrist's behavior and thinking as he contemplates accepting invitations to interact with the media. The ethics-based roles include the Teacher, the Storyteller, the Celebrity Commentator, the Hollywood Consultant, the Clinician, and the Advertiser.
Over the past few decades, acts of random violence have shaken the core of our country. These tragedies have included terrorist attacks, school shootings, assassinations of political leaders, and kidnappings. While we, as individuals, struggle to understand how these inexplicable horrors are committed, the media attempt to provide answers in a public forum, using the advice of experts from different specialty areas.
Journalists often turn to psychiatrists for analysis of these and other social, political, and cultural events that involve human behavior. Reporters believe that they need the expertise and contributions of psychiatrists and other mental health professionals to inform their work and improve its sophistication. Slovenko1 noted that the media turn to psychiatrists when commentary is sought on matters of notoriety, such as crimes. In this context, a psychiatrist has the opportunity to convey personal and professional opinions. A plethora of examples is easily found in televised, print, and online media. For example, in the midst of much national coverage of school bullying and cyber harassment, journalists turned to psychiatrists to answer questions about the long-term effects of bullying and the possible steps parents could take to prevent bullying of their children. In another example, a man who was recently discharged from a psychiatric hospital killed his family. Reporters wanted psychiatrists to explain the connection between mental illness and violence. There are already examples of psychiatrists who have been given the opportunity to discuss publicly the release of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).2
When journalists seek the expertise of mental health professionals, psychiatrists often rush to be helpful. There may be several reasons for this response. First, psychiatrists may understandably believe that they have something to contribute to the ongoing discussion generated by the media. This notion may be coupled with a desire to set the record straight or to correct misconceptions. In addition, some psychiatrists are clearly comfortable in the limelight and enjoy the publicity. Others may feel pressured to accept an invitation from the media, as the media in turn are pressured to deliver news and instant commentary before competing organizations pre-empt them. This eager participation from psychiatrists sometimes leads to ineffective performance and to statements that may well run afoul of the principles of professional ethics. The most likely violation may be of the American Psychiatric Association's (APA) guidelines set forth in the Goldwater Rule.
In this article, we first discuss the Goldwater Rule,3 highlighting the events that led to its development and the professional response to its enactment. We then review other bases on which the professionalism of psychiatrists may be impugned when they commit errors in their media presentations. After discussing the risks that may attend the psychiatrist's performance when interacting with the media, we then present a method that guides psychiatrists in their interaction with the media to help them avoid violating ethics principles or the law. The method encourages knowledge of a framework of ethics principles that in turn guides the psychiatrist's behavior and thinking as he contemplates embarking on interactions with the media.
The Goldwater Rule
The Goldwater Rule was created in 1973 and refers to Annotation 3 of Section 7 of the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.3 The Principles of Medical Ethics (hereafter referred to as the Principles) are put forth by the American Medical Association (AMA) and represent guidelines that are intended to protect patients and the profession while encouraging professional responsibility. The Goldwater Rule reads as follows:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement [Ref. 3, p 9].
The Goldwater Rule stemmed from a scandal surrounding a 1964 publication in Fact magazine that included anonymous psychiatric opinions commenting on Senator Barry Goldwater's psychological fitness to be President of the United States.4 Fact, a short-lived magazine published in the 1960s, carried opinionated articles that covered a broad range of controversial topics. In the 1964 September/October issue entitled, “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater,” the opinions of over 1,800 psychiatrists commenting on Goldwater's psychological fitness were published. This issue immediately preceded the November 1964 Presidential election between Goldwater and President Lyndon Johnson. The article began with the following:
On July 24, one week after Barry Goldwater received the Republican nomination, FACT sent a questionnaire to all of the nation's 12,356 psychiatrists asking, “Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” [Ref. 4, p 24]
The published opinions were selected by Fact editor Ralph Ginzburg from a poll of over 12,000 psychiatrists from across the country (Ref. 4, p 24), whose names were provided by the American Medical Association (AMA). Of the 2,417 respondents, 571 deferred from providing comments, 657 responded that Goldwater was fit to be president, and 1,189 responded that he was not fit. None of the psychiatrists whose comments were published had examined Goldwater, however, and none had permission from him to issue their comments publicly.4 In the article, Goldwater was described with comments including “lack of maturity” (Ref. 4, p 42), “impulsive” (Ref. 4, p 33), “unstable” (Ref. 4, p 29), “megalomaniac” (Ref. 4, p 26), “very dangerous man” (Ref. 4, p 29), “obsessive-compulsive neurosis” (Ref. 4, p 37), and “suffering a chronic psychosis” (Ref. 4, p 38). One psychiatrist offered, “He projects or blames others when a mistake is made, not being able to see the part he has had in the error” (Ref. 4, p 35). Much was made of two nervous breakdowns allegedly suffered by Goldwater, and there was commentary warning that he might launch a nuclear attack if placed under a critical amount of stress as president.
