Hindsight is 2020: Revising Goldwater in the Trump Era
President Trump addressing service members stationed in South Korea on June 30th, 2019. Photo by U.S. Air Force.
“You really want to know what I consider ideal company?” “A total piece of ass.”
This is Donald Trump, in an interview for the New Yorker in the 1990s, when asked by journalist Mark Singer if he considers himself ideal company.
Frustrated by this nonchalant answer, Singer concludes that Trump “does not have an interior life… [he lives] an existence unmolested by the rumbling of a soul.”
The Trump persona
Politicians, late-night show hosts, and news commentators across the political spectrum have all widely debated if Trump is mentally fit to be president. Crucially, many of these speculations cast doubt over Trump’s mental health, and whether he is capable of filling the most powerful shoes in the world.
His constant one-eighties on issues ranging from foreign policy to the legitimacy of the recent Black Lives Matter protests, coupled with his tendency to personally attack those members of his own staff that act out, makes one wonder just how much Trump thinks before he acts, and whether his behavior can perhaps be explained. These questions lead to even more worrying thoughts. Should we have trusted him in the first place? Can we trust him now with a global pandemic and impending recession?
Knowing how divisive the question of Trump’s fitness to serve is, we can reasonably ask ourselves whether we should even debate his mental health at all. What can professionals tell us that won’t devolve into a political ‘he said, she said’ debate? If this sounds familiar, it’s because it is. Republicans have long spun concerns about Trump’s mental health as Democratic propaganda and chosen to defend Trump and his voter base at every turn. Instead, they rationalize Trump’s behavior as part of some unknown and calculated agenda. For example, Trump’s long-time friend Thomas J. Barrack Jr, described Trump’s seemingly flighty staff as “management by controlled and orchestrated chaos.”
In his 2018 book Fire and Fury: Inside the Trump White House, journalist Michael Wolff describes the relationship between the president and his staff with great detail, demonstrating how they have internalized Barrack’s explanation of Trump’s leadership. Wolff writes that Trump “viewed each member of his inner circle as a problem child whose fate he held in his hand” suggesting he truly didn’t value them as team members. Wolff further highlights the chaotic power dynamics between Trump and staff by revealing that some staff feel they serve “at the president’s displeasure” and one even views their relationship as similar to God’s with sinners.
When responding to the book’s negative depictions of White House life, senior policy adviser Stephen Miller referred to this mythical ‘Trump’ persona, asserting that Wolff had completely misunderstood the president and that “the reality is, the president is a political genius.”
These different perceptions of Trump highlight that neither side is able to fully understand, much less explain the president’s behavior and thought process. Instead the Democrats tautologically refer to his ‘persona,’ or places the behavior in the context of some vague political agenda. HMoreover, accepting his turnarounds as evidence of him ‘simply being himself’ adds no explanation or analytical value to the discussion. Clearly, those already involved in the public debate are unequipped to deal with behaviors as mind-boggling as Trump’s and are merely attempting to explain behavior they themselves do not understand.
This is where I believe those most experienced in matters of the mind could contribute to the discourse surrounding Trump’s behavior. Theologian Joyce Ann Mercer best explains this when she argues that the input a professional contributes to the national discussion is crucial in allowing the voting public to discern between ‘unusual’ and ‘malignant’ behavior. She emphasizes “it can be very helpful to hear an expert say that the reason something seems odd is that it is odd.” The line between eccentric behavior and symptoms of potential mental illness is a fine one— and one we, the uninformed public, need psychiatrists in particular to identify for us. Some opinions are irreplaceable, meaning psychiatrists have at least a prima facie argument in favor of entering the political arena.
Why, then, do we not see prominent professionals invited onto late night shows or cable news? The answer lies in the Goldwater Rule.
The Goldwater Rule: the biggest loser
To understand why those who know best may not speak out, we must go back to 1964.
