Can a politician's mental fitness for office be diagnosed from afar?

It was a presidential election year. A magazine called "Fact" had reached out to all 12,356 members of the American Psychiatric Association (APA) about the Republican presidential candidate, who hailed from the party's extreme right-wing and was intensely disliked by liberals. Of the 2,417 psychiatrists who responded, nearly half said the Republican nominee was psychologically unfit to be president (1,189), with the rest split almost evenly between saying that he was fit (657) and demurring altogether (571). Even though this means that fewer than 10 percent of the APA members actually denounced the Republican candidate as mentally unfit for office, the ones who did so used such colorful and memorable language that it made headlines. To understand way, simply look at one one of the quotes from the anti-Goldwater psychiatrists:

"He is a mass-murderer at heart and ... a dangerous lunatic. ... Any psychiatrist who does not agree with the above is himself psychologically unfit to be a psychiatrist."

While one might imagine those words being written about former President Donald Trump, their actual target was Sen. Barry Goldwater of Arizona, who ran in the 1964 election against President Lyndon Johnson. Even though the Johnson-Goldwater contest happened nearly six decades ago, Americans are still living with the ramifications of these psychiatrists' public statements. For one thing, it will never be clear if they contributed to his landslide defeat; that said, Goldwater eventually sued Fact magazine for defamation and won, achieving an important symbolic victory over the liberal media outlets that had attacked him. Even before Goldwater's legal victory, however, the APA released a new rule — later dubbed "the Goldwater Rule" — which prohibits psychiatrists from publicly commenting on an individual unless they have previously performed a "thorough clinical examination" on them as a patient.

In theory, the Goldwater Rule stops psychiatrists from abusing the public's trust by misleadingly presenting subjective partisan opinions as objective medical information. Yet a bipartisan case could be made that the Goldwater Rule is out-of-date. Many of Trump's critics claim that the Republican shows signs of narcissism and serious psychological diseases, while President Joe Biden's opponents often accuse him of dementia and other cognitive disorders. Few medical experts would argue that it is appropriate for laypeople like pundits to diagnose politicians — but does that mean mental health professionals should not be able to offer informed observations?

"In my opinion, it is irresponsible for mental health professionals not to inform the public and initiation discussion regarding concerns based upon objective facts (not speculation)."

Salon spoke with five mental health experts on this subject. Only one of them, psychiatrist Dr. Paul S. Applebaum from Columbia University, offered an unqualified endorsement of the Goldwater Rule.

"The Goldwater Rule is relevant today for the same reasons it was relevant when it was adopted," Applebaum told Salon by email. "Psychiatrists (the only mental health professionals technically covered by the Rule) are not capable of rendering accurate diagnoses in the absence of a personal examination; doing so risks dissemination of inaccurate information that can harm the person supposedly being diagnosed; and this kind of 'shoot-from-the-hip' approach to diagnosis can legitimately call into question the objectivity and responsibility of the psychiatric profession, thus deterring patients from seeking care."

The other four mental health professionals were highly critical of the Goldwater Rule, albeit in varying degrees and by raising different points.

"The problem with the Goldwater rule is that it arose out of a political compromise," explained psychiatrist Dr. Bandy Lee, who was fired from Yale University in 2020 for making public statements about Trump's mental health and the president's first impeachment lawyer, Alan Dershowitz. Lee pointed out that only a small percentage of the APA psychiatrists from 1964 responded to the "Fact" questionnaire, which most had identified as sketchy and unreliable, and that the APA's motives for creating the new rule were not as pure as they might want people to believe.

"Instead of keeping the professional world separate from the sensational, the American Psychiatric Association capitulated when the highly political — and mostly discredited for being overtly Republican — American Medical Association pressured it to respond," Lee explained. "This is how the APA became the only mental health association, probably in the world, to have the Goldwater Rule — a 'rule' that violates the Geneva Declaration and most other core tenets of medical ethics. So I believe it should either be radically modified or be eliminated," since there is a clear public interest in allowing psychiatric professionals to express grounded concerns.

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"Of interest to the public are fitness and dangerousness, and these are different mental health assessments than diagnosis," Lee pointed out. "Given the dangers of unfitness in an influential office, it should be one of the most vital societal responsibilities for health professionals to point this out, in order to protect the public's health and safety."

Lee also noted how she had experienced adverse career consequences as a result of the Goldwater Rule — namely, her firing from Yale — and described this as "exemplary of the current authoritarian trend of silencing whistleblowers and truthtellers," which was particularly ironic given that Lee says she was not part of the APA at the time.

In a similar vein Dr. Jerome Kroll, a professor of psychiatry emeritus at the University of Minnesota Twin Cities, also characterized the Goldwater Rule as oppressive to psychiatric professionals.

"What psychiatrists owe their patients (confidentiality, respect, thoughtfulness, technical knowledge) has nothing to do with offering public comments about a public figure about whom there is a controversy," Kroll wrote to Salon. "I see this as an issue of free speech, which often leads to ill-advised, divisive, even stupid statements, but not to an ethical breach of my professional responsibilities. A court of law can determine my liability if the person commented on takes offense."

