Abstract
Section 7.3 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (the so-called Goldwater Rule) provides guidance on the ethics of making psychiatric comments about public figures who have not been interviewed and have not given consent. I argue that the wording of Section 7.3 is ambiguous, and I document disagreement over the scope of the rule and consider the implications of this disagreement. If one reads Section 7.3 narrowly, as banning media comments without interview and consent, but allowing such comments in institutional settings, then the general principle articulated in the text and often repeated in the media begins to appear insubstantial. If one reads Section 7.3 broadly, then the work of psychiatrists in the courts, in government agencies such as the Central Intelligence Agency, in insurance companies, and in the academy becomes ethically problematic. I trace the American Psychiatric Association's own interpretation of Section 7.3 and conclude that the APA has advocated a narrow reading. I assert the need for an integrated theory of psychiatric ethics for settings where interview and consent are absent. Such a theory, articulating why comments in institutional settings are ethical, but comments to media are not, may reduce public confusion and provide a basis for revising Section 7.3.
Adopted in 1973 in the wake of a controversial incident involving Fact magazine,1 Section 7.3 of the American Psychiatric Association's Principles of Medical Ethics with Annotations Specific to Psychiatry (the so-called Goldwater Rule; hereafter the Rule)2 is an ethics guideline concerning psychiatric comment on public figures who have not been interviewed and who have not given consent. The Rule has been a perennial topic of discussion in the popular press since its adoption.3,4 In the pages of the New York Times, Psychology Today, and other publications, psychiatrists and others have explained the Rule, recalled its origins in the 1964 presidential election,5 probed its relation to contemporary politics and international affairs, and dissented from its prohibitions.6 With the exception of the work of Jerrold Post,7 however, for many years the debate barely entered the pages of our scholarly journals.
Although a scholarly discussion has now begun to develop,8,–,13 in some respects, psychiatrists who wish to study the foundations of the Rule's ethics and implications still have relatively little to work with. In particular, it has not always been clear from popular or scholarly accounts how ambiguous the text of Section 7.3 is; how necessary interpretation has been; and how, in response to members' questions, the American Psychiatric Association (APA) has offered its own readings of Section 7.3. To date, the ethics-related implications of this ambiguity have not been adequately explored.
The Literature: Interpreting Section 7.3
For a psychiatrist hoping to learn when comment on a public figure's mental health is ethical, the best starting point is the text of Section 7.3, which appears in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry:
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. 2, p 9].
The reader may be struck by certain ambiguities in the language of this important guideline. Section 7.3 opens with what might be called a contingent frame, one apparently localized to circumstances in which public figures are involved and in which psychiatrists are in the merely passive role of being asked for an opinion. By the time it reaches its third sentence, the text opens into what appears to be a much more general statement of principle: “it is unethical …” The effect of juxtaposing a narrow frame with a broad principle is somewhat jarring. What, exactly, is the status of that resounding generalization? Is a comment ever allowable in the absence of a personal interview and consent? Or, to put the matter paradoxically, is there only a limited set of circumstances in which the general principle applies7,10?
The use of the passive voice in Section 7.3 tends to render somewhat hazy the institutional contexts in which many psychiatrists actually work, as well as the role conflicts they may encounter in those circumstances. “Asked” by whom? In the media-specific sense, presumably Section 7.3 has reporters in mind. “Granted” by whom? Here, we are presumably referring to the public figure. But there are many other settings in which psychiatrists give an opinion without an interview, and many other possible givers of “proper authorization.” A book publisher may ask for a psychological study of a deceased historical figure or a living politician; a court or an insurance company may ask for an opinion based on a review of the record; or the Defense Department may ask for a profile of a world leader to advance war aims. Will any of these situations pass the ethics test? Section 7.3 does not say.
In fact, the text of Section 7.3 has always required interpretation, what one psychologist, in dealing with her own profession's rules, calls “decoding the ethics code.”14 The ethics guidelines for forensic psychiatry of the American Academy of Psychiatry and the Law (AAPL) do not address the psychiatric profiling of public figures or offer comment on Section 7.3,15 but others have published divergent opinions on what the Rule means. For example, psychiatrist Nassir Ghaemi favors a narrow reading focused on political comment only, but he acknowledges that not everyone agrees with him: “Some have argued that psychiatrists should not make any psychological analyses or interpretations of anyone without personally examining such persons.” For Ghaemi, this “extremely broad interpretation” will not do. A broad reading, he notes, would ban Eriksonian psychohistory, well-documented profiling, and work for the military; he sees a broad construction as inconsistent with the letter and spirit of the Rule.16 Paul Appelbaum, in this issue, offers a similar narrow reading.11 On the other hand, Kroll and Pouncey have recently argued that the Rule involves a straightforward and broad “proscription on diagnosis without formal interview” (Ref. 10, p 226). “We read the Goldwater Rule,” they say, as claiming that “standard diagnostic practice in the United States requires a personal interview before making a diagnostic formulation” and that it is unethical “to openly discuss the diagnoses and psychodynamics of a person whom the psychiatrist never interviewed and who has not expressly consented to public commentary” (Ref. 10, p. 227).
