Episode 218: Where Psychiatry Meets Politics: The Goldwater Rule

Mark Mullen, M.D., David Puder, M.D.

Introduction

An informed electorate is crucial to a functioning democratic process. Citizens have a crucial interest in understanding how political candidates approach decision making. Such decision making is informed by the values and policies that are espoused by candidates during political campaigns, but are also affected by individual factors relating to a particular candidate. For example, voters may want to know to what degree a candidate is able to understand factual information and appreciate how that information applies to a particular context (two tenets of decisional capacity). Psychiatrists are professionally trained to evaluate such functions, and thus may be called upon to render relevant professional opinions in the political sphere.

There is an extensive history of psychiatry and politics intersecting. Perhaps the most visible flashpoint occurred during the 1964 presidential campaign and gave rise to a movement in organized psychiatry that has resulted in issuance of formal ethical guidance (the “Goldwater Rule”). Such guidance continues to inform psychiatry’s approach to politics today. In this podcast, we will:

1. Orient listeners to the history of ethical guidelines for psychiatrists providing professional opinions on political candidates, commonly referred to as the “Goldwater Rule.”

2. Review the American Psychiatric Association’s justification and rationale for the Goldwater Rule.

3. Discuss common critiques of the Goldwater Rule.

History Of The Goldwater Rule

The 1964 presidential election featured Senator Barry Goldwater running against incumbent President Lyndon B. Johnson. Goldwater was a United States senator from Arizona, a World War II pilot, and a major general in the Air Force Reserve. Goldwater rose to national prominence after authoring a best-selling book, The Conscience of a Conservative (1960).

During the run-up to the 1964 presidential election, a periodical called Fact Magazine published what it touted as “the most intensive character analysis ever made of a living human being,” with Barry Goldwater as the subject. In addition to a narrative analysis of Goldwater’s psychology authored by the magazine’s editor, Ralph Ginzburgh, Fact surveyed American psychiatrists and published the results.

Fact mailed a survey to 12,356 board-certified psychiatrists containing a single question: “Do you think that Barry Goldwater is psychologically fit to serve as President of the United States?” Prior to reading the survey question, respondents read a synopsis of Goldwater written by Fact which referenced his “public temper tantrums,” “occasional outbursts of profanity,” and two alleged “nervous breakdowns” (which were later denied by Goldwater and his family). Fact received 2,417 responses and published 41 pages of excerpts.

A plurality of survey respondents opined that Goldwater was “psychologically unfit” to be president: 1,189 said he was unfit, 657 said he was fit, and 571 declined to weigh in. The responses were impressive. Published excerpts included:

• “Barry Goldwater’s mental instability stems from the fact that his father was a Jew while his mother was a Protestant.” 

• “I believe Goldwater has the same pathological make-up as Hitler, Castro, Stalin and other known schizophrenic leaders.” 

• “From TV appearances it is apparent that Goldwater hates and fears his wife.” 

• “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.”

• An “anal character”  

• A “counterfeit figure of a masculine man”  

• “Dangerous lunatic” 

• “Has a grandiose manner” and “Godlike self-image”  

• “Stronger identification to his mother than to his father”

President Johnson won the election in a landslide. Senator Goldwater then sued the editors of Fact for defamation and libel. Goldwater won the lawsuit after a jury agreed that the defendants knew they were publishing defamatory statements and “were motivated by actual malice when they published the statements.” Goldwater was awarded $75,000 in damages.

Goldwater was able to win the defamation lawsuit by demonstrating the following elements necessary for such a case:

• False Statement of Fact: The defendants made numerous statements about Goldwater’s mental health and character that were false.

• Publication: These false statements were widely disseminated through the publication of Fact Magazine.

• Identification: The statements were clearly about Barry Goldwater, making it easy to identify him as the subject of the defamatory remarks.

• Harm: The defamatory statements caused harm to Goldwater’s reputation, affecting his public image and potentially his political career.

• Fault: As a public figure, Goldwater had to prove “actual malice,” which means that the defendants either knew the statements were false or acted with reckless disregard for the truth. The jury found that Fact Magazine and its editor were indeed motivated by actual malice.

The American Psychiatric Association and the Goldwater Rule

The American Psychiatric Association (APA), the professional organization for psychiatrists in the United States, was not pleased with the Fact Magazine piece. The president and medical director of the APA immediately wrote to Fact: “By attaching the stigma of extreme political partisanship to the psychiatric profession as a whole in the heated climate of the current political campaign, Fact has, in effect, administered a low blow to all who would advance the treatment and care of the mentally ill of America.”