"I see this as an issue of free speech, which often leads to ill-advised, divisive, even stupid statements, but not to an ethical breach of my professional responsibilities."

Kroll added, "Those psychiatrists who think the Goldwater Rule is just incorrect and self-serving think that the APA leadership have no special expertise in ethical issues and no mandate to intrude upon Article I of the Bill of Rights."

Kroll also drew attention to how the APA seems to not entirely comprehend how day-to-day psychiatrists do their jobs. The Goldwater Rule deems things like an "in-person interview" and "obtaining a 'full' psychiatric history and medical report" as essential to making informed psychiatric observations, yet "celebrity persons reveal much about themselves, whereas regular patients can and do often withhold important information (for various reasons) from their doctors." In both this way and others, the notion that a doctor must physically meet someone and know them "fully" to make an accurate assessment flies in the face of doctors' real-world experiences.

"Doctors in emergency rooms frequently have to make rapid diagnoses and important decisions of persons they have never seen before, have little reliable information, no previous records, and no reliable way to evaluate the accuracy of the person they are assessing," Kroll pointed out. "Yet they have to assign a working diagnosis and a treatment plan, such as involuntary admission to a psychiatric ward, on just a few salient features of the interviewed person. This is accepted and ethical practice for doing all this; there is no luxury of delay in the ER, other than perhaps an overnight stay for observation. The APA leadership just ignores these realities of daily work of psychiatrists."

When psychologist Dr. Ramani Durvasula explained to Salon why she thinks the Goldwater Rule "tends to be overinterpreted," the professor of psychology and expert on narcissistic personality disorder and narcissistic abuse also detailed how the rule contradicts the realities of life in the medical profession.

"I think back to graduate school when we were regularly tested and did case conferences on the basis of cases we would read and then provide diagnostic hypotheses on — so we were reading about behavior, history etc and formulating a hypothesis," Durvasula recalled. "This was an anonymous or fictional person, but I was in fact drawing a diagnostic hypothesis on someone without having treated or evaluated them (which are the assumptions of the Goldwater Rule)." In Durvasula's point-of-view, that example from our education system illustrates how modern approaches to the Goldwater Rule take a potentially admirable impulse and move it too far in one direction.

"If a person is in the public eye and we are able to observe their behavior, their use of language, their appearance, and also have other historical data on them (past behavior, shifts from past behavior) — while I acknowledge that it is only the publicly facing behavior we are seeing — is it any different than a client coming in and telling us only what they tell us and leaving out what they want to leave out?" Durvasula asked.

"The right way to think about the Trump presidency was not to focus on the individual, as the APA did, but on the larger cultural phenomenon of his rise, what it indicated, and what it would do psychologically to larger society if we continued to allow it."

Dr. David Reiss, a psychiatrist and expert in mental fitness evaluations who along with Lee contributed to the book "The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President," likewise told Salon by email that he believes the Goldwater Rule "definitely should be reformed." While he acknowledged that there are good reasons to apply some limits on what mental health professionals can publicly say about public figures, the Goldwater Rule "is at least out of date – and in my opinion, was never well conceived." If nothing else, it does nothing to distinguish between attacking a politician's policy views by calling them mentally ill — which Reiss agreed would be unprofessional and unethical — and clinical observations that are not only medically valid, but also can be serious enough to warrant the public being made aware of them.

"A psychiatrically-impaired POTUS is capable of doing so much harm," Reiss told Salon. "In my opinion, it is irresponsible for mental health professionals not to inform the public and initiation discussion regarding concerns based upon objective facts (not speculation)."

Indeed, Lee believe that already happened in the case of Trump.

"Everything we predicted happened, with the exact severity and the precise time course we estimated," Lee told Salon. "This should not be surprising, since it is our area of scientific and clinical training. The right way to think about the Trump presidency was not to focus on the individual, as the APA did, but on the larger cultural phenomenon of his rise, what it indicated, and what it would do psychologically to larger society if we continued to allow it."

Because Trump is running for president again, his mental health will once more become a focal point of public attention. Yet there are also public concerns about Biden's mental fitness, and while some of that criticism may be dismissed as ageism, many believe there are legitimate concerns.

"I have not personally seen (observed) any statements or behaviors by Biden that suggest cognitive impairment (including when I personally met and spoke with Biden, on a totally non-clinical basis, prior to his election)," Reiss wrote to Salon. "It is well known that Biden has had a life-long stutter – which has often been the basis for speculation about 'cognitive impairment.'" At the same time, Reiss also said that regardless of a president's party, all aspiring POTUSes should receive a "medical and cognitive Fitness-for-Duty" evaluation. Lee also supports that kind of testing.

"If basic mental fitness tests for presidents and presidential candidates were impossible to implement, then at least we should be able to inform the electorate on the basic principles of mental health — for the public to be able to protect itself — but mental health experts were muzzled and excluded from public discourse in order to placate the then-president," Lee explained.