Jerrold Post, a psychiatrist and political profiler who has been the most prominent challenger of the Rule, notes his frustration in trying to grasp exactly what the Rule allows. He calls the text of Section 7.3 “a masterpiece of internal contradiction” (Ref. 7, p 636) and specifically argues that other important principles, such as serving society as a consultant to and advisor of the government (Ref. 2, Section 7.1) and advancing public education about mental illness (Ref. 2, Section 7.2), conflict with Section 7.3 (Ref. 7, p 636). Yet an anonymous reviewer of the present article argued that the three sentences in Section 7.3 may be read as linked rather than internally contradictory (hence the words “in such circumstances”). In this reading, Section 7.3 becomes a specific qualifier to the general encouragement of government work and public education outlined in sections 7.1 and 7.2. These complex readings of the text by different psychiatrists are plainly at odds with one another, highlighting the interpretive challenge posed by Section 7.3.
In contrast, it is striking how straightforward the Rule appears when described in the popular press. Most popular articles are impressionistic, picking up the soaring rhetoric in Section 7.3's third sentence (“it is unethical”) and implying that the Rule is a simple ethical ban. Typically, uncertainties over interpretation or qualification as to institutional setting are omitted. One example is the Wikipedia entry on the Rule. At the time I drafted this article, it said that the Rule “forbids psychiatrists from commenting on individuals' mental state without examining them personally and being authorized by the person to make such comments.”17 This stark summary may leave the reader with the impression that without an interview and consent, any psychiatric comment in any setting is unaccetable. But the lack of any qualification found in Wikipedia's sweeping statement can be found in professional publications as well. In the AMA Journal of Ethics, a recent case study states that “the American Psychiatric Association proscribes its members from commenting on the mental health of public figures under a nonbinding rule known as ‘the Goldwater Rule’.”18 If popular accounts leave the public with a simplified and misleading impression of our ethics guidelines and if psychiatrists themselves cannot agree on what the Rule covers, then it is not hard to understand how confusion about the Rule might linger.
In fact, the way we summarize Section 7.3 for the public and in our scholarly journals has important implications. If one reads Section 7.3 narrowly, as banning media comments about public figures only, then the general principle articulated in the text and so often repeated in the media begins to appear much more circumscribed than its resounding language would suggest. If one reads Section 7.3 broadly, as banning all comment unless a personal interview and consent have been obtained, then much routine work of psychiatrists in the courts, in insurance companies, in government agencies, and in the academy becomes ethically problematic. What is the scope of our Rule, and how ought we to describe it to the public?
APA Literature on Section 7.3
A starting point is the recognition that the APA itself has published a substantial body of literature on Section 7.3. Almost from the moment the Rule was issued, the APA saw a need to provide additional clarification to members. This commentary, appearing from 1976 to 2017 and scattered through several official APA publications dealing with ethics, typically receives relatively little publicity but has an important bearing on the question raised by Kroll and Pouncey (Ref 10, pp 228–9) of how the APA itself understands the Rule. Relevant sources include the report of the APA's 1976 Task Force on Psychohistory19; portions of Opinions of the Ethics Committee on The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry,20 which includes opinions provided to members from 1973 to 2013; and the APA Commentary on Ethics in Practice,21 which appeared in 2015 under the combined aegis of the Ad Hoc Work Group on Revising the Ethics Annotations and the APA Ethics Committee. This literature on Section 7.3, sometimes mentioned but never explored systematically, is important in understanding the hermeneutics of the Rule.