1964. The year of the Tokyo Summer Olympics, Beatlemania, the Civil Rights Act… the Goldwater-Johnson presidential election. Democratic nominee Lyndon B. Johnson, having assumed office after the asassination of President John F. Kennedy in 1963 was the incumbent running against Republican nominee Senator Barry Goldwater of Arizona. Goldwater was the rising underdog. Having been in office for nearly a decade, Goldwater’s views were conservative even compared to fellow Republicans at the time; he saw the Civil Rights Act as an egregious overextension of federal power, was known for his militant approach to anti-communism, and was feared for his aggressive containment strategy for Asia, which many felt might result in nuclear war.
These political beliefs led many to question Goldwater’s fitness for office— none more vocal than critic Ralph Ginzburg, publisher and editor of the left-leaning Fact magazine. Prior to the 1964 election, the magazine had mailed questionnaires to over 12,000 psychiatrists, receiving responses from 2,417, of whom 1,819 declared Goldwater mentally unfit for the presidency. Within these 1,819 responses, respective diagnoses ranged widely from schizophrenia to delusional disorder. This was printed in a special issue of the magazine, and was accompanied by an article contending that Goldwater was mentally unstable, and therefore unfit to be president.
Goldwater brought a civil suit against Mr. Ginzburg for defamation as libel, alleging that the magazine had published “false, scandalous, and defamatory statements referring to and concerning [the] plaintiff.” Taking the stand, Goldwater defended himself as a well-adjusted man whose views were rational and not symptomatic of mental illness. Additionally, he successfully challenged Mr. Ginzburg’s assertions that he and his wife had suffered several ‘nervous breakdowns’ - a term that Mr. Ginzburg himself admitted “may mean many things”, and had not been properly investigated by his journalistic team. Goldwater further strengthened his case by bringing forth several witnesses ranging from life-long friends to colleagues, all of whom testified that they had never witnessed such ‘nervous breakdowns’ or similar concerning behavior related to his mental fitness.
The U.S. District Court awarded $1 in punitive damages, and $75,000 (half a million dollars today) in compensatory damages. Ginzburg’s appeals to the Court of Appeals and Supreme Court were rejected, although an interesting twist was presented when the Supreme Court’s rejection of the writ was accompanied by a dissenting opinion, penned by Justices Hugo Black and William O. Douglas. In this dissenting opinion, the Justices foreshadowed future criticisms of the judgment’s impact on mental health professionals:
“In our times, the person who holds that high office has an almost unbounded power for good or evil. The public has an unqualified right to have the character and fitness of anyone who aspires to the Presidency held up for the closest scrutiny.”
Although this reply by the Justices holds no legal value, it is important to note that concerns about psychiatrists’ ability to exercise their right to freedom of speech existed from the beginning. The Justices feared that this judgement, if taken too far, would effectively silence an entire profession whose inputs strengthen the public’s “unqualified right” to understand a candidate’s character and fitness.
Criticisms notwithstanding, the American Psychiatric Association (APA) crystallised the original judgement in Rule 7.3 of their first-ever code of ethics, now known as the ‘Goldwater Rule’. Per Rule 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.”
Consequently, if a psychiatrist wishes to discuss his or her general qualifications, and promote their profession, they can do so. However, to go further and provide professional opinions on behavior or comments made by a public official, as was the case of Goldwater, would be unethical, and could result in a formal warning from the APA (if the psychiatrist was affiliated). Although this may sound like a slap on the wrist, the stigma that comes with an ethical reprimand essentially stalls or even ends the professional’s career. Thus, although Goldwater lost his election, he cleared the field by immunizing future public officials and keeping mental health out of the public arena.
After Trump announced his campaign in 2015, psychiatrists were wrought by internal discord: some felt their ethical obligations should come second to a higher duty to inform the voting public on their opinions, whereas others believed such outspokenness would lead to a political weaponization of psychiatry. The APA responded to this controversy by doubling down and expanding the Goldwater Rule: it now applies not only to diagnoses, but also to “an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry.” In a video with Vox, Yale University professor and psychiatrist Bandy X. Lee described this as a “gag rule”.
What are the dangers of keeping the rule, as opposed to abolishing it?
