A Resident Perspective on the Goldwater Rule

The Literature

We cannot know how psychiatry would be perceived in the absence of the Goldwater rule, but it seems likely that psychiatrists' general adherence to the rule has influenced the public's view of psychiatry over the past five decades by decreasing the number of psychiatrists who offer commentary on public figures. Surprisingly, however, much of the peer-reviewed literature discussing the rule's merits or whether there are legitimate exceptions to the rule has been published only recently. In addition, at least until quite recently, there was minimal guidance in the peer-reviewed literature regarding explicit definitions for ethical interaction with the media. Given that communities not uncommonly turn to physicians for expert opinions on medical matters, this omission is particularly troubling.

Searching PubMed as broadly as “Goldwater” [title/abstract] returned 21 results, only 4 of which relate to the Goldwater rule. Of note, each of those four articles was written in 2012 or later. Searching for the terms “public figure*” plus “discussion*” [title/abstract] returned one relevant result, and “public figure*” plus “psychiatrist*” returned only two relevant results. We were unable to find any articles related to residents' perspectives on the rule.

We also searched for examples of residents who violated the Goldwater rule. We conducted an online Google search (“psychiatrists commenting on public figures” and “resident violate Goldwater rule”), asked mentors and fellow residents, and reviewed the articles that were returned by the PubMed search described above. We were unable to find instances in which residents had been reprimanded for running afoul of the Goldwater rule.

Rationale for a Didactic Curriculum

In our experience, residents are not often asked to serve as psychiatric experts to the media. Given the prevalence of social media, however, many smaller scale opportunities for offering opinions and analysis of public figures could present themselves. For instance, one could imagine a blog offering psychiatric analysis of politicians or a YouTube channel offering commentary about bizarre celebrity behavior. Given that examples of health care professionals violating patient confidentiality in social media are readily available (for instance, see Dimick⁶), one might predict that examples of health care providers violating the Goldwater rule in social media would be easy to find, as well.

An attempt to locate instances of residents violating the Goldwater rule in high-profile ways, however, did not yield any examples of this behavior. In addition, in instances where nontrainee psychiatrists had faced accusations of possible violations, such as Keith Ablow,⁷ Jerrold Post,⁸ and Justin Frank,⁸ it was also clear that the alleged violation did not stem from lack of awareness of the Goldwater rule. Typically, these commentators addressed the rule directly in responding to accusations of unethical behavior.⁴

In our experience, although residents may not know the Goldwater rule by name, they generally have some awareness of a prohibition against diagnostic speculation about public figures. This awareness is useful in preventing public speculation that might be embarrassing to training programs and to the profession more broadly. It is also useful in its provision of a launching point for a more nuanced discussion of the rule in the educational curriculum.

Current guidelines state an expectation that programs will distribute to residents and operate in accord with the AMA Principles of Ethics with Special Annotations for Psychiatry, in addition to ensuring trainee adherence to professional standards of ethical behavior.⁹ These are important first steps and, in our experience, when respected attending physicians model ethical behavior, it can have the greatest impact on trainees' professional development, especially when an attending faces and talks through a real-world ethics dilemma, such as when he has achieved sufficient public standing to receive invitations to offer potentially problematic commentary and refuses to do so. This modeling can be effectively supplemented with formal teaching, and that teaching presents many opportunities for an enriching discussion around questions of professional identity. For instance, what role (if any) should a psychiatrist play in the community beyond treating individual patients under a traditional treatment model? How can one be an educator and thought leader with regard to the science of mental illness without “crossing the line” into ethically dubious territory? When psychiatric opinions come under scrutiny (such as in high-profile court cases or political rows), how would one evaluate the opinion for scientific and ethical defensibility?

With the current controversy surrounding the Goldwater rule as a valid ethics-based requirement,² and the frequent temptation to offer potentially harmful commentary about public figures a more nuanced discussion of the boundaries of professional behavior is called for. Combining brief but thoughtful explanations of the “why” behind ethical behavior can help residents maximize benefit from the “how” that is modeled throughout their training.

A Model Didactic Curriculum

A useful discussion of the Goldwater rule could take place within a single didactic hour. Such a discussion ideally would cover the current form of the rule and the story behind its creation, provide guidelines for drawing the line between statements that violate the rule and those that do not, and introduce the reasons that some psychiatrists have called for the rule's repeal. The current form of the rule is easily accessed online under the Annotations Section 7.3.¹⁰ The story behind the rule's creation is detailed by multiple sources^2,3 and helps underscore the potential for harm created by unchecked diagnostic speculation by psychiatrists, both to the image of the profession and to the victims of such “analysis.”

After this brief introduction, the discussion could be usefully balanced by introducing trainees to the types of media interactions that are currently considered to fall within ethics guidelines. For instance, Cooke et al.³ have identified a range of ethics-related roles which they characterize as the teacher, the storyteller, the celebrity commentator, the Hollywood consultant, the clinician, and the advertiser. Sharing concepts such as these may help trainees feel more comfortable taking on roles as educators for the public rather than avoiding any public comment altogether out of a reactive concern about where the ethical boundary lies.

Another area for exploration, if time permits, could come from understanding forensic standards of practice for evaluations in which an opinion is offered, but the subject of the evaluation is not interviewed. As Kroll and Pouncey² highlight, psychiatric opinions are offered and acted on without direct personal examination in many contexts. For example, insurance companies frequently review treatment records to ensure diagnostic accuracy and treatment quality. In psychiatric malpractice cases an expert may offer opinions about diagnoses and treatments without examining the patient, most obviously in suits involving a completed suicide but in other contexts as well. Again, without setting any specific agenda for these discussions, we envision that exploring the standards used in these contexts and how they differ from commentary on public figures (if indeed they do) might help residents place offering opinions without direct examination into a wider and richer context.

Finally, with new generations come new interpretations of ethics-based duties. For trainees to make informed decisions as future leaders, training programs should provide a brief introduction to the controversy so aptly articulated by Kroll and Pouncey.² As mentioned earlier, these authors contend that psychiatrists frequently offer psychiatric opinions without having directly examined patients. They assert that there is little evidence for the claim that only personal examination can lead to valid diagnoses and emphasize that the rule can place personal and professional ethics in conflict, for instance when raising psychiatric concerns about public figures as acts of conscience. They assert that it is not appropriate for a professional organization to require that professional obligations always trump personal commitments in this way. They also point out that the Goldwater rule may curtail legitimate scholarly enterprises such as psychobiography. These concerns cannot be dismissed out of hand, and if the next generation of trainees is to approach them thoughtfully, that process must begin with awareness. The goal in introducing these topics, as we envision it, is to allow space for residents to understand the current standards and to begin exploring their own reactions to them. Especially for those residents with an interest in ethics a brief introduction could serve as a launching point for productive debate.