Reflections on the Goldwater Rule

Purpose of the Rule

As others have noted, Fact's special issue, with its 38 pages of comments from American psychiatrists, many of them offering negative formulations of Senator Goldwater's mental functioning and embracing a range of diagnoses from character disorders to frank psychosis, constituted a huge embarrassment for the psychiatric profession.^6,7 That so many psychiatrists were willing to speculate openly about the psyche of a prominent public figure, based only on what they knew from the popular media, called into question both the scientific grounding of the profession and its trustworthiness. There seems to be little question that part of the motivation behind the Rule was to prevent such public humiliation in the future.⁷

Whatever the initial impetus, however, I want to suggest that there are other, arguably more important, justifications for the position taken by the APA. To the extent that the focus of a psychiatrist's public comments is a living human being, that person may be injured by poorly grounded, inaccurate speculation about his mental condition. As part of the successful legal action that Senator Goldwater brought against Fact's publisher,⁸ Ralph Ginzburg, the former presidential candidate testified to the degree of upset he experienced after the episode, never knowing if people on the street who smiled at him were being genuinely friendly or inwardly smirking about (as some survey respondents suggested) his impaired masculinity.³ Real harm to real people constitutes a reason beyond professional embarrassment for psychiatrists to avoid judgments on the basis of information gleaned from the media.

The potential consequences of psychiatric speculation about public figures, however, extend beyond the person in question. To the extent that members of the public observing these episodes conclude that psychiatry must be an unscientific discipline whose practitioners are prone to drawing conclusions on the basis of fragmentary information or their personal opinions, they may write off the value of psychiatric evaluation and treatment. That conclusion can only be reinforced by what appears to be the motivation for many public pronouncements of this sort by psychiatrists: a moment of glory in the media spotlight. For a discipline already hindered in its efforts to help people with mental disorders by misconceptions about their origins and the stigma attached to diagnosis and treatment, this is not an insubstantial concern.

Critiques of the Rule have tended to focus on avoiding embarrassment to the profession as its primary motivation.⁶ However, I suggest that harm to the subjects of the public comments and to other people who may thereby be discouraged from seeking psychiatric care are much more substantial concerns against which arguments for abrogating the Rule must be weighed. It is to those arguments that I now turn.

Weighing Criticisms of the Rule

Although the Goldwater Rule has been criticized from several perspectives (former APA president Alan Stone famously objected that it constituted a fruitless effort to “legislate against stupidity”),⁷ I consider here what I take to be the two most substantive critiques. The first of those is that the Rule may hamper public education about mental illness and its consequences by placing severe restrictions on psychiatrists' comments to the media. This argument is often accompanied by contentions that, in a particular case, there may be enough information to draw a diagnostic conclusion without examining the subject; and in any event, if psychiatrists refuse to become involved, less well-trained commentators will take center stage.

Insofar as concern about the Rule is motivated by a desire to facilitate public education, it seems clear that a great deal of public education can be accomplished without applying specific labels to individuals.⁵ Even within the constraints of the Rule, psychiatrists are free to speak in general terms about the nature and impact of mental disorders on human behavior. This task can be accomplished while the psychiatrist underscores his or her own lack of knowledge about a particular individual's diagnosis.⁹ Here, I can speak from experience: I am often contacted by the media after some horrific violent event, which gives me an opportunity to explain what we know about the precipitants of violence, including the role of mental illness, while disclaiming any knowledge about what motivated a specific violent act. Is there a risk that some readers or listeners will conclude nonetheless that I am speaking about the perpetrator? Of course there is, but the obligation is mine to try to minimize that risk as best I can. Although some of the lesser media outlets may be disappointed by my unwillingness to shoot from the hip, most understand and respect mental health professionals who resist making diagnoses or drawing causal inferences at a distance.

