In Defense of Prudence and the APA's Goldwater Rule: A Response to Kroll and Pouncey

Editor:

In the most recent issue of the Journal¹ Jerome Kroll and Claire Pouncey revisited Section 7.3 of the American Psychiatric Association (APA) Code of Ethics, which proscribes psychiatrists from offering a professional opinion about a public figure's mental health in the absence of direct clinical examination and the individual's consent. They argued that the Code's prohibition is overbroad and inappropriately constricts the psychiatrist's freedom of conscience to inform the public about the psychological makeup of a public figure. In response, we draw upon the virtue of prudence to show that Kroll and Pouncey are misguided in their criticism of the Goldwater Rule, especially regarding political figures.

We acknowledge that there are times when psychiatrists may feel a duty to “speak up about political leader's behaviors that strongly suggest psychopathology” (Ref. 1, p 232), especially those who could be “potentially dangerous” (Ref. 1, p 232). Notably, this article was written and published in advance of the 2016 U.S. Presidential election, headlined by two unpopular major party nominees.² However, the authors' position is imprudent for two reasons.

First, the authors failed to clarify when a psychiatrist may justifiably speak out about a political figure. Using the authors' own example, it is difficult to distinguish why psychiatrists responding to the Fact article “analyzing” Goldwater³ were acting unethically but the author of Bush on the Couch⁴ was not. They note that there should not be “speculative or ad hominem attacks that promote the interests of the individual physician or for political and ideological causes” (Ref. 1, p 226). Is there any conceivable situation where a psychiatrist makes a diagnostic claim about the mental state of any political figure that would not reflect the personal ideological biases of that psychiatrist? Otherwise, what aspect of the psychiatrist's conscience would be so wounded as to justify the public declaration? Given our hyperpoliticized and polarized culture, we posit that any such declaration by a psychiatrist would be met with general suspicion and be no less ridiculed than in the Goldwater case. Given that, prudence dictates that psychiatrists have an ethics-based duty to refrain from actions that would similarly shame the profession.

Second, diagnosing public figures via observations culled from the media represents poor diagnostic methodology. The authors note that there are legitimate situations in which the APA does not proscribe diagnosis without an interview, such as historical psychobiographies or to meet the requirements of third-party payers. However, these exceptions are narrow and serve a discrete purpose, and the risk of error is known and acceptable. Public figures, especially politicians, intentionally cultivate a public persona that may not accurately reflect their psychological state. Given the risk and potential harm of error, it would be imprudent for any psychiatrist to render an opinion of a public figure's subjective thoughts or motivations, conscious or unconscious, in the absence of a personal and value-free diagnostic interview.

The APA's Goldwater Rule exemplifies a necessary and justifiable professional norm that is intended to temper the potentially imprudent and self-indulgent motivations of psychiatrists to use the cloak of their profession to further a particular political ideology and neutralizes a fallacious appeal to their own authority. Justifications based on freedom of speech, conscientious objection, or the public interest fail to offset the likely harms to the psychiatrist, profession, and public figure. We argue that the dictum remain firmly entrenched in the APA's Code of Ethics and the professional norms of prudent psychiatrists.