Most of the APA's ethics literature comes with disclaimers underlining the fact that ethics rules (including Section 7.3) must be interpreted, and at least an implicit acknowledgment that such interpretations may differ. Thus, the 1976 Task Force report emphasized that its recommendations “do not necessarily represent the views of the officers, trustees, or all members of the Association” (Ref. 19, front matter). In the words of the APA Ethics Committee, the opinions it has issued over the years “do not represent official positions of the American Psychiatric Association” (Ref. 20, p 1). The recently published APA Commentary on Ethics in Practice puts the matter most thoughtfully when it declares that some ambiguity will always remain intrinsic to the task:
This document is intended to aid in understanding the complexity of psychiatric ethics and how they apply in different situations. It is not a “rule book” but rather a tool. It is not intended to cover all ethically important situations and novel ethical questions that psychiatrists may encounter in the course of their careers…. Furthermore, it cannot fully capture all of the circumstances that alter the ethical nature of a particular decision or action [Ref. 21, p 1].
Thus the APA has recognized what John Burt22 in a different context has called “implicitness”: the ongoing need to revisit, in light of changing circumstances in an interpretive community, the implications of a founding text. In assigning interpretation to different bodies at different times, the APA has made it clear that none speaks with absolute authority; neither Ethics Committee opinions nor ethics publications, for example, have undergone the process of formal adoption by the APA Board of Trustees. Where necessary, however, the APA publications under review here have each made definitive interpretative statements about ethics-related questions. Thus, although official APA ethics publications do not have the same authority as Section 7.3 itself, they represent the closest thing we have to the organization's own understanding of the text.
Forensic Psychiatry
Among the most explicit of the APA's interpretations of the Goldwater Rule is a 1983 entry in the Opinions of the Ethics Committee. The committee took up a topic raised by Kroll and Pouncey: that psychiatrists in many settings are called upon to render an opinion based solely on a review of records, without a personal interview (Ref. 10, pp 229–30). As in most of its opinions, the Ethics Committee stated its view in the form of an answer to a question posed by an APA member, who appears to be trying to understand whether the Rule applies to psychiatric work in the courts:
Question: A psychiatrist testifies for the state in a criminal case about the competency of the defendant. The psychiatrist based the testimony on medical records and did not examine the defendant nor have the defendant's approval to render an opinion. Was this ethical?
Answer: Yes. See Section 7, Annotation 3 (APA): [quotes Section 7.3, as given above] Confusion has arisen by taking the second sentence above and not connecting it to the first sentence as was intended. It is common for forensic experts to offer opinions as was done according to the question. Further, it would be too great an extension of the Goldwater Rule to say that a person, by being a defendant in court, has entered into “the light of public attention.” This annotation was developed to protect public figures from psychiatric speculation that harms the reputation of the profession of psychiatry and of the unsuspecting public figure [Ref. 20, p 35].
The committee agreed that confusion about the language of Section 7.3 had arisen. In response to the member's question, it was willing to describe with authority the original intent of the Rule. It described that intent (along with the definition of a public figure) as narrow, rather than broad. Offering its own procedure for reinterpretation in context (linking the first and third sentences), the committee limited the applicability of the general principle to the specific situation delineated in the opening sentence of Section 7.3. Thus, we have an explicit statement that a personal interview and consent are not needed for ethical practice in forensic psychiatry and a clear implication that such is very likely the case in other institutional contexts where psychiatrists have well-accepted roles. The Ethics Committee reaffirmed this view in detail as recently as March 2017.23 It is surprising that these important points have seldom been appreciated or even mentioned in the published literature on the Rule.
In its 1983 opinion, the Ethics Committee clearly viewed forensic testimony without interview or consent as acceptable, but it was not explicit about whether forensic psychiatrists may make comments to the media. At least one influential author views forensic psychiatrists' comments to the media as covered by the Rule if no consent from the defendant has been obtained.24
Other Settings
The Ethics Committee has addressed whether the Rule covers work in other settings where a psychiatrist has not been granted an interview and consent. In 1976, a member asked about the ethics of consulting to a religious organization. “I review reports and information gathered about the individuals [involved] and give an opinion on whether they are competent to request an annulment. I do not examine them personally. Is this ethical?” The committee replied:
Answer: Yes…. To ask [consultants] to perform a personal examination in each case would be impractical and prevent such agencies from benefiting from psychiatric consultation [Ref. 20, pp 34–5].
When it addressed a 1983 question about psychiatric work for insurance companies, the committee's affirmation of the ethical nature of such work was even briefer. Again, a member asked a question about the Rule:
Question: I am asked to render an opinion for insurance purposes to determine if a suicide was a result of illness. Is it ethical for me to offer a diagnosis based on a review of records and without having had an opportunity to examine the patient?