Many of the psychiatrists and other mental health professionals who comment freely to the media on the psychodynamic motivations and diagnoses of public figures, of course, believe that they have ample data from which to draw conclusions. Especially when political leaders are the focus of their comments, there may be a long public record of behavior and discourse from which to draw, making it all the more important to recognize why diagnoses made without the opportunity to evaluate the person and without access to any other professional's evaluation, are so perilous. As I have explained elsewhere in a very different context (i.e., psychiatric testimony at death penalty hearings given without having examined the defendant), the expertise associated with reaching a diagnostic judgment goes well beyond applying the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM).¹⁰ It includes knowing how to obtain the data relevant to making a diagnosis, ruling out some possibilities and increasing the likelihood of others. Without the option of a direct examination, or reliance on the judgment of a competent professional who conducted such an evaluation, most diagnostic conclusions are so likely to be subject to error as to be essentially worthless. Responsible media outlets often recognize this; hence, good journalists will frequently begin by reassuring a psychiatric source that they will not be asking the psychiatrist to offer a diagnosis.

Does the argument that psychiatrists who decline to offer opinions to the media will see that role filled by less well-trained people have any weight in judging the validity of the Rule? Given the voracious appetite of the media for opinions on current affairs, seemingly regardless of the credentials of the person offering them, there is little doubt that if psychiatrists (and, one hopes, other mental health professionals) choose not to comment, someone else, in fact, will step up to opine. Indeed, as I write this piece, a colleague has just sent me a link to a lengthy article in a major national magazine in which a sports journalist with a penchant for political commentary, and a bachelor's degree in communications, concluded that a presidential candidate is a psychopath.¹¹ That judgment, however, is likely to be given just the weight it deserves by most people, notwithstanding the author's claim to have consulted with a “psychoanalyst” about how to apply the Hare Psychopathy Checklist: they will recognize the utter lack of qualifications of the person offering it. At the very least, it will not come cloaked in the authority of the psychiatric profession, with the multiple harms outlined above to which that can lead.

The second substantive criticism of the Rule that warrants consideration is that it can impede the work of psychiatrists who undertake the study of political figures and others for reasons other than media comment. Such psychiatrists may seek to provide guidance to government officials by studying the behavior and motivations of foreign leaders (a field sometimes referred to as “political psychology”); Walter Langer's well-known psychoanalytical examination of Adolf Hitler during World War II and Jerrold Post's work on Saddam Hussein in the lead-up to the first Gulf War are notable examples.^12,13 Other efforts may pursue better understanding of historical figures, such as Lincoln and Churchill, both of whom have been subject to what might be called psychobiographical examination.^14,15 Or psychiatrists may undertake scholarly assessment of the impact of mental states on behavior, for example, in studying the roots of terrorism⁷ or the nature of artistic genius.¹⁶

The impact of the Goldwater Rule on these activities is less easy to dismiss and indeed may require some clarification to avoid application to situations that the Rule was not intended to cover. Jerrold Post, a Washington, D.C.-based psychiatrist, has been at the forefront of raising these questions.⁷ Post deserves great credit for his persistence in challenging, in his academic writings and presentations at professional meetings, what he sees as an unreasonable rule, rather than simply abandoning his professional organization and going about his work, as he could have long ago. Summarizing his argument, he writes: To address the hazards of injudicious opinions by psychiatrists and yet permit useful contributions, the prohibition might be replaced with guidelines to the effect that such professional opinions should be based on research consistent with psychiatric principles and knowledge; be conveyed in a responsible manner that is mindful of the responsibility to society; and treat the subject with respect [Ref. 7, p 646].

Part of the answer to Post's challenge, I believe, lies in correctly understanding the scope of the Rule. Both its genesis and its language suggest clearly that it addresses psychiatrists who share their opinions with the public, including through the news media and, especially today, via the Internet. Recall the key sentence, “In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general” (Ref. 4, p 9). There is no limitation in the Rule on psychiatric analyses carried out for purposes other than public comment. Thus, Post and his colleagues are free to produce reports for government agencies, private corporations, and other entities that believe they may benefit from such work. (Such entities, though, would do well to pay attention to the very real limitations of diagnosis at a distance.) If the current version of the Rule is considered to be unclear on this point, although I do not believe it is, this is one place where clarification may be helpful.