The APA then created section 7.3 of “The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.” This section of the ethical guidelines is colloquially referred to as the “Goldwater Rule.” It reads: “On occasion, psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, 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.” 

It is important to contextualize the Goldwater Rule in this document. The two sections preceding it encourage psychiatrists to engage in public activity, whereas the Goldwater Rule sets limits on this engagement. This creates a tension that has been the source of eternal discussion. Section 7.1 reads, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” Section 7.2 reads, “Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness...Psychiatrists shall always be mindful of their separate roles as dedicated citizens and as experts in psychological medicine.”

Justification and Rationale

The American Psychiatric Association has intermittently produced media clarifying and supporting the Goldwater Rule over the last 5 decades. One of the most recent clarifications came from an APA Ethics Committee Opinion in 2017, which outlined a basic rationale for the guidance. We will consider 3 justifications:

1. Consent or authorization

1. It is a fundamental principle of medicine that physicians practice under informed consent. Thus, a psychiatric evaluation requires consent or authorization, and the relationship between a physician (psychiatrist) and a patient is one of mutual consent or understanding.

2. There are some notable examples in psychiatry where it is practiced without consent, for example in forensic evaluations. In such circumstances, psychiatrists are permitted to evaluate individuals based on other authorization, such as a court order.

3. It follows that psychiatrists are ethically prohibited from evaluating individuals without consent or authorization.

2. Standard of care

1. A comprehensive psychiatric interview is the gold standard for psychiatric diagnosis. Physical examination, collateral information, and other sources are important, but are not commensurate with the standard of care.

2. It is a departure from the methods of the profession to render an opinion without an examination and evaluation. Such behavior compromises the integrity of the psychiatrist and of the profession itself.

3. Stigma

1. Offering opinions without consent, authorization, or an evaluation has the potential to stigmatize those with mental illness. Patients may experience increased stigma about their own mental health problems.

2. Patients may wonder about the rigor and integrity of their own clinical care.

3. In most violations of the Goldwater Rule, psychiatric opinions are used to treat a political candidate as “other” or “less than,” thus using the powers of the psychiatric profession not to heal a suffering individual but to argue against one’s abilities.

Common Critiques Of The Goldwater Rule

The Goldwater Rule has been controversial since its inception, with one APA board member who voted against the rule opining that it is “a denial of free speech and of every psychiatrist’s God-given right to make a fool of himself or herself.” The critiques of the Goldwater Rule are virtually endless, and it is a topic about which reasonable people can certainly disagree. It is also a topic where one’s position is particularly vulnerable to bias, given that our pre-existing political opinions and values clash directly with professional objectivity. We will briefly summarize three common critiques: 

1. Freedom of speech

1. The “Goldwater Rule” impinges on an individual’s freedom of speech as it pertains to personal duty and civic responsibility. This is particularly problematic as political speech is a form of speech that should be most fiercely protected. Should a professional organization really be able to require psychiatrists to prioritize professional identity over personal conscience?

2. Aren’t psychiatrists uniquely qualified to be offering such opinions, especially if the conversation is already happening in the media? Withholding opinions from the most qualified professionals leads to a less well-informed, less robust public conversation.

3. The APA has responded that this freedom of speech argument “Confuses the personal and professional roles of the psychiatrist.”

2. Standard of care

1. Psychiatrists are sometimes asked to render opinions without conducting an examination of an individual. This happens in collaborative care models, forensic cases (recent Depp v. Heard trial as an example), and in psychological profiling – all of which are approved by the APA to a greater or lesser extent. So why can some psychiatrists offer these opinions in some contexts, but it is unethical to do so in other cases?

2. It is important to note that in the above cases, there is consent or authorization for the professional opinion. Additionally, when such opinions are rendered they must include the evaluative framework, parameters for how and where the information can be used. These opinions must clearly identify the methods used and the limitations of the methods—that is, they must acknowledge the lack of a comprehensive evaluation.

3. Duty to warn

1. In matters of national/international security, psychiatrists are uniquely situated to identify psychopathology and we have a duty to warn the public about dangerous individuals.

2. This critique is the cited justification for psychological profiling performed by APA members on world leaders. Jerrold Post’s profile of Saddam Hussein is a relevant example.

3. The APA has responded that “this position is a misapplication of the Tarasoff doctrine.” The Tarasoff doctrine only applies when a psychiatrist is providing treatment or evaluation of an individual, and offers crucial guidance for psychiatrists on when confidentiality should be violated. Additionally, for information in the public domain it is not the role of an individual psychiatrist to protect the public—there are law enforcement agencies that have access to greater information, are better equipped to address these threats, and are specifically tasked with doing so. 