Answer: Yes [Ref. 20, p 33].
In 1988, a member asked whether it was ethical for a supervising psychiatrist to give a diagnosis to an insurance company if the patient is under the care of another professional and the supervising psychiatrist has “not examined the patient.” The committee answered that providing a diagnosis is ethical, as long as the psychiatrist assures that proper care is provided and clearly indicates his or her own role (Ref. 20, p 66–7). This opinion echoes a more general 1975 opinion on so-called curbside consultations. “Ethical psychiatrists should refrain from giving specific patient management advice, assuming there is not an emergency situation, unless they are very much aware of the capabilities of the receiver of the advice and have sufficient information about the patient to make the advice reliable” (Ref. 20, p 37). In other words, under the right conditions, supervision and thoughtful curbside consultations are acceptable under the Goldwater Rule.
Government Settings
Recognizing the many questions raised by the Fact incident, the APA's Council on Emerging Issues commissioned a Task Force on Psychohistory, which published its report in 1976. The task force was charged with the mission of proposing ethics guidelines for psychiatrists and scholars working in psychohistory, psychobiography, and psychological profiling. This mission required the task force to consider the ethics of psychiatrists' conducting profiling for government employers.
Surveying risks and benefits, the task force noted the problematic nature of confidential profiles “sponsored by and put at the disposal of various governmental (and sometimes private) agencies” (Ref. 19, p 3). Yet consistent with Section 7.1's endorsement of a consulting and advising role for psychiatrists in government (Ref. 2, p 9), the task force said it took for granted that in the main, profiling undertaken confidentially for government agencies, especially the military, would be nonproblematic. The most significant ethics concern that the task force could identify was the potential that a confidential government profile could be leaked to the public. Remarkably, the risk of physical harm or death to an enemy who is profiled for a government agency in the midst of a war effort was not mentioned (Ref. 19, p 12). In 2017, the Ethics Committee again said that evaluating a public figure for national security decision-makers is ethically acceptable, yet in the next sentence said that relying only on publicly available information is “insufficient” as a basis for such opinions and constitutes “a misapplication of psychiatric practice.”23 In the absence of an interview, what information may be appropriately used in such profiling is unclear.
On the subject of assisting law enforcement in finding unknown perpetrators, the 1976 task force said it may be appropriate to publish a profile based on information from the media and from law enforcement, but it also went on to emphasize the risks involved (Ref. 19, p 13). A year later, the Ethics Committee said clearly that it would be ethical to publish such profiles (Ref. 20, pp 32–3). By 2015, however, the Commentary reverted to a more cautious stance, advising psychiatrists to emphasize the “inherent uncertainty in profiling” (Ref. 21, p 12). In its 2017 opinion, the Ethics Committee sharply differentiated profiling from “self-initiated public comments,” emphasized that the methodological limits of profiling should be noted, and stressed that no diagnosis should be given.23
Psychiatric Education
As far as I am aware, neither the APA nor the AAPL has published an opinion on the ethics of discussing public figures without interview or consent in educational settings. In 2014, in the context of my own teaching of medical students, I asked the APA Ethics Committee if it would be ethical to use a book by a public figure who acknowledges his or her own depression and describes his or her treatment in positive terms. The committee replied that using the book would indeed imply a diagnosis but “would not cross the 7.3 line”: The intent of the Rule, it said, “is to discourage psychiatrists from cavalierly labeling public figures with psychiatric conditions in nonmedical settings (e.g., in the press, the media, through public opinion polls or surveys) to meet their own needs for self-aggrandizement and attention.” Assigning such a book, if done thoughtfully, serves “the noble cause of providing medical education” (APA Ethics Committee, personal communication, November 10, 2014).
Psychobiography of Deceased Persons
At the time the 1976 task force was appointed, several prominent psychohistorical works had appeared and had gained wide acclaim. Noting the many potential problems associated with psychohistory, the Task Force report approached its work in nuanced fashion. For example, it cited Erikson's Ghandi's Truth (1969) as one of several such works “generally regarded as masterpieces” that have not raised ethics-related problems (Ref. 19, p 3). The report ultimately concluded that ethics-based considerations “do not appear to be of grave weight with respect to studies of subjects no longer living or active” (Ref. 19, p. 9). It did note the possible exception of a recently deceased subject, in which case a psychobiography might conceivably harm living relatives or friends of the subject. In that case, informed consent from next of kin should be sought. Otherwise, “there can be no question about the ethics of publishing psychohistorical studies or biographies of deceased persons” (Ref 19, p 13).
