This post is one article in a series covering the Goldwater Rule and the debate surrounding its use. The views expressed in this article are those of the author. 

In 1973, Erik H. Erikson was invited to give the Jefferson Lectures in the Humanities in Washington, D.C. The invitation came as the country was struggling with the emerging Watergate scandal; the explosive Senate hearings that investigated President Richard Nixon’s likely abuse of power got underway in the same month that the eminent psychoanalyst gave his lectures. At that time, Erikson noted “humanistic insights and public issues” seemed to have “parted ways as never before” (Erikson 1974).

In the age of Donald Trump, professionals again faced the issue of how to express their concerns as public life changed for the worse. If a president abuses power or if his behavior veers toward authoritarianism, for example, what is a scholar’s role? Erikson decided to discuss principles but did not discuss Nixon specifically. After Trump’s election in 2016, many scholars similarly turned to indirect methods to explore public figures’ violations of social and ethical norms.

To my mind, two of the most remarkable scholarly books that worked in this vein are David A. Bell’s Men on Horseback: The Power of Charisma in the Age of Revolution (2020) and Stephen Greenblatt’s Tyrant: Shakespeare on Politics (2018). In many ways, despite vast differences in the time periods and cultures they examine, the books complement each other. Bell, a historian of France in the 18th century, explores the fate of revolutions that started with heroism and hope in the United States, France, Haiti, and Latin America. His epigraph, taken from Rousseau, captures the dilemma faced by those who sought to overturn monarchy and establish a new kind of authority: “The great problem in politics…is to find a form of government that sets the law above man.” The common fate of charismatic revolutionary leaders, Bell shows, was not a transition to lasting democracy (a new form of government that itself needed charisma and the admiration of devoted followers in order to survive) but a descent into self-regard, betrayal of principle, and authoritarianism. In Bell’s brilliant but sobering international perspective, George Washington and the American Revolution emerge as notable exceptions. Trump is not named but is implicitly present throughout the discussion.

The eminent Shakespeare scholar Greenblatt illuminates similar territory: the recurring preoccupation in the Bard’s plays with power, its usurpation, and its slide into authoritarian rule. Never naming Trump directly, Greenblatt evokes him continuously, probing scenes from Henry VI, Macbeth, King Lear, and Julius Caesar, among others. Shakespeare’s dramatis personae include many that a student of Trump would recognize at once: populist leaders, emotionally unstable tyrants, enablers, victims, and resisters. These characters populate a world like Bell’s in which charismatic rulers rise, lose their moral bearings, and finally precipitate their own downfall. In Shakespeare’s world, royal order is (precariously) restored at last but not before repeated episodes of ambition, murder, cruelty, and trauma lead the King’s subjects to wonder if they have seen the worst this world has to offer.

In my opinion, forensic psychiatrist Bandy Lee joins this tradition of moral concern for the welfare of society when she makes the case that mental health professionals have a primary responsibility to society and can provide a “crucial check on powerful political figures.” Without this informed professional check, she believes, “society becomes all the more susceptible to tyranny.” Taking on Trump directly, Lee has provoked much thought about the role of psychiatric ethics in a society gone awry, in the circumstances that Robert Jay Lifton calls “malignant normality.” How are citizens and officeholders to adjust when a leader bans conscience and creates a new normal? As the earnest Brutus reflects in Julius Caesar, “Th’ abuse of greatness is when it disjoins / Remorse from power” (II.i.18-19).

For its part, the American Psychiatric Association (APA 2013) has insisted that it is unethical for its members to comment on the mental health of public figures, a principle articulated in the Goldwater Rule. For the APA, without a personal examination and consent, such professional comment cannot be justified. The contrast with Lee’s thinking is sharp. For example, Charles Dike, an APA ethics committee member, attended a conference organized by Lee in 2017 on the Goldwater Rule and asserted strikingly that psychiatrists “do not owe society a primary duty.” Far from seeing psychiatrists as helpfully placing a check on errant public figures, one former APA president has drawn an analogy between comment on public figures and the misuse of psychiatry in Nazi Germany and in the Soviet Union. Yet the APA has no objection to psychiatric profiling undertaken for the American government, including the Central Intelligence Agency. Indeed, psychiatrists in the agency may, without interviewing their subjects, routinely opine on how psychological understanding can contribute to a war effort being conducted against the subject of their profile. Forensic psychiatrists whose defendants refuse to speak with them may reach diagnostic conclusions and recommendations without an interview and discuss them in open court where the psychiatrist’s evaluation may lead to a defendant being sent to a hospital or even to prison (Martin-Joy 2020).

In 1973, the APA adopted a simplistic prohibition on comment that does not acknowledge these complexities. The Goldwater Rule appears to be phrased as a global ban on all comment without interview and consent (“it is unethical…”). In fact, however, the APA has always intended the rule’s prohibitions to be limited to psychiatrists who speak about public figures in the media without interview and consent. The rule views this kind of media comment as a central violation of psychiatric ethics, on a par with the violation of confidentiality and the exploitation of patients. In contrast, psychiatrists who publicly express their concern about the emergence of a potential present-day Hitler or Stalin are subject to the APA’s elaborate mechanisms for receiving, investigating, and judging ethics complaints about its members (Martin-Joy 2020).

