Lingering Questions Prompt 'Goldwater Rule' Evaluation

Psychiatrist Richard Friedman, M.D., revisited the Goldwater Rule and its implications in an article in the September 17 Journal of the American Medical Association. Friedman told Psychiatric News he was motivated by publicity surrounding the resignation of New York Gov. Elliot Spitzer following revelations of his involvement with prostitutes.

“There were a lot of mental health professionals, mostly psychologists, theorizing and speculating about the motivations for [Spitzer's] behavior,” Friedman said. “It caused me to think, What is the sensible and ethical thing for a psychiatrist to say publicly about public figures that he or she doesn't know?

“Often it just looks silly or ridiculous,” he continued.“ On the other hand, just because you haven't examined someone doesn't mean you have to be quiet. You might have something valuable to say, and to withhold it would be a public disservice.”

He is a professor of psychiatry at Weill Cornell Medical College.

Friedman illustrated the distinction in his JAMA article.“ [A] mental health professional commenting on former Gov. Spitzer's actions would be free to speak generally about psychological principles that help the public understand his behavior,” Friedman wrote. “The psychiatrist only needs to indicate that he or she has no professional relationship with the public figure and is not making a diagnosis. Thus, it would be unethical for a psychiatrist to say that Spitzer had a narcissistic personality disorder, which is a diagnosis, but would be permissible to discuss the psychology and symptoms of narcissism in general; the public could then decide whether the information applies to the given individual.”

The line is not a bright one. “I think it's kind of hazy,” Friedman said. “But guidelines have to be somewhat inexact since you can't possibly think of every possibility, and it's better than having nothing at all.”

“As in so many things, it's at the extremes that the line is brightest,” said Appelbaum. “When you get to the gray zone in the middle, it gets a little fuzzier. I would agree with Dr. Friedman that it is entirely appropriate for psychiatrists to speak publicly about mental health disorders or personality traits and the effects these can have on behavior. What's important in those cases is to make clear one is not commenting on a particular person. It's all too easy for a general comment made in the context of a public figure's behavior to be seen as a comment on that case.”

The distinction is made more difficult in the case of psychiatrists who have made the study of political leaders a scholarly endeavor.

“Whenever I have discussed the work I do that is at the core of my career, everyone agrees it is ethical and valuable,” said Jerrold Post, M.D., a professor of psychiatry, political psychology, and international affairs at George Washington University. “But if you took very literally the language of APA's ethics code, it veers perilously close to being in violation.”

Post has confined his work to psychological profiles of leaders of other countries and does not comment on American political figures. He is also the author of “Ethical Considerations in Psychiatric Profiling of Political Figures,” which appeared in the September 2002 Psychiatric Clinics of North America in an issue themed “Ehics in Psychiatry.”

It was Post who famously delivered Congressional testimony in the early 1990s profiling former Iraqi dictator Saddam Hussein as a malignant narcissist; he was criticized by some but has steadfastly maintained the value of his assessment.

“I am confident from the feedback I have had that my clarification was useful to Congress and to the public at large,” he told Psychiatric News.

“In my own view, one does need to be careful and mindful of the reputation of American psychiatry and the potential influence such commentary can have on that reputation,” Post said. “Having said that, I think there are occasions when our expertise can usefully contribute to public understanding. I worry that there are occasions when some of us who follow these matters closely may be inhibited at times when we might have something useful to contribute.”

There is enough disagreement about where exactly to draw the line and how brightly to paint it that a Board of Trustees Task Force to Update the Ethics Annotation has discussed a revision. In part, the draft revision reads as follows: “For some in our profession, psychiatry can extend beyond the physician-patient relationship into the broader domain of public relations: in administration, politics, the courtroom, the media, and the Internet.”

The draft also states, “In some circumstances, such as academic scholarship about figures of historical importance, provisional diagnostic evaluations may be made and should be subject to peer review and academic scrutiny based on relevant standards of scholarship.”

Richard Milone, M.D., a member of the task force, emphasized that the revision is only in draft form and has no effective force without being approved by the Assembly and the Board. But he said he believes that, if passed, it would encompass the kind of work that Post does.

“It enlarges the Goldwater Rule by making allowance for individuals who are doing scholarly research and for true psycho-historians and psycho-biographers,” he said.

Still, opinion about revising the code is sharply divided.

“It's fair to say there are members who feel strongly both that the provision should remain exactly as is and that it ought to be changed at the very least to allow more clearly for scholarly endeavors,” said Appelbaum. “I lean toward the latter position, but I'm not sure it will be at all easy to find a formulation that would clearly define what is acceptable and what is not.”

“Role of Physicians and Mental Health Professionals in Discussions of Public Figures” is posted at<http://jama.ama-assn.org/cgi/content/full/300/11/1348>.▪