Of course, Post and less responsible practitioners of “political psychology” want more than this. They want the ability to share their analyses with the public, whether in public forums, popular media, or more academic publications, as Post himself did with his work on Saddam Hussein. About that episode, he wrote, “the assessments of Saddam's political personality and leadership that [were] guiding policy seem[ed], to me, to be off, and policy decisions [were] being made based on errant perceptions that could lead to significant loss of life. Accordingly, it would have been unethical to have withheld this assessment” (Ref. 7, p 637). I admire Post's strongly held views about Hussein and his determination to change U.S. policy. However, a rule that said psychiatrists cannot diagnose people they have not examined except when they feel strongly that it would be important to do so would be no rule at all. In what recent presidential election have at least some people not felt that the future of the republic was at stake if the wrong candidate were elected? Post's proposed rule would justify work motivated by political partisanship and a desire to be in the public eye that fails to rise above the lowest level of pop psychology.

What should a psychiatrist in Post's situation do? A psychiatrist who believes public policy has gone astray based on a misreading of the psychology of a foreign leader would, in my reading of the Rule, be entirely justified in sharing that opinion and the information on which it is based with relevant government agencies, with which Post has had relationships stretching back several decades. What he should not do is share such analyses on the Web or in the media. Indeed, Post's experience demonstrates the futility of that approach. Although he expresses great pride in being asked to testify before a congressional committee about his analysis of the personality of Saddam Hussein,⁷ there is no reason to believe that his conclusions about Hussein had any impact whatsoever on U.S. policy.

Finally, Post has raised, as another example of scholarship that might be precluded by the Rule, his work on understanding the psychodynamic and other underpinnings of terrorism.⁷ This situation seems unproblematic to me, because the profession already has approaches to deal with these concerns. Case reports should be sufficiently disguised so that their subjects cannot be identified; if that is impossible, consent should be obtained. Of course, in some cases that would mean that case reports could not be published. But given that case reports are unreliable bases for generalizable conclusions in any case, data generally should be aggregated and presented in a manner that does not reveal individual identities. That may preclude the telling of dramatic stories, but should not interfere with the presentation of scientifically valid conclusions.

Historical Figures

Work addressing historical figures is, in some respects, a more difficult problem. Historians often call on methodologies from other fields to help illuminate the lives and motives of the people they study. Psychohistorical or psychobiographical work has evolved into a popular genre, dating back to Freud and Bullitt's biography of Woodrow Wilson,¹⁵ with both historians and mental health professionals contributing to it. Although the value of such work, sometimes derided as “pathography,”¹⁷ may sometimes be questionable and limited by the difficulties noted above in acquiring reliable data about the person, given that it occurs after a historical figure's death, the balance of interests may be different. Direct harm to the person can no longer occur, and although public figures often work hard to ensure that their positive reputation will survive them, we would all do well to recognize that seeking to control what others think of us after we are gone is a fruitless task. It is true that family members may be upset by postmortem analyses of their notable relatives. If accompanied by appropriate cautions about the methods involved and the inherent uncertainties in the process, the balance of considerations probably tips in the direction of exclusion of historical and biographical studies of deceased figures from the scope of the Rule.

In fact, a more recent APA document that explicates the profession's ethics appears to recognize this. With regard to the Goldwater Rule, it indicates that: In some circumstances, such as academic scholarship about figures of historical importance, exploration of psychiatric issues (e.g., diagnostic conclusions) may be reasonable provided that it has a sufficient evidence base and is subject to peer review and academic scrutiny based on relevant standards of scholarship. When, without any personal examination, the psychiatrist renders a clinical opinion about a historical figure, these limitations must be clearly acknowledged.¹⁸ I think this conclusion is valid as far as historical figures are concerned, which I take to mean people of note who are no longer alive and agree that the Rule itself should be modified to indicate that.