Appeal for Principle before Rule, and Uniform Application of Rules: A Case of Psychiatric Ethics


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Topic(s): Ethics Politics Privacy Psychiatric Ethics Public Health

by Bandy X. Lee, M.D., M.Div.

I am the editor of The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (Macmillan, 2017), which is intended as a public service. Even all the royalties are going into a fund for public good. Yet there has been harsh pushback, with Dr. Jeffrey Lieberman leading the effort, criticizing the book for making a public diagnosis (see, for example, his commentary in Psychiatric News.

Yet this is based on several misconceptions. Dr. Lieberman does not seem to recognize, for example, that we do not diagnose the president in the book (this is a common misunderstanding for those who have not read the book). In fact, he has demonstrated very little knowledge of what is in the book while calling it, “simply tawdry, indulgent, fatuous, tabloid psychiatry.”

We keep to the letter of the Goldwater rule, which directs psychiatrists to refrain from diagnosing public figures from afar but to educate about psychiatric issues in general when asked about such a figure. When we mention Mr. Trump, it is in keeping with the principle the Goldwater rule falls under: “to participate in activities contributing to … the betterment of public health” (Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, Section 7). We even restrict ourselves further by refraining from speaking about Mr. Trump except under an analogous concept of “duty to warn”—a standard of our profession that requires us to warn and to protect potential victims, including the public, about danger. We limit our reasoning to objectively observable speech and behavior that are highly associated with future danger in the literature and do not diagnose.

Interestingly, Dr. Lieberman himself speculates on Mr. Trump’s personal mental health in the popular magazine Vice and proposes a specific diagnosis, including the probable locus of defect. We ourselves certainly do not go this far in the book. Furthermore, while he has harshly criticized us, he has not made any comment about the blatant breach of the Goldwater rule by Dr. Allen Frances, who stated on multiple occasions while speaking to the media that Mr. Trump does not have narcissistic personality disorder.

Another way in which Dr. Lieberman has shown little knowledge of our book is the way he uses the same examples as we do to express the same concerns about the potential for abuse of psychiatry. In fact, on ethical principles alone, we arrive at the same conclusions and are in agreement. However, Dr. Lieberman confuses our educating and warning the public about matters of medical concern (that the issue happens to fall in the political realm is fortuitous, but there is no rule that the presidency should be immune) with political use of psychiatry. Still, he himself does not hesitate to comment on what is or is not appropriate for the 25th Amendment in the above said article.

My colleague Dr. James Gilligan (also an author in the book) and I, even as we have recently consulted with Congressional members at the invitation of a former assistant U.S. attorney, make clear that the 25th Amendment, or other political decisions, are not our area of expertise. Unlike Dr. Lieberman, we are forensic psychiatrists with experience in giving expert testimonies to state and city courts and governments, to foreign governments, and to the International Criminal Court of the Hague. Forensic psychiatrists are trained to maintain our neutrality, to avoid investment in specific judicial or political outcomes, and not to speak outside our area of expertise. When we offer our expertise in the political realm, it is “to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government” (Principles of Medical Ethics, Section 7.1—a rule that comes before the Goldwater rule).

Dr. Lieberman has likened our efforts to Nazi or Soviet misuse of psychiatry, but as Dr. Judith Herman and I discuss in our prologue, “Professions and Politics,” we caution about the American Psychiatric Association’s (APA’s) recent expansion of the Goldwater rule as potentially leaning in that direction. In March 2017, barely two months into the current administration, the APA announced an interpretation that is inconsistent with the way the rule is written in the code and contradicts the principles of medical ethics. More importantly, it was a dramatic reversal from the way it had been interpreting the rule in the past (the latest interpretation of the rule had been restricted to giving a specific diagnosis of a public figure to the media, in the midst of discussions about turning the rule into an etiquette or abolishing it altogether). Under the current interpretation, it is by fiat a gag rule, whereby psychiatrists are forbidden from making any comment on any aspect of a public figure’s speech or behavior, even in an emergency.

With permission of the editor _______________

Our warning is that the APA may be making an error akin to what the American Psychological Association did a decade ago when it modified its ethical guidelines under political pressure, to allow for torture during the Iraq War. Norms and standards should not change by political situation. As I am a strong proponent of the Goldwater rule, having kept to it even with minor public figures over my twenty-year career as a forensic psychiatrist (forensic psychiatrists are often asked by legal bodies to diagnose someone they have not seen), I am especially wary of modifying it under political pressure. Many are in agreement: at least several dozen members have resigned from the APA, which has been flooded with letters of protest for modifying an ethical rule without consulting its membership.

Misconceptions should be corrected, not fueled. When Dr. Lieberman invited himself as a speaker to my October 2017 talk at Weil-Cornell Medical College, against the organizers’ wishes and without notifying me, he was embarrassed for not knowing what was in the book. Multiple articles and public appearances later, there is still little evidence that he has read it. In some criticisms, he does not disclose that he is a past president of the APA. I have on multiple occasions tried to engage him privately or in a more nuanced debate without success. The misconceptions now seem to have influenced the APA’s recent call to end “armchair psychiatry” and the use of psychiatry for political or self-aggrandizing purposes, following Dr. Lieberman’s reasoning (while using Twitter to label me as “naive misguided,” “undistinguished”, and “pathetic”, he has stated: “maybe Dangerous Case will get her promoted”).

I and my colleagues in the National Coalition of Concerned Mental Health Experts, now numbering in the thousands, are concerned that these actions are silencing debate. We know from history that silence can be as serious a form of complicity as active cooperation with a dangerous regime, which led to the World Medical Association’s Declaration of Geneva. This universal declaration clarified the humanitarian goals of medicine shortly after the experience of silence on the part of psychiatrists and active participation on the part of other doctors assisted some of the worst atrocities under Nazism.

We are taking considerable risks to act on the belief that we have an affirmative duty to warn the public when our leaders, who have access to the ultimate weapons, appear to be psychologically disturbed. We do not believe that alerting the public about the information they need to know to further their safety and wellbeing is afoul of ethical guidelines. To impose silence through a radical modification of a previously reasonable rule (as a rule without limits is no ethical rule) and to restrict our ability to function as “witnessing professionals,” as Dr. Robert Jay Lifton describes us in the book, impairs our ability to serve the highest principles of medical ethics.

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