Psychobiography of Living Persons
The 1976 task force frankly acknowledged that the question of living, active persons was “thornier” (Ref. 19, p 3). Here, it said, ethics-related considerations take on “considerable weight” (Ref. 19, p 9). It noted the physician's guiding principle of “First do no harm” and judged the likelihood of harm to living subjects from such studies as “very considerable.” Yet it also noted the potential value of work on living persons; the report concluded that whether profiles may be written ethically without an interview and consent is finally a “complex” question that “may not be answerable in a categorical way” (Ref. 19, p 12). Oddly, it then went on to provide just such an answer: “it is difficult for the Task Force to perceive how this could be done ethically without the written, informed, and freely given consent of the [living] subject or subjects” (Ref. 19, p 13). The vacillating quality of the thought here is an indication that commentary on living persons was the most difficult area the task force had to confront. Describing the Fact publication as “irresponsible psychoprofiling in the public prints,” it nonetheless wanted to leave some room for responsible profiling. This stance was consistent with Section 7.2's endorsement of public education (Ref. 2, p 9). Yet the task force concluded by urging the APA to educate members about “the risks inherent in this new field of scholarly endeavor” (Ref. 19, p 14).
There, the matter stood until 2008, when Jerrold Post asked the Ethics Committee for an opinion on his work. Post had faced an ethics complaint arising from a New York Times article reporting on a presentation he had made to a committee of the U.S. House of Representatives about Iraq's leader, Saddam Hussein; Post's presentation was based on a detailed psychopolitical evaluation that had not included interview or consent.7 According to Post, the APA looked into the matter and exonerated him.7,9 Hoping for further clarity, Post then submitted the following query, based on his concern that ethics principles can conflict:
Question: Does the ethical prohibition embodied in Section 7, Paragraph 3 of the Annotations apply to psychologically informed leadership studies based on careful research that do not specify a clinical diagnosis and are designed to enhance public and governmental understanding?
Answer: The psychological profiling of historical figures designed to enhance public and governmental understanding of these individuals does not conflict with the ethical principles outlined in Section 7, Paragraph 3, as long as the psychological profiling does not include a clinical diagnosis and is the product of scholarly research that has been subject to peer review and academic scrutiny, and is based on relevant standards of scholarship [Ref. 20, pp 74–5].
The relevant conflict here is with a psychiatrist's duty, enumerated in the introduction to Section 7, to contribute to “the improvement of the community and the betterment of public health” (Ref. 2, p 9). The 2008 opinion, though still banning diagnosis and leaving the definition of “historical figure” unclear, resolved much of the ambivalence that had marked the 1976 task force report.
In 2015, in the APA Commentary on Ethics in Practice, the area of ethically permissible comment on living figures was broadened even further. The Commentary included this framing statement, which is more comprehensive than that found in the text of Section 7.3 itself:
For some in our profession, psychiatry can extend beyond the physician–patient relationship into the broader domain of public attention: in administration, politics, the courtroom, the media, and the internet. Psychiatrists need to sustain and nurture the ethical integrity of the profession when in the public eye. A psychiatrist may render a professional opinion about an individual after an appropriate clinical examination and accompanying waiver of confidentiality and should not do so unless the examination and waiver have occurred [Ref. 21, p 12].
In this statement, an acknowledgment of the importance of institutional context has been added (although the potentially self-contradictory aspects of Section 7.3 itself remain). The media context is now revisited in the following more specific way:
When a personal examination has not been performed and when a psychiatrist is asked for a professional opinion about a person in light of public attention, a general discussion of relevant psychiatric topics—rather than offering opinions about that specific person—is the best means of facilitating public education. 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. Moreover, labeling public figures cavalierly with psychiatric conditions, based on limited or indirect clinical knowledge is not consistent with this approach and undermines public trust in the profession of psychiatry [Ref. 21, p 12].
Here, the APA continues to emphasize its long-held concern about irresponsible comment, but for the first time, it sees diagnosis without interview and consent as potentially ethical, if conducted in an appropriate scholarly context. Yet, in 2017 the Ethics Committee said that profiling of historical figures in peer-reviewed scholarly work “should not include a diagnosis,”23 appearing to reverse the view it had participated in just two years earlier in the Commentary. This puzzling development illustrates that the APA's internal ethics processes are neither static nor unitary in character.
