What a Psychiatrist Won’t Tell You About the Candidates

Why the Goldwater Rule Gags Psychiatrists

News clipping about Goldwater libel suit (top left), Goldwater for President poster (bottom left) and APA President-Elect Maria A. Oquendo, M.D. (right).  Photo credit: Google News Archive, Goldwater for President 1964 / Wikimedia and American Psychiatric Association
Reading Time: 10 minutes

In 1964 over 1,200 psychiatrists passed judgment on Barry Goldwater’s mental health and fitness for the presidency. Goldwater sued for libel and won.

In 1973 the American Psychiatric Association (APA) adopted the Goldwater Rule, which prohibits its members from offering opinions on the mental health of anyone they have not personally evaluated.

In this week’s podcast, WhoWhatWhy’s Jeff Schechtman talks to the president of the APA, Dr. Maria Oquendo, about this rule and why so much attention is being focused on it right now.

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Jeff Schechtman: Welcome to the program. I’m Jeff Schechtman.

Usually when we conflate talk of politics with talk about mental health, it’s usually about public policy. It’s about federal or state dollars for mental health programs, about mental health coverage and the Affordable Care Act, or some other related issue. It’s rare that talk turns to politics, politicians and their mental health. Nonetheless it does happen. It’s happened during some bruising battles in early American history and then again in 1964, and now in 2016. Those two campaigns are connected by what the American Psychiatric Association calls: The Goldwater Rule. Joining me to talk about what this is and what it means for popular discussion of the mental wellbeing of candidates is my guest Dr. Maria Oquendo. She’s the president of the American Psychiatric Association. She’s soon to be the new chair of the Department of Psychiatry in the Pearlman School of Medicine at the University of Pennsylvania, she’s currently on the faculty of Columbia University where she’s vice chair for education and director of residency training for the New York State Psychiatric Institute. She’s an international leader in the treatment to neurobiology of mood disorders with a special focus on suicide and global mental health. It is my honor to welcome Dr. Maria Oquendo to Radio Whowhatwhy. Dr. Oquendo, thanks so much for joining us.

Dr. Oquendo: Thank you so much, it’s a pleasure.

Jeff Schechtman: First of all, tell us what the Goldwater Rule is and how it evolved within the ranks of the American Psychiatric Association.

Dr. Oquendo: So the Goldwater Rule essentially provides guidance to psychiatrists about ethical approaches to dealing with information that’s available publicly on people who are in the news, if you will. And so the idea is that for an individual psychiatrist to make a comment about a person’s mental health, they must have examined that person themselves, personally, and that making diagnoses without the benefit of an examination is not really ethical. One of the things this stems from is, as you mentioned, in 1964 when Barry Goldwater was running for president, there was a survey conducted asking psychiatrists whether they thought Mr. Goldwater was fit to be president. And many psychiatrists stated that they thought that he was not and on the heels of that, Mr. Goldwater sued for libel and won. Although it was started by this very sort of sentinel event, with a lawsuit that was very visible and a lot of discourse, really if you take a few steps back and think about why it makes sense to have a rule like this, it becomes apparent very quickly, and maybe I could just give you a couple of examples. For example, although abnormal behavior may be due to a psychiatric condition, often times it’s due to other things. One example is, for example if a person has a very high blood sugar, they might develop very abnormal behavior and that behavior will go back to normal if the sugar is normalized. If you just observe the behavior, you would have no way of knowing that this was actually secondary to diabetes, for example, and you could actually make a very life threatening mistake by calling something a psychiatric condition when in fact you have a medical emergency on your hands. So that’s just one example of the kinds of problems that can come up if you try to diagnose simply based on behavior without the benefit of an examination, not only of the person’s mental status but also of their physical condition.

Jeff Schechtman: It seems that the key word in this is the word “diagnosis”. Is there a difference of kind or substance between a psychiatrist saying that so and so exhibits behavior that might be outside some kind of prescribed norm as opposed to making an actual diagnosis?

Dr. Oquendo: Psychiatrists like everyone else can make observations about behavior, but I think that it crosses the line when you start saying that an individual who you have not examined has features of a diagnosis or has a diagnosis. And one of the things that I think is very interesting about this polemic is that there’s been this idea that psychiatrists have an obligation to speak up to protect the public, but in fact, really, the behavior is evident for everyone to see. Especially in a situation for example, like an electoral situation like we had in 1964 and now, the citizens can observe the behavior and make their decisions based on the behavior that’s being manifest. In fact, what the underlying cause of it is isn’t all that relevant to the decision that they have to take.