The most obvious effect of the rule is that it leaves space for potentially unprofessional and more politicised discussions. Descriptors such as ‘narcissist’, ‘insane’, and ‘psychotic’ are, for liberal commentators, almost synonymous with Trump’s leadership style. The issue is that these descriptions have taken the place of any formal discussion of Trump’s mental health, and that such indictments of his character have been issued by late night hosts and politicians – none of whom are qualified to make such evaluations.
Furthermore, related to the Goldwater Rule, some fear that abolishing it will only further confuse the public – what do we do if professionals cannot agree on a single diagnosis for a public official? Again, this fear ignores the fact that professional disagreement is already present within the mental health profession, and particularly so in criminal trials, where each side provides a different account of the defendant’s state of mind, or personality. Oscillating between two extremes – the voting public can either have all the professional information, including disagreements, or none – implies only two nuclear options exist, resulting in a black-or-white fallacy. There is no admission that perhaps some information can be given by professionals that might inform the average voter without conclusively deciding their vote.
Lastly, there is a genuine fear that armchair diagnoses will only further stigmatize mental health. As Dan P. McAdams wrote in The Strange Case of Donald J. Trump, his profound fear is that an abolishment of the Goldwater Rule will lead to candidates in later elections hiring teams of mental health professionals who will purposefully diagnose the opponent, thus dooming his campaign. Although he agrees that professionals ought to contribute to the national discussion, he is wary of the potential weaponization for political gains – thus further entrenching the idea that mental illness is an anomaly that ultimately defines an individual.
Reframing the Rule
Now that we have dealt with the main arguments in favor of maintaining the status quo, we must then consider what we are losing through the Rule’s continued application. Three issues arise. Firstly, the Rule is premised upon the assumption that a direct interview will give the professional irreplaceable insights that will greatly impact public opinion. Secondly, the fact that educated professionals are not allowed to use their expertise to weigh in on issues of national importance does a disservice to the voting public, and limits psychiatrists’ right to freedom of speech. Thirdly, this limited national discussion impedes the potential operation of the Twenty-fifth Amendment.
In my analytic sections, I will propose that a reformed Rule be implemented, whereby psychiatrists will not face ethical and professional repercussions should they choose to assess public officials, as long as this assessment falls short of deciding fitness for office.
The ‘interview illusion’
The Goldwater Rule presumes that a psychiatrist will only be able to diagnose an individual after having interviewed him. In an interview with National Public Radio, Columbia Professor of Psychiatry Paul Appelbaum argued that the interview allowed the professional to identify “constellations of pathological symptoms that might constitute a syndrome… None of that is discernible by watching somebody on TV or reading what they have to say in the newspaper.” This certainly coincides with our general understanding of how important an in-person evaluation is. An in-person evaluation would be needed before the doctor could reach any valuable conclusion.
The issue with this instinctive reliance on the interview is that there is little evidence to support the proposition that an interview can replace all other observations. Generally, clinical interviews directed by physicians are unstructured, as the flow is seen to help the interviewer glean the most information about how the individual behaves and feels about his behavior. This results in a lack of standardised criteria and questions. In a 2018 review of the scientific literature underpinning this ‘illusion’, psychologists Scott O. Lilienfeld, Joshua D. Miller, and Donald R. Lynam challenged the ‘interview illusion’ on three grounds.
Firstly, a diagnosis of personality disorders, in particular, requires both pervasiveness and temporal persistence: symptoms of the disorder must be everywhere, for a long time. A single interview will therefore never be enough for a valid diagnosis, as the physician will be unable to really pinpoint the wide variety of behaviors (such as lack of empathy, a grandiose sense of self-importance, and opportunistic tendencies) through one discussion. Even if he were to achieve this gargantuan task, it would likely be rendered more difficult by the interviewee’s defensiveness, cognitive bias, and poor memory.
