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The New England Journal of Medicine (N. Engl. J. Med. eller NEJM) är en engelskspråkig medicinsk tidskrift som är referentgranskad och som publiceras av Massachusetts Medical Society. Det är den äldsta kontinuerligt utgivna medicinska tidskriften i världen och är den mest lästa, citerade och inflytelserika allmänna medicinska tidskriften i världen.
Perspective
President Trump’s Mental Health — Is It Morally Permissible for Psychiatrists to Comment?
December 27, 2017DOI: 10.1056/NEJMp1714828
Ralph Northam, a pediatric neurologist who was recently elected governor of Virginia, distinguished himself during the gubernatorial race by calling President Donald Trump a “narcissistic maniac.” Northam drew criticism for using medical diagnostic terminology to denounce a political figure, though he defended the terminology as “medically correct.”The term isn’t medically correct — “maniac” has not been a medical term for well over a century — but Northam’s use of it in either medical or political contexts would not be considered unethical by his professional peers.
For psychiatrists, however, the situation is different, which is why many psychiatrists and other mental health professionals have refrained from speculating about Trump’s mental health. But in October, psychiatrist Bandy Lee published a collection of essays written largely by mental health professionals who believe that their training and expertise compel them to warn the public of the dangers they see in Trump’s psychology. The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President rejects the position of the American Psychiatric Association (APA) that psychiatrists should never offer diagnostic opinions about persons they have not personally examined. Past APA president Jeffrey Lieberman has written in Psychiatric Newsthat the book is “not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous tabloid psychiatry.” I believe it shouldn’t be dismissed so quickly.
To understand why thoughtful, experienced, well-meaning mental health professionals would be condemned by their professional association leadership, one needs to understand the history of the Goldwater rule. U.S. psychiatrists follow the same code of ethics as other physicians, the Principles of Medical Ethics articulated by the American Medical Association (AMA). Section 7 of that code reads, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”3The point of Section 7 is that all physicians have a duty to promote public health and safety. The AMA principle does not specifically commit physicians to whistle-blowing or impose a “duty to warn” of the sort Lee and her colleagues take themselves to have, but presumably it commits a physician with a concern about local environmental pollutants, safety in schools, infectious disease transmission, or other public dangers to notifying others of the risk. Protecting public health and safety is part of the ethical commitment we make as physicians.
In 1973, the APA convened an ethics committee for the first time and charged it with annotating the AMA ethics code with considerations uniquely relevant to psychiatric practice. Part of the impetus for these annotations was the APA’s embarrassment in 1964, after Fact magazine published an informal survey of psychiatrists’ opinions about the mental stability of presidential candidate Barry Goldwater, who, among other concerns, had made radical statements about the use of nuclear weapons. The “Goldwater rule” is Section 7.3 of the APA ethics code, one annotation of Section 7 of the AMA code. It specifies that “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.”4For a few decades, the Goldwater rule received almost no attention in the professional literature — the Fact embarrassment was long past by the time the annotation was published, and the threat of nuclear war had receded from public awareness. Psychiatrists who spoke to the press about mass shooters, erratic artists, and other public figures simply issued disclaimers such as “I haven’t examined this person” and then went ahead and made their remarks.
The relevance of the Goldwater rule has spiked in the past 2 years in the setting of Trump’s candidacy and now presidency. There are good reasons to respect the intention of Section 7.3. Most psychiatrists want to teach the public about the myriad presentations of mental illness and character pathology and not to oversimplify, stigmatize, promote stereotypes, or disparage the persons whose mental health we work to improve. We believe that people with mental illness can flourish and contribute to our communities, and on the flip side, we do not assume that everyone who behaves erratically or earns public disapprobation is mentally ill. Most psychiatrists do not think we have superpowers that let us know the inner thoughts and psychological workings of strangers. Section 7.3 reminds us to remain humble about the claims we can reasonably make and to present ourselves responsibly for the sake of our patients and our profession.
Increasingly, however, some psychiatrists are expressing professional concern about Trump’s public remarks and behaviors and what they mean for public safety. Lee and her coauthors clearly take themselves to be fulfilling the moral obligation of Section 7 by using their specific expertise as mental health professionals.
The Goldwater rule, like the other APA annotations, is meant to clarify a principle of medical ethics, not contradict it. Yet in March 2017, shortly after Trump’s presidential inauguration, the APA broadened the rule to apply to “any opinion on 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”— an expansion that would silence psychiatrists who want to honor the moral obligation of Section 7 by educating the public about the dangers they see in Trump’s psychology. The problem is that psychiatric diagnostic terminology has been colloquialized, so the public and the press use it to describe Trump, but when a psychiatrist does so, use of the same words is considered to be a formal diagnosis (at least in the eyes of the APA). As a result, psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.
The Dangerous Case of Donald Trump challenges the APA position that a psychiatrist cannot know enough about a person she has not interviewed to formulate a diagnostic impression. Contrary to the APA, a physician who has not formally evaluated a patient is not making a diagnosis in the medical sense, but rather using diagnostic speculation and terminology informally, with the benefit of education. That characterization applies to the orthopedist or physical medicine specialist speculating on the knee injury of the football player limping off the field and the dermatologist wincing at a stranger’s melanoma in the grocery line as well as to the psychiatrist interpreting Trump’s public statements. Physicians don’t stop knowing what we know when we leave the clinic. Psychiatric terminology has become part of the common parlance, and the authors in Dangerous Case describe and define that terminology much better than, say, Ralph Northam. The question is whether psychiatrists are the ones we should hear it from.
I expect that the APA will denounce and dismiss this book and its authors, but I encourage others not to do so. Dangerous Case is unapologetically provocative and political, and the authors clearly take themselves to be contributing to the improvement of the community and the betterment of public health, as the AMA (and APA) principles of medical ethics direct. Dangerous Case will have supporters and detractors for good reasons — some political, some social, some psychiatric — that have much more to do with views of Trump’s mental health than with the Goldwater rule. I believe that the APA, in the interest of promoting public health and safety, should encourage rather than silence the debate the book generates. And it should take caution not to enforce an annotation that undermines the overriding public health and safety mandate that applies to all physicians. Standards of professional ethics and professionalism change with time and circumstance, and psychiatry’s reaction to one misstep in 1964 should not entail another in 2017.