Discussion
Since 1973, scholars and APA members have disagreed about how to interpret the text of Section 7.3. A narrow reading (rendering unethical only evaluations of an “unsuspecting” public figure, while leaving as ethical a wide range of evaluations performed in institutional contexts) threatens to erode the much-cited general principle that a psychiatric evaluation requires an interview and consent to be ethical. Yet, a broad reading (rendering unethical any psychiatric comment not based on an interview and the consent of the subject) threatens to invalidate traditional psychiatric work in courts, government agencies, and insurance companies.
I have provided evidence that in response to members' hermeneutic and ethics-related queries, the APA itself, in the form of its Task Force on Psychohistory, the Opinions of the Ethics Committee on the Principles of Medical Ethics, and the APA Commentary on Ethics in Practice, has defined the Rule as applying narrowly. Thus, it is evident that the generalization in the third sentence of Section 7.3, “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,” is not in fact intended as a general principle applicable across other psychiatric settings, but is intended to apply primarily in media contexts where psychiatrists are asked for a comment on public figures. This is not only a narrower reading than that proposed by Kroll and Pouncey, but is narrower than the possible readings implied in the many questions submitted to the Ethics Committee about psychiatric comment where an interview and consent for comment are not obtained.
Enshrining a confusingly phrased statement as a core principle in our ethics code can itself lead to problems. Among these are uncertainty in our profession and in society about what is ethical, and why. When psychiatrists are asked to explain Section 7.3 and its rationale, we are unlikely to advance public understanding if we cite a general principle that does not in fact apply across all settings, but providing a more integrated explanation that takes account of what is ethical in different settings might be of great service to the public.
In 2015, I described the Rule this way: “In 1973 APA created a new ethical standard prohibiting psychiatrists from offering a diagnosis (later widened to include any professional opinion) without conducting an interview and obtaining consent” (Ref 9, p 729). I no longer think this shorthand adequately conveys the complexity of the Rule. As an alternative, I suggest that in our statements to the media and to the public, as well as in our scholarly writing, we carefully describe the qualifications that are implicitly present in the Rule. One such version might be the following:
Under Section 7.3, it is unethical for a psychiatrist to provide ‘cavalier’ media comment on a public figure without conducting an interview and obtaining appropriate consent. However, outside of media settings, careful psychiatric comment without interview or consent is often ethical. For example, when a psychiatrist is acting within his or her role in the courts, in government agencies, in insurance companies, or in the academy, the APA views it as ethical to assess a defendant, a patient, or a public figure in the absence of interview and consent, if the assessment is evidence-based and otherwise meets relevant professional standards.
Summarizing the guideline in this way has its advantages. Making do without the support of a simple-sounding principle, we will be acknowledging more openly that principles can have conflicting ethics and that such principles may apply differently in different settings. The 2017 Ethics Committee opinion began to move in this direction.23 If we adjust our comments about Section 7.3 in this way, we also must make it clear on what basis an institution (a court, the military, the CIA, or an insurance company) can provide consent for psychiatric comment, or on what basis institutions can give authorization for comment in the absence of consent from the subject. We must explain why comment without an interview and consent is ethically acceptable in many institutional settings, yet unethical in the media context. The 2017 Ethics Committee opinion says that forensic opinions are permissible because there is a “court authorization” and a framework that includes parameters for how the information may be used. Unauthorized comments, on the other hand, compromise “the integrity of the psychiatrist and of the profession” and may undermine patients' trust in the integrity of their diagnoses and the confidentiality of their treatment.23 An integrated theory of psychiatric ethics in the absence of interview and consent has seldom been attempted.25
Finally, then, an examination of the ambiguity of Section 7.3 opens into a recognition of the need to reframe our thinking about the ethics of commenting to the media in a wider context. An integrated theory of psychiatric ethics in the absence of interview and consent would go far to reduce the current confusion about Section 7.3. With such an account in hand, we might be able to rethink the language of this core principle of our ethics, aiming for wording that is clearer and subtler than the version that has been in place since 1973.
Acknowledgments
For helpful comments, the author is grateful to Paul Appelbaum, James Armontrout, Thomas Gutheil, Meredith Levine, Sagar Vijapura, and two anonymous reviewers for the Journal. These colleagues did not necessarily agree with all the points made here, but their thoughtful feedback greatly improved the manuscript. Thanks are due to Teresa Gorman for help in preparing the manuscript.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2017 American Academy of Psychiatry and the Law