Secondly, unreliable interviewing methods will only be exacerbated in ‘high stakes’ or ‘strong’ situations – such as a psychiatric evaluation for suitability for office. Essentially, any reasonable politician (with or without a mental illness) would likely understand how to behave such that the psychiatrist would find him fit for office. This pressure would likely lead the candidate to occlude and moderate any perceivably extreme behaviors – meaning that any interview required by the Goldwater Rule would be diagnostically worthless.
Lastly, it would be unrealistic to expect an interviewer to be completely impartial. If we can imagine Trump undergoing a psychiatric evaluation for his 2020 electoral campaign, we would be hard-pressed to find a psychiatrist who hasn’t heard of his scandals or has a strong political opinion of him. This knowledge alone of Trump’s behavior could reasonably drive the psychiatrist to focus on certain symptoms indicative of some personality disorders, over others, such as focussing on symptoms indicative of paranoia over those indicating memory loss. As a result, some diagnoses are completely overlooked.
Consequently, the Goldwater Rule is based on the false premise that an interview can provide all, or extra, information that might lead to a more valuable (and more ethical) diagnosis.
Moving forward
Should the Rule be reformed, a professional should be able to assess a public official they have not examined, though only if two conditions are met. Firstly, the professional must have examined a sufficient and sufficiently wide variety of materials before giving the assessment. Secondly, the professional must steer clear of discussing whether this assessment has any implications on fitness for office.
I use the term ‘assessment’ instead of ‘diagnosis’ on purpose: the word creates the illusion that one either ‘has’ or ‘does not have’ a certain mental illness when the reality is that even the most serious disorders operate on a spectrum. An assessment amounts to a nuanced psychological profile and allows for the voter to come to his or her own decision regarding whether such behaviors warrant questioning the official’s fitness for office or not. In fact, in the world of medical diagnoses (which include psychological/psychiatric ones), an assessment merely relates to the “process of gathering and evaluating data” - although some conclusions can be made, no single piece of evidence is eliminated during this process. This assessment is usually the basis for the final diagnosis - a step professionals should steer clear from when it comes to public officials they have not obtained consent from.
Such an assessment should be possible without a direct interview, given the wealth of information publicly available recording the public official’s behavior across a variety of situations. The requirement of an interview for public engagement is even mooter when we consider that what psychiatrists would be providing are not diagnoses, but ‘assessments’ amounting to psychological profiles - something psychiatrists have already been commissioned by the government to do with regards to leaders of terrorist organizations. Why should it be any different when applied to American public figures?
Therefore, a psychiatrist should move forward, be able to provide assessments of public officials even without having interviewed them, as such a process would make use of the information available to the general public anyway, as well as get rid of what seems to be a problematic and diagnostically futile requirement. The second prong of the test - just what the psychiatrist should be telling the public - will be addressed in the next section, after outlining the ‘duty’ argument.
The duty
The second argument in favor of reforming the Goldwater Rule is its potentially harmful effect on the First Amendment. This is further highlighted by the fact that no equivalent to the Goldwater Rule exists for other professions. Economists, lawyers, and political scientists often weigh in on issues of public policy and face no repercussions.
Exception notwithstanding, what circumstances might allow for a psychiatrist to override the Goldwater Rule and exercise their First Amendment right?
Bandy X Lee’s 2017 book, The Dangerous Case of Donald Trump provides an unorthodox way of sidestepping the Goldwater Rule, and looks at the ethical dilemma facing psychiatrists as one of preventing ‘dangerous’ public officials from assuming office. Written in conjunction with 27 other mental health professionals, the book acts as a warning to scientists who stay silent during difficult times. Lee’s ‘duty to warn’ has some legal footing in the 1976 Tarasoff decision by the Supreme Court of California, which holds that psychiatrists have a duty to warn third parties if their patient shows a reasonable intent to commit violence unto them. By analogy, the voting public would be the psychiatrist’s ‘third party’, and the official their ‘patient’.
