The ethics of public diagnosis

Is it ever appropriate for doctors to comment openly on the mental health of well-known individuals?

Even when we aren’t in active clinical mode, doctors can’t entirely switch off the professional part of our brains. Many of us will have noted a person with a particular gait on the street and almost automatically worked through possible diagnoses. But, outside of a clinical setting, we certainly wouldn’t engage with someone we don’t know to confirm our conclusion.

I’m sure that I am not alone amongst readers in wondering about the health of President Donald Trump, based on his media appearances and social media comments. And just as in the case of the person with an abnormal gait whom we observe on the street, we keep these thoughts to ourselves. But is it ever appropriate for doctors to comment on a president’s mental health, or that of other public figures?

While heads of state are entitled to medical confidentiality, their decisions can have far-reaching consequences. This raises the question of whether professional barriers against public commentary should sometimes be set aside. The ethical tensions involved were examined in a recent opinion piece in the British Medical Journal by Consultant Neurologist David Nicholl and Professor of Primary Care Trish Greenhalgh.

They note that professional standards generally prohibit clinicians from offering diagnoses without direct assessment. And they advise strongly against attempts to diagnose specific conditions on the basis of media reports or publicly available material.

However, the authors distinguish between making a diagnosis and expressing broader “clinically informed concerns”. They refer to how, in 2016, three academic psychiatrists wrote to the then President Barack Obama, raising concerns about President-elect Donald Trump’s mental fitness for the role.

The 2016 correspondence stated: “Professional standards do not permit us to venture a diagnosis for a public figure whom we have not personally evaluated.”

However, the psychiatrists noted that reported features of Trump’s personality indicated that an “impartial” medical assessment was an urgent priority. Nicholl and Greenhalgh agree that such an assessment remains an appropriate course of action.

In the US, the ‘Goldwater Rule’ is an ethical standard established by the American Psychiatric Association (APA) in 1973, which outlines limits on what psychiatrists can publicly say about the mental health of well-known individuals. The rule takes its name from events during the 1964 presidential race involving Barry Goldwater, the Republican nominee who ran against Democrat Lyndon Johnson.

In the lead-up to the election, Fact magazine released findings from a survey in which psychiatrists were asked, “Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” Slightly less than half of the 2,400 respondents indicated that they believed he was not. Following publication, Goldwater brought a defamation case against the magazine and won, with the publication ultimately being held liable for damages.

The APA had already raised concerns about the survey before its release and later formalised the Goldwater rule within section 7.3 of its ‘Principles of Medical Ethics’. This provision states that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement”.

Perhaps not unexpectedly, the original guideline has become misconstrued. It was intended as a principle and a matter of professional judgement, rather than an absolute prohibition, according to Dr Allen Dyer, Professor of Psychiatry and Behavioural Sciences, George Washington University School of Medicine and Health Services, US.

“With regard to Goldwater and Trump, way down deep there is general agreement that public statements should be made carefully and cautiously…,” Dyer wrote in 2020. “Professionals, for good reason, try to remain above politics, to hold principle above expediency.”

Commenting on the intricacies of the Goldwater Rule, Nicholl and Greenhalgh point out that it is possible to be mentally ill and still fit to hold public office and not to be mentally ill and unfit for such a role.

But they also note that concerns about Trump’s health now relate to his alleged cognitive decline. They quote from a number of media reports that suggest the possibility of this decline.

However, the authors “caution strongly against making the diagnosis of a defined cognitive condition on the basis of media clips and we offer no clinical comment on statements made by doctors who have attempted to do so”.

They conclude by advising that doctors exercise caution and humility when engaging in debate about the health of public figures.