Goldwater responded by bringing libel action against Ralph Ginzburg, Warren Boroson, and Fact.5 Mr. Ginzburg was the President and sole stockholder of the magazine, and Mr. Boroson was its contributing editor. He claimed that the magazine included “false, scandalous and defamatory statements” (Ref. 5, p 327). The United States District Court for the Southern District of New York returned a verdict in favor of the senator. The defendants appealed to the United States Court of Appeals for the Second Circuit6 and lost based on the “actual malice rule,” which permitted public figures to receive damages for smears or false reports if made with “‘actual malice’—that is, with knowledge that it was false or with reckless disregard of whether it was false or not” (Ref. 7, p 280). Ginzburg and Fact petitioned the United States Supreme Court for a writ of certiorari, but their petition was denied.6
The Medical Director of the APA sent a letter to Fact warning of the invalidity of the survey because responses were sought from psychiatrists, although none of those asked to respond had made a “thorough clinical examination” of Goldwater (Ref. 5, p 60). This warning letter was not published with the article. Perhaps the argument suggested by the warning letter was also recognized by psychiatrists who received the survey: of the over 12,000 solicitations mailed from Fact to psychiatrists, 80.5% were not returned.
The AMA and APA immediately condemned the remarks made in the Fact article after its publication.8 Individual psychiatrists also spoke out against the ethics of the published comments. Dr. Lawrence Friedman of the Los Angeles Institute of Psychoanalysis issued a statement, “I shall do everything I can to help defeat Mr. Goldwater, but I shall point to his ideas, his statements, his political orientation, and his associations, not to his psychology.”9 An anonymous psychiatrist from Florida criticized the survey respondents as ones who use “crystal balls.”9 In response to this “fiasco” (Ref. 10, p 172), the APA created the Goldwater Rule “to protect public figures from psychiatric speculation that harms the reputation of the profession and of the unsuspecting public figure” (Ref. 11, p 35).
Some professionals, however, were concerned with the restrictions imposed by the Goldwater Rule. Dr. Alan Stone admitted he “opposed this change at the time as a denial of free speech and of every psychiatrist's God-given right to make a fool of himself or herself” (Ref. 10, p 172). He added that adherence to this ethics rule would prevent a psychiatrist from giving public lectures on the clinical aspects of a notable figure, such as John Hinkley.10
The debate also raised the question, “Is it possible to separate personal opinions from professional opinions?” Dr. Jeremy Lazarus, a past chair of the APA's Ethics Committee, answered in the negative: “It is important to remember that once identified as a psychiatrist, your public opinion on important public figures will be heard from you as a psychiatrist and not as an ordinary citizen” (Ref. 11, p 108). Describing one's comments as “personal opinions” or “clinical impressions” as an attempt to avoid offering “professional opinions,” might be a subtlety lost on the public.
Other psychiatrists wondered if adherence to the Goldwater Rule made it ethically impossible to engage in psychohistory or provide political psychology profiles. If the Goldwater Rule was interpreted strictly to prohibit these practices, then it appeared to contradict parts of Sections 7.1 and 7.2 of the Principles:
Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government. A psychiatrist should clarify whether he/she speaks as an individual or as a representative of an organization.
Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness. Psychiatrists should always be mindful of their separate roles as dedicated citizens and as experts in psychological medicine [Ref. 3, p 9].
Later, Lazarus attempted to clarify the dilemma:
The ethics annotation [i.e., paragraph 3 of Section 7] does not relate to legitimate and responsible scientific study as contained in psychohistory, psychobiography, or psychiatric profiling…The ethics annotations were not meant to stifle such work or to prevent members from exercising their rights of free speech when their opinions could have important public policy implications [Ref. 12, p 108].
