Psychiatrists’ responsibility to society: Rethinking the Goldwater Rule

The opinions expressed in this post are those of the author.

As the United States exceeded a COVID-19 death toll of 500,000, the Lancet Commission on Public Policy and Health in the Trump Era released a report estimating that 40% of these deaths were avoidable. What the Lancet report outlined after the fact was exactly what mental health experts had anticipated before the fact. Since late January 2020, my colleagues at the World Mental Health Coalition and I declared that a large portion of deaths from COVID-19 would be attributable to then-president Donald Trump’s mental state rather than the characteristics of the virus. By March 2020, we issued a “Prescription for Survival,” urging that without removal of the president or at least his influence there would be an unacceptable loss of life. Indeed, since late 2016, we stated that faced with a crisis Donald Trump would disastrously mismanage it as president and vastly increase its consequences.

These projections and warnings, despite their accuracy and importance, were denounced by the American Psychiatric Association (APA). In fact, the APA intercepted any professional public input with its “Goldwater Rule,” which restricts diagnosis of public figures without an examination and authorization. The apparent prioritization of “the rule”—in quotes because it is supposed to be a guiding principle, not a rule—over all other societal obligations is alarming and should not go unchallenged by members of the psychiatric profession. The APA’s dereliction of duty should lead all mental health experts to ask: What are our priorities?

Clarity of Priorities

Medical students are taught the ultimate litmus test: to ask the question, “How does it help the patient?” The code of medical ethics stipulates that “a physician must recognize responsibility to patients first and foremost, as well as to society.” A physician’s responsibility does not explicitly extend to public figures, however. But the courtesies that are shown to public figures in fact begs the question: How does keeping silent about a dangerous public figure help society?

An analogy comes to mind. A surgeon asks her colleague, “How did the operation go?” The colleague answers, “It was a wonderful success. The patient died, but the surgery was a wonderful success.” Myopic focus on technical adherence alone was responsible for many egregious breaches of medical ethics in history, which indeed led to the Declaration of Geneva in 1948. Should members of the psychiatric profession feel proud to have impeccably adhered to a rule even though public health was harmed?

Questions like these plagued me throughout the Trump presidency, enough to organize an ethics conference at Yale School of Medicine in April 2017, which brought together some of the top minds in the field. Later that year, I edited The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President containing multiple essays devoted to ethics. What troubled me was not that we should be cautious when speaking about public figures—which I agreed with and adhered to for over 20 years—but that the APA modified a “rule” to create a gag order in March 2017 shortly after Trump’s inauguration. Professional ethics are supposed to be science- and practice-based, not modified to suit political convenience.

Principles, Not Rules

Within three months of the publication of The Dangerous Case of Donald Trump, an unprecedented New York Times bestseller of its kind, the president’s mental health had become the number one topic of national conversation. But the APA intervened aggressively and decisively, denouncing me and my fellow authors as “armchair psychiatrists” who used “psychiatry as a political tool” for “self-aggrandizing purposes.” We went from being invited to all the major news programs and receiving congressional support of our activities to being blocked altogether, notably at a time when Trump had yet to consolidate his cult of personality, when the media were actively inviting us, and when the public was highly receptive. By falsely attributing motives to us without an examination and without consent, the APA even broke its own gag order on public figures. Yet we believed ourselves to be in keeping with the original Goldwater Rule by refraining from diagnosis or any other assessment for which we did not have sufficient information—a stark contrast to past APA officers, including one who made a very detailed diagnosis and another who cleared the president of specific diagnoses (also a form of diagnosis). There was not a word of response from the APA about these actual diagnoses, likely because they benefited the president.

One of the most consequential breaches of ethics by the APA was to encourage the public’s conflation of public health with patient care, and the informing of dangers with diagnosing. Internally, it tried to create an ethical guideline without exceptions and without a countervailing rule (if there were instances where speech is restricted on public figures, should there not be instances, such as danger to the public, where speech is obligated?). Externally, it promoted public ignorance, making courtesy to a public figure the equivalent of patient confidentiality. It further stigmatized psychiatry, excepting it from all other fields and medical specialties. By turning a reasonable guideline into a gag order, the APA was in fact preventing us from fulfilling our most basic public health duty.

Professionals, Not Technicians

In this era when political pressures can easily distort perceptions of what is right, mental health experts must be vigilant against becoming technicians rather than thinking professionals. In order to combat the aforementioned trends of politicization, I propose returning to the Declaration of Geneva, a universal physician’s pledge adopted by the World Medical Association 25 years before the Goldwater rule. Instituted after the Nazi regime’s medical crimes were uncovered, the pledge clarifies that the priorities of medicine are humanitarianism, prevention of harm, and social justice. Either silence or cooperation with a destructive government would violate this pledge. Another guiding principle should be the one the Goldwater Rule itself falls under: “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” This context places the rule as an affirmative obligation, not just a prohibition.

The APA acted inappropriately when it used its membership rule to convince media organizations not to air mental health experts instead of pursuing legitimate investigations and taking appropriate disciplinary action, neither of which has been done. Notably, the APA has disproportionately gained more funds and privileges from the Trump administration when compared to other scientific and medical institutions during the same period and compared to its previous record. There is a wider issue than psychiatry at stake: if independent, professionally-trained experts cannot share their knowledge with the public, then a crucial check on powerful political figures is lost, and a society becomes conditioned for tyranny.

Bandy X. Lee, M.D., M.Div., is a forensic psychiatrist and violence expert who taught at Yale School of Medicine and Yale Law School for 17 years. She is president of the World Mental Health Coalition, a professional organization that assembles mental health experts to collaborate with other disciplines for the betterment of public mental health. She also served as a research fellow at the National Institute of Mental Health and consultant to the World Health Organization. She is the author of the textbook, Violence (Wiley-Blackwell, 2019), edited The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President (Macmillan, 2017 and 2019), and authored Profile of a Nation: Trump’s Mind, America’s Soul (World Mental Health Coalition, 2020). Twitter: @BandyXLee1

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