1. It’s important to note that the duty to warn varies significantly across states. For instance, California imposes a mandatory duty to protect, requiring mental health professionals to take steps like notifying potential victims or law enforcement. Conversely, states like Florida do not impose a legal duty to warn unless the threat is specific and identifiable. 

4. Relevance Kroll, J., Pouncey, C. (2016). The Ethics of APA’s Goldwater Rule. J Am Acad Psychiatry Law. 

1. The Goldwater Rule is not consistently enforced. Is it fair or relevant to have such rules if the enforcement mechanisms are vanishingly ineffective?

2. The volume of information, disinformation, and misinformation has increased by orders of magnitude since 1964. Does this change the stakes? In 2024, everyone can instantaneously share public opinions accessible worldwide... except psychiatrists. Is this fair?

Conclusion

The Goldwater Rule offers important ethical guidance for psychiatric professionals who are trying to determine how best to interface with questions at the intersection of psychiatry and politics. The rule has been firmly supported by the APA for five decades, but has been strongly critiqued since its inception. Each psychiatric professional must decide for themselves how best to answer these important political and moral questions, but should be advised that deviation from the ethical standards of psychiatry may come with consequences. We must also consider the legal consequences of defamation and how this might apply if comments against a public persona are both false and also with malice. We hope this episode helps you consider both sides of the argument and deepen your understanding of the overall dynamics that might unfold if the rule were to go away. 

References:

American Psychiatric Association (APA). APA Ethics Committee Opinion. March 15, 2017. https://www.psychiatry.org/news-room/news-releases/apa-reaffirms-support-for-goldwater-rule

Blotcky, A., Pies, R., Moffic, H. (2022). The Goldwater Rule is Fine, if Refined. Here’s How to Do it. Psychiatric Times, (3)1. https://www.psychiatrictimes.com/view/the-goldwater-rule-is-fine-if-refined-here-s-how-to-do-it-

Brendel, R. (2017, July 20). The Goldwater Rule is Still Relevant. Psychiatric Times. https://www.psychiatrictimes.com/view/goldwater-rule-still-relevant

Buckner, C.  (2021, March 23). Former Professor Says Yale Fired Her Over Tweet on Trump, Dershowitz. Yale Daily News Blog. https://yaledailynews.com/blog/2021/03/23/former-professor-says-yale-fired-her-over-tweet-on-trump-dershowitz/

Burks, E. (1968, May 28). Goldwater Wins $75,000 in Libel Action. New York Times. https://www.nytimes.com/1968/05/25/archives/goldwater-awarded-75000-in-damages-in-his-suit-for-libel-goldwater.html

CBC Radio. (2018, Jan. 12). Psychiatrist’s New Warning That Trump’s Mental State Is a National and International Security Risk. Quirks & Quarks - CBC Radio. https://www.cbc.ca/radio/quirks/science-explains-when-to-visit-the-hospital-answer-emails-psychiatrist-s-new-warning-on-trump-s-mental-state-1.4480633/psychiatrist-s-new-warning-that-trump-s-mental-state-is-a-national-and-international-security-risk-1.4480637

Ginzberg, R. The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater. Fact 1(5). 

Frances, A. (2017, Feb. 14). An Eminent Psychiatrist Demurs on Trump’s Mental State. The New York Times. Opinion. https://www.nytimes.com/2017/02/14/opinion/an-eminent-psychiatrist-demurs-on-trumps-mental-state.html

Glass, L (2017, Jan. 20). Dealing with American Psychiatry’s Gag Rule. Psychiatric Times. https://www.psychiatrictimes.com/view/dealing-american-psychiatrys-gag-rule

Grisso, T., Appelbaum, P. S. (1998). Assessing competence to consent to treatment: A guide for physicians and other health professionals. Oxford University Press, USA. https://doi.org/10.1093/oso/9780195103724.001.0001

Kroll, J., & Pouncey, C. (2016). The Ethics of APA’s Goldwater Rule. The Journal of the American Academy of Psychiatry and the Law, 44(2), 226–235. https://pubmed.ncbi.nlm.nih.gov/27236179/

Lee, B., Glass, L., Brown, L. (2017, April 23). Yale Psychiatrists Cite Duty to Warn About Unfit President. New York Magazine - Intelligencer. https://nymag.com/intelligencer/2017/04/yale-psychiatrists-cite-duty-to-warn-about-unfit-president.html

Martin-Joy, J. (2020). Diagnosing from a Distance: Debates over Libel Law, Media, and Psychiatric Ethics from Barry Goldwater to Donald Trump. Cambridge: Cambridge University Press. https://doi.org/10.1017/9781108761222