This opinion was echoed by the psychologist and psychohistorian Alan Elms, PhD, who argued, “Throughout their vote-seeking careers, politicians regularly hold themselves up for public inspection, and I think professional psychobiographers have as much right and responsibility to inspect their qualifications for office as journalists and competing politicians” (Ref. 13, p 252). A definitive position has yet to be reached by our profession.
The Risks Beyond Goldwater
Public expressions of a psychiatrist's opinions may lead to ethics violations beyond a Goldwater Rule infraction. Beneficence, truth telling, and respect of persons are the tenets most vulnerable to infringement. This risk occurs because of the unique setting of the interaction with the media. The psychiatrist is now performing outside the examination room (without a patient and therefore without obvious reminders of clinical ethics) and outside the courtroom (without an oath to tell the truth). Despite the change of venue, however, the psychiatrist continues to have a responsibility to practice within professional guidelines. Physicians do not have the luxury of deciding when to act ethically.
In addition to professional ethics violations, psychiatrists risk civil action when making opinions public. If the psychiatrist has not conducted an examination and later speaks negatively about a person, then he may be liable for invasion of privacy or defamation of character. A psychiatrist who has not been granted the authorization to speak publically about a patient could face a lawsuit for breach of confidentiality on the basis of a common law or statutory right to confidentiality. For example, the Health Insurance Portability and Accountability Act (HIPPA) of 199614 provides federal protections for personal health information held by covered entities and gives patients certain rights with respect to that information.
However, the risk of this type of civil action may be minimal. Of recent allegations of malpractice against psychiatrists, claims of breach of confidentiality and libel or slander are infrequent: four percent and two percent, respectively.15 Furthermore, data from 1991 through 2005 show that among those practicing in other specialties, psychiatrists have the lowest annual probability of facing a malpractice claim (2.6%).16
Risks also appear in the form of logistical conflicts. Television interviews and other deadlines often appear unexpectedly, infringe on clinical and administrative responsibilities, and distract the physician and cause anxiety. The finished product may also be a source of frustration. For example, although a psychiatrist may spend much time preparing for an interview, the televised version is likely to last only seconds to several minutes. Furthermore, it is easy for the message that the psychiatrist intends to convey to be misunderstood, misinterpreted, and taken out of context.
An important concern for the forensic psychiatrist who interacts with the media is the problem of scrutiny. Once information enters the public domain, it becomes accessible to any interested party. Television interviews and personal web pages may be analyzed in the same fashion as scientific publications or prior testimony. Attorneys could use this information to discredit or impeach a forensic psychiatrist.
Several notable cases illustrate how the courts and the public have responded to complaints against psychiatrists who have publicly expressed opinions related to patients. The landmark case of Doe v. Roe17 decided by the New York County Supreme Court in 1977 involved a patient who sued her former psychiatrist for breach of privacy. The psychiatrist had released a book that chronicled her psychoanalytic treatment, eight years after his therapy with the patient had concluded. Despite the exclusion of identifying factors (e.g., names), the trial court found in favor of the plaintiff, because the book was a violation of privacy that served as unreasonable publicity and did not represent “a major contribution to scientific knowledge.”17
The case of Angelo v. Brenner18 involved a psychiatrist, Dr. Arthur Brenner, who, after being detained for making an illegal U-turn, told a police officer's supervisor, “[A]s a psychiatrist, [I believe that the officer] is unfit to be a policeman.” The police officer brought suit claiming slander but summary judgment was granted for the defendant. The case was appealed before the appellate court of Illinois in 1980, which affirmed the lower court's decision finding “no evidence … to support a finding of actual malice”18 and that the psychiatrist's response was “not … anything more than an angry comment” and should not be considered “professional opinion.”18 This case shows a court's ability to distinguish a physician's professional opinion from an emotional reaction.