However, valid criticisms have been posited: the official is clearly not a patient by virtue of never having been interviewed and diagnosed, so the Tarasoff analogy dies there. Additionally, there is confusion as to what ‘dangerousness’ means. It holds no real value in psychiatry, as it does not constitute an independent diagnosis, and is particularly susceptible to political leanings and whims: what might be ‘dangerous’ to a Republican psychiatrist might not be termed as such by a Democrat. Additionally, I believe this ‘duty to warn’ wades into very murky waters: terming a politician ‘dangerous’ to others – and especially being termed as such by a professional – renders the question of fitness for office a moot point. Imagine seeing an exclusive report, where a psychiatrist comes onto a major network because they have a ‘duty to warn’ the public of an official’s ‘dangerousness’ - upon hearing this, the majority of the public could reasonably write that official off completely, all because of a vague, diagnostically worthless opinion. This would clearly be a latent misuse of the professional’s expertise.
The second approach posited by Dr. Lilienfeld is more restrained: instead of an urgent ‘duty to warn’ that contains an inherent discussion of fitness for office, Dr. Lilienfeld draws an analogy between a psychiatrist’s role in the national discussion, and the role a professional plays in determining a defendant’s insanity in a criminal trial, arriving at a ‘duty to inform’.
In a criminal trial, an expert’s contribution is strictly limited to the determination of the defendant’s state of mind. The eventual determination is left to the judge and jury, and respects the notion that legal sanity is only informed by professionals, not adjudicated by them. Similarly, Dr. Lilienfeld argues that professionals owe the voting public a duty to inform in cases where there is ample evidence indicating a public official suffers from a mental illness. However, the mental health professional’s assessment should end there: there should be no discussion about whether this mental illness (or lack thereof) renders the official unsuitable for office. This limited ‘duty to inform’ therefore grants the voting public access to professional information, as well as to an explanation for potentially odd behaviors, without deciding the question for them.
Know thy limits
The second prong of my proposed test is that the psychiatrist’s ‘assessment’ steer clear of deciding whether such a psychiatric profile would affect the public official’s tenure in office. The limits of this engagement clearly echo Dr. Lilienfeld’s analogy with expert witnesses’ role in a criminal trial. This limited approach has three advantages over the ‘duty’ approach to public engagement.
Firstly, a fair assessment would not attract complaints of unethical behavior by the APA, and a deterrent against flippant assessments would exist in the fact that the psychiatrist could leave themselves open to potential civil lawsuits for negligence or defamation, a limit imposed upon all who contribute to the public debate on public officials. The limitations I propose echo Dr. Lilienfeld’s ‘limited duty to inform’ and imitates the role experts play in criminal trials.
Secondly, it would not be susceptible to potential weaponization by politicians. If we can imagine a mental health professional ‘assessing’ his employer’s political opponent and concluding that the official suffers from a major depressive disorder, the psychiatrist’s First Amendment right to freedom of speech would not protect such a malicious statement. The psychiatrist would remain open to a civil claim in defamation, a claim where one of the performative remedies is the issuance of a public apology reneging the defamatory ‘assessment’. Thus, the fair assessment strikes the right balance between a ‘wild west’ rife with flippant diagnoses, and a gag rule – all whilst still protecting the professional’s First Amendment right.
Thirdly, the reformed Rule would not impose some fictitious ‘duty’ to inform or warn the public: its continued application would normalize professionals’ presence in the public sphere. The absence of some formless ‘duty’ hanging over the professional’s head has the added benefit of simplifying the debate on when professionals should speak out.
End of the line: the Twenty-fifth Amendment
Some professionals have suggested an altogether more covert route: introducing the professional opinion only in situations when the Twenty-fifth Amendment is in question. In particular, Section 4 of the Twenty-fifth Amendment states that the Vice President can, in conjunction with other members of the executive branch and a majority in Congress, declare the President “unable to discharge the powers and duties of his office.” This declaration would have the effect of making Mike Pence, the current Vice President, Acting President whilst Trump remained in office but stripped of all authority.