In a provocative essay, Otto Kernberg (1997) describes how bureaucratic systems can function to contain and channel the potential for paranoia, aggression, and loss of individual identity that are inherent in large groups. In response to such regressive pressures, he notes, organizations often develop simplistic ideologies, offering a “calming, reassuring doctrine that reduces all thinking to obvious cliches.” They also develop complex bureaucracies (elaborate process focus and division of labor) as a defense against the outbreak of aggression within their ranks. Suspicion and a breakdown of social relationships can become pervasive in such “paranoiagenic” organizations. I worry that the scenario Kernberg describes is close to the current situation within the APA. As Lee notes, the APA has publicly denigrated principled critiques of public figures by its own members as mere “armchair psychiatry” undertaken for purposes of self-aggrandizement. How does the APA know its members’ motivations, and why does it have such difficulty respecting pluralism in its ranks? A number of prominent APA members, including psychoanalyst Leonard Glass, have resigned because of the group’s disrespect for the individual conscience of its members on this issue.

Are there risks inherent to commenting? The most sophisticated proponents of the Goldwater Rule, such as former APA president Paul Appelbaum (2017), have recognized that there are risks but also that there are arguments to be made on both sides of the resulting ethics issue. In other words, the Goldwater Rule does not simply ban an outrageous practice; it raises a conflict of principles that must be resolved. Appelbaum’s formulation emphasizes the risk of harm to public figures and the risk that the public, seeing irresponsible psychiatric comment in the media, will choose to avoid mental health treatment. Appelbaum finds the Goldwater Rule to be valuable on balance. But it is a balance.

The historical evidence, though limited, supports the proposition that public figures have been hurt by careless psychiatric comment. In 1964, publisher Ralph Ginzburg surveyed psychiatrists and published in Fact magazine a series of their comments on the mental health of candidate Barry Goldwater. It was a media sensation. But Goldwater later said under oath that he found the cumulative impact of the comments “rather depressing”; he considered the Fact issue to be a clear violation of medical ethics. In 1968, in the midst of the Vietnam War, President Lyndon Johnson faced the prospect of a similar issue about himself. Documentation held in the LBJ Library shows that he was concerned about the potential for political damage. Johnson suggested to his staff that responding publicly “might just advertise” Ginzburg’s survey; he asked his men to gather information on Ginzburg and to get opinions from the APA. He was ready to fight back. In 1971, President Richard Nixon’s men pressured CIA psychiatrists to produce a psychological profile of anti-war activist Daniel Ellsberg who had just leaked the Pentagon Papers to the press. In their need to discredit the president’s critic, Nixon’s “Plumbers” (leak-fixers) burglarized the office of Ellsberg’s former psychiatrist, hoping to turn up embarrassing private material for use in the profile (Martin-Joy 2020).

What is striking about these instances is that none of them involve the careful use of evidence by a psychiatrist for the purpose of forming and sharing with the public an impression of a powerful public figure of concern. Ralph Ginzburg later acknowledged that he had edited, condensed, and improved many of the psychiatrists’ responses for publication, sometimes combining two responses into one for heightened effect. (In a libel action, he was found liable.) The Ellsberg incident was widely viewed as a violation of the CIA’s domestic charter, the burglary contributed to Nixon’s impeachment, and even the director of the CIA admitted the Ellsberg profiling episode was “not our finest moment” (Martin-Joy 2020).

Yet, as the work of psychiatrist Jerrold Post (2002) shows, responsible profiling can be accomplished in a way that is both useful to the country and consistent with professionalism. As Post did, one can use interdisciplinary methods, sift evidence in light of theories of political leadership, and acknowledge that respect for public figures sometimes conflicts with concerns about public safety. Only then can one make an informed choice.

In my view, it is unethical for a psychiatrist to lie, to twist evidence, or to make slipshod comments or impressionistic slurs on public figures they dislike or with whom they disagree. But when a psychiatrist believes the public’s safety is at stake and then uses evidence responsibly to make her case, her good faith comments about a public figure’s mental health should be respected, debated, and if necessary, disagreed with—but not condemned as grossly unethical.

There is a public interest at stake here. As James Madison once wrote, a popular government “without popular information…is but a Prologue to a Farce or a Tragedy; or perhaps both.”

John Martin-Joy is a psychiatrist in private practice in Cambridge, Massachusetts. He is a fourth-year candidate at the Boston Psychoanalytic Society and Institute (BPSI) and the author of Diagnosing from a Distance (Cambridge University Press, 2020) and the Psychology Today blog “Politics, Psychiatry, and Psychoanalysis.” Twitter: @Johnmartinjoy

References

American Psychiatric Association: The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2013. Accessed February 26, 2017, at https://www.psychiatry.org/psychiatrists/practice/ethics/.

Appelbaum. Paul S. (2017). Reflections on the Goldwater Rule. J Am Acad Psychiatry Law 45(2):228-232. Accessed on March 18, 2021, at http://jaapl.org/content/45/2/228.

Bell, David A. (2020). Men on Horseback: The Power of Charisma in the Age of Revolution. New York: Farrar, Straus and Giroux.

Erikson, Erik H. (1974). Dimensions of a New Identity: The 1973 Jefferson Lectures in the Humanities. New York: Norton.

Greenblatt, Stephen (2018). Tyrant: Shakespeare on Politics. New York: Norton.

Kernberg, Otto F. (1997). Ideology and Bureaucracy as Social Defenses Against Aggression. In Edward R. Shapiro, ed., The Inner World in the Outer World: Psychoanalytic Perspectives (New Haven: Yale University Press), pp. 97-121.

Lee, Bandy X., ed. (2017). The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. New York: St. Martin’s Press.

Lee, Bandy X. (2021). Psychiatrists’ Responsibility to Society: Rethinking the Goldwater Rule. The Rule of Law Post.org, blog of the Center for Ethics and the Rule of Law, University of Pennsylvania.

Martin-Joy, John (2020). Diagnosing from a Distance: Debates over Libel Law, Media and Psychiatric Ethics from Barry Goldwater to Donald Trump (Cambridge University Press, 2020).