Finally, many may be familiar with the controversy surrounding Anne Sexton, an American poet born in 1928, and Dr. Martin Orne, her treating psychiatrist for eight years. Orne audiotaped the sessions to help Sexton remember the content of the therapy, which uncovered an alleged history of abuse. Sexton died in 1974 after committing suicide by carbon monoxide poisoning.19
With the approval of one of Sexton's daughters who was the conservator of her estate, Orne released his audiotaped sessions to Sexton's biographer. The release of the tapes was met with “thunderous condemnation.”20 Physician and layperson, alike, debated the ethics-related tenets of the case.19,–,25 This case illustrates the complexity involved in a physician's acquiring proper authorization from a patient to reveal confidential information to the public. Furthermore, the voluntariness of informed consent is threatened when the party giving consent may not fully comprehend the degree to which the information will be publicly used (e.g., shared among professionals for patient care, published for education without identifying information, or published in a biography to benefit the author).
Guidance for Psychiatrists: Ethics-Based Roles
Even though we have clearly described certain concerns about potentially breaching professional ethics or being sued, we do not intend to discourage our colleagues from engaging in professional activities with the media. Instead, we are emphasizing that interactions with the media should adhere to a method that permits the psychiatrist to avoid the pitfalls that we have described. This method relies on an integrated structure of ethics principles and performative roles that we believe will be of considerable help to professionals who seek to engage in this work. The concept of performative roles represents an extension of the work by Griffith et al.,26,27 who have articulated ideas about how forensic psychiatrists, especially, should incorporate elements of performance into both their written and oral work. In the oral work context considered here, the performative roles are particularly relevant.
The ethics principles to be considered are relatively straightforward and apply to the psychiatrist in two conditions: when the psychiatrist's work in the public media concerns one of his patients or someone who is not his patient. The psychiatrist's association with his patient is bound by the physician-patient relationship. Principles of confidentiality, beneficence, nonmaleficence, and respect for persons apply. In general, the psychiatrist needs the patient's permission to engage in public discourse concerning the patient. Even with the patient's permission, the physician should remain within the bounds contoured by the four principles just mentioned, taking care not to exploit the patient. Where there is no patient-physician relationship, the psychiatrist should proceed carefully, with an eye on principles of truth-telling and respect for persons. Those ethics principles militate against exaggerating and saying things that may make the psychiatrist look good to the public, but are not based on integrity and respectful caution.
The performative roles we propose (Table 1) are frameworks that allow the psychiatrist to ask himself what objectives he wishes to fulfill in the interaction with the media, how he wishes to behave, what role he is qualified to play, whether he is comfortable with the role, and whether it is one that is concordant with how he thinks about himself as a psychiatrist and physician.
Psychiatrists' Roles in the Media
The Teacher
The psychiatrist who adopts this role aims to increase the public's general medical knowledge. The Teacher may translate jargon, explain the nature of illness, discuss the basics of treatment, or recommend resources to assist the audience in how to get help for an afflicted family member. The Teacher may also generate ideas via scholarship with the purpose of advancing the field of knowledge. The Teacher is readily found in peer-reviewed academic journals, non–peer-reviewed publications, recorded conferences, internet videos (e.g., YouTube), television interviews, blogs, and other news outlets.
This role is clearly concordant with the Principles, which permit psychiatrists to share their knowledge with the public:
Section 5: A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated [Ref. 3, p 8].
Section 7.2: Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness [Ref. 1, p 9].
A common pitfall for the Teacher is ensuring that the distinction between facts and public education versus opinions is readily discernible.8,28 Consider for example, the news station covering a murder allegedly committed by a person with mental illness. A psychiatrist invited to talk on the news could discuss the warning signs of mental illness and available community resources without offering diagnoses or other analysis of the mentally ill defendant. The trap can be avoided if the Teacher preemptively establishes boundaries for the interview and declines any invitation that asks for diagnostic impressions of public figures.
The Teacher must also be cognizant of his audience. Redacted academic presentations occur routinely and usually without the patient's consent. Psychiatrists making broader presentations to a more general audience must give more attention to the sensitivity of protected health information, remaining mindful not to violate patient confidentiality. Another common manifestation of the Teacher's role appears when a psychiatrist is invited to promote a book on a talk show. At least one example illustrates how a talk show host prioritizes his own agenda and ratings at the expense of manipulating a guest to provide entertainment. Dr. Nassir Ghaemi was interviewed by the political satirist Stephen Colbert on the Colbert Report regarding Ghaemi's book, in which the author proposed ideas connecting mental illness to leadership. Ghaemi quickly lost control of the interview. He was drawn dangerously close to the Goldwater Rule when Colbert invited him to state which, if any, of the Republican presidential candidates for the 2012 race were mentally unstable.29 Although the Teacher may appear on television to discuss his newly published ideas and research, the talk show host may simplify a complex topic, losing context and nuance and invading privacy.