This is the only section of the Amendment that has never been invoked, though it was considered in 1987, during Ronald Reagan’s presidency, and in response to his apparent inattention and ineptitude. Considering Reagan was diagnosed with Alzheimer’s disease five years after leaving office, with early signs being apparent in the late 1980s, this concern was not unfounded. In 2017, after Trump fired FBI director James Comey, acting FBI director Andrew McCabe apparently held secret discussions about approaching Vice President Mike Pence to plan a possible Section 4 declaration. Again, such concerns were not unfounded: Trump had just fired the neutral arbitrator leading an investigation on potential Russian intervention in a national election.
Clearly the Twenty-fifth Amendment ought not to be taken lightly. Consequently, it can be argued that the constitutional duties that would befall a psychiatrist brought in to diagnose the President would clearly override the Goldwater Rule, or at least meet its requirements of an in-person interview and subsequent consent (by the President, or by Congress if the President is unable to grant consent) to divulge its results.
Standardized capacity
A second, wholly separate solution, would be to incorporate an independent capacity test for cognitive competence into any examination that a public official must take before assuming office. This has previously been suggested by Dr. Bandy X. Lee, though support for this measure has fallen along partisan lines: editor Elaine Godfrey of The Atlantic reported that “the number of congressional Democrats interested in hearing from Lee appear[ed] to be growing,” whereas “congressional Republicans ha[dn’t] shown the same interest.” The benefit of such a test would standardize all aspects of fitness for office and would provide a benchmark against which any consideration of the Twenty-fifth Amendment could be measured.
Its disadvantage is merely the climate in which it has been suggested: a bipartisan bill implementing such measures seems unlikely, meaning that such a step forward cannot be expected before the 2020 election. As such, it remains a potential long-term solution that entrenches the professional’s role in what is ultimately a question of mental health as defining fitness for office.
Final thoughts
The overwhelming evidence against the rule’s most basic assumption – that an interview is necessary – as well as the lack of strong arguments supporting the Rule’s continuing application (i.e. the politicization of mental health and denigration of the profession) mean that the rule must be reformed and replaced by a better balance between professional ethics, and valuable contributions to the national discussion. Instead, we should allow those who know best to speak out and discuss behaviors if they are symptomatic of certain illnesses, though in a way that clearly shows that the ultimate decision of whether to vote for the candidate or not, lies forever with the public. In doing so, we would be strengthening not only the professional’s First Amendment right but also the quality of the voting public’s voice, as well as the health of the democracy.
One clear counterargument is the concern that by discussing the mental health of public officials, psychiatrists will, if anything, further stigmatize mental health, and push the issue back another 20 or 30 years. Politicians will be less outspoken about their past struggles, and the entire point will recede into the darkness of private circles and rumor mills. This is a valid concern and one that will likely not be addressed in the short-term.
However, the pressure and fear of such a thorny issue should not deter the citizenry from tackling it in the first place. Mental health has been politicized and misconstrued in the absence of informed contributions by mental health professionals. By stubbornly doubling down on its defensive stance, the APA has ensured that the Goldwater Rule has outlived its purpose: the profession’s enduring silence even in the face of clearly unsettling behavior exhibited by the most powerful man in the world has undermined the public’s understanding of mental health, and psychiatrists’ ethics - the two very things the Rule had been created to protect.
Although the stigma surrounding mental health is sure to continue for the foreseeable future, normalizing such inputs from mental health professionals will not only allow for the official’s personality and mental health to become just one aspect of their presence and campaign but would also elevate the level of discussion on this topic as a whole. In my opinion, the public’s short-term ignorance and potential misuse of the professional opinions doled out for voters to consider is a price worth paying, if the result is a better-informed public and long-term awareness of mental health.
Reforming the Goldwater Rule into a guideline permitting engagement with the voting public on issues professionals understand best is a smart way forward. Not only would this bring the profession in line with others, but it would also add to the country’s deliberative democracy. Perhaps by reintroducing professionals to the equation, we may finally move beyond partisan explanations, and get closer to understanding just who Trump really is.
Matilde Masetti-Placci is a rising final year law student at University College London. Sadly, you won’t find her on campus, but you’re welcome to email her to chat about American and English law, politics, and literature.
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