How can the Teacher handle these potential pitfalls? Specific disclosures and warnings are necessary. Remind the audience of the constraints of medical ethics and the limits of one's knowledge. For example, as James Knoll looked for clues to motivation and signs of mental illness in the final communications of two recent pseudocommandos,30 he was both transparent and deliberate. First, he reminded the reader of the constraints of the Goldwater Rule. Then, he framed his purpose:
The intent of this article is to explore, via public-domain writings, the general psychology and motivations of Mr. Cho and Mr. Wong. I refrain from offering a professional opinion about specific diagnoses; rather, I offer limited and broad hypotheses about their motives and psychopathology [Ref. 30, p 264].
This tactic may be necessary for those who venture into psychohistory or profiling political figures. There is a danger of revealing personal information for sensationalism. There are questions regarding whether confidential information has been used and whether the length of time from the writing to the death of the subject makes a difference. As described earlier, some have argued that the Goldwater Rule does not apply to scientific studies that have “public policy implications” (Ref. 12, p 108). Even if the Teacher does not draw on patient information, he should continue to have respect for persons and not overreach in his analyses, as the information may become available in the public domain.
Likewise, speculation and unfounded commentary can be distinguished from valid psychological profiling to assist law enforcement in finding a criminal. The Teacher may use similar skills to educate the media about criminals and their actions (e.g., what type of people commit certain types of crimes or terrorist acts), so long as it is not claimed with conviction when data are limited or absent. The Teacher must be aware, however, that some will view him as more interested in self-promotion than in educating the public.
The Storyteller
The psychiatrist accepting this role focuses on personal narrative from a position of transparency and honesty. This approach is increasingly popular and is found even in peer-reviewed journals.31 The Storyteller may choose to disclose personal or familial struggles with mental illness or substance abuse. Outside of psychiatry, there have been several recent and notable examples: two from psychologists include one's personal disclosure of borderline personality disorder32 and the other's struggles with bipolar disorder,33 and one neurologist's recent account of his drug use.34 At other times, the Storyteller may focus on medical experiences, training, or dilemmas as Dr. Christine Montross did, using her experiences as a first-year medical student in the anatomy laboratory to begin an exercise in self-reflection.35
The Storyteller's role is typically a benign one, less likely to conflict with ethics or legal standards. The largest obstacle is likely to be the psychiatrist's level of comfort when deciding to make personal disclosures. The Storyteller should remain sensitive to the effect that such disclosures may have on family, colleagues, patients, and future referrals. For example, a psychiatrist's disclosure of having a mental illness could contribute to transference reactions by his patients. Colleagues might question his stability to deliver sound clinical care. Attorneys might choose to work with an expert whose personal history would receive less attention in cross-examination.
The Celebrity Commentator
Often introduced as an expert, the Celebrity Commentator is invited to provide psychiatric analyses of people in the national spotlight. These comments and opinions are often based on pure speculation. This role is played on most major television networks, in the lay press, and on the Internet. Psychiatrists are interviewed to comment on the mental health of politicians, professional athletes, and movie stars. Some are ready to give opinions about a person accused of a crime, which may unfairly affect the accused.
The Celebrity Commentator has the greatest opportunity to violate the Goldwater Rule and other ethics principles. Given the ethics framework, it is easy to understand why. If the celebrity figure were the doctor's patient, then the doctor would be muzzled. If the celebrity were not his patient, then the doctor would abide by the Goldwater Rule and not provide commentary, diagnoses, or opinions about an individual whom he had not personally examined.
A problem may also arise despite a psychiatrist's purposeful adherence to the Goldwater Rule. A psychiatrist who is invited to speak about a public figure could deliberately avoid offering diagnoses or suggesting that an evaluation has occurred. For example, instead of saying that a celebrity has bipolar disorder, the psychiatrist may attempt to take the role of the Teacher and provide education about the mental illness. The subtlety of the psychiatrist's message will be lost on the audience should text box graphics convey misinformation to the viewer (e.g., “Psychiatrist says [insert name of public figure here] is mentally ill.”) or as images of the celebrity are being shown on the screen, even though the psychiatrist is not directly speaking about the person.
The Hollywood Consultant
The Hollywood Consultant provides services and expertise for media productions. This role may occur behind or in front of the camera. For example, psychiatrists are sometimes hired by movie and television productions that involve characters with mental illness. This consultation is typically not a confidential one, as many Hollywood Consultants include it in their curriculum vitae.
In front of the camera, a physician may accept a visible role, as did one, who served as host of a cable television show about a psychiatrist who profiles serial killers, mass murders, and psychopaths.36 Behind the camera, the role might garner unwanted attention as it did for a psychiatrist involved with the television show Law & Order during the Andrea Yates case.37 Before testifying in court, a forensic psychiatrist may find it useful to review his involvement with the media, similar to reviewing other items from his curriculum vitae that might receive attention during questioning (e.g., opinions offered in publications or lectures).
Psychiatrists who accept the role of consultant on television shows and movies must be careful to “uphold the standards of professionalism” (Ref. 3, p 2) and not misrepresent the complexities of mental illness and human behavior. The Hollywood Consultant should also be mindful not to blend the truth (e.g., confidential information about actual patients or evaluees) with fiction (e.g., the story line of a Hollywood production).
The Clinician
The psychiatrist acting as the Clinician places his medical skills in the media spotlight. A multitude of examples demonstrate society's fascination with learning about medicine by observing physicians in their daily work. One daily television show38 features four physicians who discuss a variety of medical topics. On some reality television shows, excerpts of psychiatric39,40 or medical41 evaluations are shown. There is at least one example in which a psychiatrist who works as a contributor to a major news network has video clips online of his experience in interviewing strangers on the street and providing quick analyses and recommendations.42
The role of the Clinician is tenuous. We imagine that there are legal disclaimers signed by the soon-to-be televised “patients” that limit liability. The role, however, appears to violate the fiduciary nature of the doctor-patient relationship. According to Sections 1 and 8 of the Principles: “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and right” (Ref. 3, p 3), and, “A physician shall, while caring for a patient, regard responsibility to the patient as paramount” (Ref. 3, p 4).
Care must be taken that the Clinician does not exploit the individual who is seeking help. The role of Clinician may lead to a breach of confidentiality. In addition, videotaped examinations of “patients” also involve the ethics of informed consent. Accordingly, the interviewee must be competent to make this decision, be fully informed of the potential consequences of his decision (e.g., loss of privacy), and be allowed to decide without coercion (e.g., from pressures exerted by the television production or interviewing psychiatrist).43
The Advertiser
The psychiatrist who interacts with the media in the role of the Advertiser uses television, print media, mailings, and the Internet to market his services. A clinical psychiatrist might advertise expertise with specific diagnoses or demographics. A forensic psychiatrist might advertise experience with certain cases or legal matters, similar to other small businesses that engage in marketing.44
Psychiatrists may use passive or active websites.45 Most forensic psychiatrists use passive sites, which provide brief information about background, educational materials, the scope of the practice, and contact information. The sites are not interactive and do not accept payments, which are typical attributes of active sites. It has been recommended that one's site be professionally designed while limiting extravagant claims and carefully posting one's credentials.46 The forensic psychiatrist playing this role must also consider how this type of information could be used by opposing counsel in an attempt to discredit the expert in front of a jury.
Discussion
In this article, we have described the inherent complexities of psychiatrists' interactions with the media. This venture involves a delicate balance of maintaining respect for persons and not speaking with “actual malice,” conveying personal versus professional opinions, upholding the reputation of the profession, promoting public policy, adhering to social responsibility, and preserving the strict confidentiality of patients. We have elucidated the many risks incurred by psychiatrists and the responsible manner in which they may interact with the media.
We are unaware of any other ethics guidelines that specify the limitations of commenting on public figures, as does the Goldwater Rule enforced by the APA. There is risk of violating other ethics and legal standards. As a resource for its members, the APA has made available a toolkit of media relations for psychiatrists, which includes interview tips, talking points, and other strategies.47
Although not intended as a direct response to the Goldwater Rule, the “American Academy of Psychiatry and the Law (AAPL) Ethics Guidelines for the Practice of Forensic Psychiatry”48 may provide guidance in these matters. In detailing the principles of honesty and objectivity, conducting a personal examination is emphasized:
Honesty, objectivity and the adequacy of the clinical evaluation may be called into question when an expert opinion is offered without a personal examination …. If, after appropriate effort, it is not feasible to conduct a personal examination, an opinion may nonetheless be rendered on the basis of other information. Under these circumstances, it is the responsibility of psychiatrists to make earnest efforts to ensure that their statements, opinions and any reports or testimony based on those opinions, clearly state that there was no personal examination and note any resulting limitations to their opinions [Ref. 48].
The lesson from this forensic practice guideline may be relevant for a psychiatrist who provides commentary on public figures, regardless of whether the commentary is delivered via courtroom testimony or a television interview. When not conducting a personal examination of his subject, the psychiatrist should explicitly state this limitation.
The lure to express one's opinions publicly is often enticing. Forensic psychiatrists might especially be drawn to this, as it is often what they do in their daily work. One should recognize that this practice is ethics-based. If a psychiatrist decides to interact with the media, he should ask if the subject of the discussion is a patient. If yes, then the expected ethics constraints apply: specifically, confidentiality and autonomy. If the subject is not a patient, then a different set of ethics principles applies; the psychiatrist should strive to be objective, tell the truth, and be circumspect about the situation without making overreaching or exaggerated statements. He should discuss areas of psychiatry in general without specifically commenting on the person who is in the public spotlight. In other words, leave the role of speculation to the media. If no one in particular asks the psychiatrist to talk about a subject, then he should reflect and ask what is driving the desire to express the opinions publicly.
Psychiatrists who speak to the media after a notorious crime should recognize the possibility that their actions might be perceived as a desire for public attention or for self-promotion. Speculation about irrelevant topics misrepresents our field and makes the profession look bad, even if the subject is not a political figure like Goldwater.
Furthermore, if a psychiatrist decides to proceed with this venture, then we recommend proceeding with careful consideration. The psychiatrist should remain cautious to avoid manipulation or the temptation to make exaggerated statements to please a television host. The media often allow sloppy analysis of people who engage in bad acts or are unpopular. Psychiatric commentary interjected in the media-generated fray may result in dissemination of opinions that are not factual or complete. Such commentaries should not establish the benchmark for competent analysis. Instead, forensic psychiatrists who choose not to shy from this adventure can rise to the challenge of social responsibility and fill an obvious need to educate and inform the public on the nature of mental illness and human behavior without speaking specifically about the individual.
Forensic psychiatrists also run the risk of being drawn into the media spotlight to discuss a case on which they have worked after the verdict has been given. Appeals may still be possible, so the case may not be over. The forensic psychiatrist's public commentary then may influence the future direction of the case. Such speculation appears to be given without concern for the harm it can cause. It serves as another example that does not violate the Goldwater Rule, per se, but may run counter to ethics-based practice. Further, the forensic psychiatrist may not remember which information was revealed in open court as opposed to other elements of the case that did not become public. Discussing this information in the media may violate confidentiality.
We have proposed a framework of roles that will help psychiatrists interact with the media. This subject has not been explored in much detail in the literature. These roles highlight many of the common pitfalls that may draw the psychiatrist away from a practice consistent with established ethics precepts. The roles we have proposed have a mixture of advantages and disadvantages. One starting point for the psychiatrist faced with media-related opportunities is to decide which performative role is appropriate and whether the subject is associated with someone who is his patient. In addition, the psychiatrist should be prepared for his interactions with the media, establish boundaries on interview discussions, remind the audience of the limits of his knowledge and experience, and not overreach in his analysis.
The scandal following the Goldwater incident occurred because psychiatrists were saying things without being mindful of an ethics-based practice that guides a professional's behavior. We should remember, however, that ethics-based work in our field has greatly evolved since the Goldwater era. Although interacting with the media may be personally and professionally rewarding, psychiatrists should always carefully consider such invitations, seek consultation when necessary, and proceed with caution.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2014 American Academy of Psychiatry and the Law