Jeff Schechtman: The very fact that this issue has come up and that you felt the need to write something about it in the blog of the American Psychiatric Association, what does that tell us about what’s going on right now that there’s a need to revisit this Goldwater Rule?

Dr. Oquendo: Well, I think that we’ve seen that there are many conversations going on including amongst clinicians about diagnoses for the candidates and when you start seeing that kind of conversation bubbling up, you want to make sure that certainly the individuals who are members of our association, psychiatrists and ethics bind us to a certain type of behavior even if it seems to others that we should be acting in a different way.

Jeff Schechtman: Talk a little bit about ethically, what’s required beyond the Goldwater Rule itself as it relates to the Association, talk about it from the individual ethics of a particular doctor.

Dr. Oquendo: So I’m glad you brought this up because I think that if you think about this a little more broadly, I like to think about psychiatry as a member of the house of medicine as we like to refer to it, right, so no different from internists, no different from surgeons who are unlikely to make a diagnosis without examining a patient. And in a way we’re in exactly the same kind of situation, not only because we could be wrong, and egregiously wrong, but the other issue that I think is implied is that perhaps if somebody has a psychiatric condition, it means by definition that they’re not fit to run or not fit to serve. And I would argue that that’s actually not correct because we do know that there are many people who have treatment for their psychiatric condition who have very important and responsible positions and do an excellent job. And so I think there’s also a subtle stigma that comes through in trying to view behavioral or psychiatric conditions under a different light than the way you would view a neurological condition or the way you would view a medical condition or a surgical condition.

Jeff Schechtman: Isn’t that stigma at the heart of this discussion really, because I think that if an internist or a candidate or a public figure or a CEO of a company is acting in a certain way, bent over or having to drink water a lot or whatever it might be, they would feel less restricted to offer an opinion as to what might be wrong or what the problem might be for that particular person, but because of this stigma that’s often associated with mental health and mental illness, it becomes a larger potential problem. Talk about that.

Dr. Oquendo: That’s a very interesting point. I actually am not aware of situations where physicians have made comments about somebody’s physical condition, but it may be just that I’m not aware. But I think it would be very unusual for that to happen.

Jeff Schechtman: We’ve had situations where… I mean we’ll use politicians for example, where they’re talking too much, they get hoarse or they’re coughing. People talked about it even with Reagan, after he was shot and how he was recovering and Eisenhower after he had a heart attack and doctors were frequently willing to chime in with respect to “well, he seems better, he seems like he’s fully recovered, he’s out playing golf,” he’s doing this, doing that. So there have been historical precedents where doctors have been willing to comment on the physical health of an elected official or a candidate. There seems to be a different set of rules or a different stigma, as I say, with respect to mental health.

Dr. Oquendo: Well, there’s no question that there is more stigma associated with mental health. I would argue that it would be most prudent for physicians not to make comments like that. In a particular sense, it’s very difficult to judge somebody’s health condition without the benefit of a thorough examination.

Jeff Schechtman: Back when this incident happened with respect to Goldwater, one of the things that I found shocking, I had no idea the number was so high, that there were over 1200 psychiatrists who participated in this.

Dr. Oquendo: Well, there actually are in our organization, we have 36,000 members and we think that probably the bulk of psychiatrists do belong to the organization, so there are a lot of psychiatrists out there. I think that the fact that individuals responded to the survey is of interest, if nothing else, in terms of the level of engagement with the survey because as you may know, response rates to surveys tend to be very, very low.

Jeff Schechtman: Talk a little bit about why it took so long, from 1964 until the Goldwater Rule was put in place in ’73.

Dr. Oquendo: That’s a very interesting question and I can’t say that I really understand the reason for that, but I think you’re right, it’s very interesting.

Jeff Schechtman: You touched on something before that I want to come back to a little bit and that is whether or not, if a doctor or psychiatrist sees something in the way of behavior in a public person, do they have any kind of broader obligation to say something, even if not publicly then maybe privately through other channels?

Dr. Oquendo: So this goes back to that point about whether psychiatrists have the duty to alert the public about a behavior that seems, quote, unquote, abnormal. And I think that the issue with making the statement in that particular way is related to the fact that if you have an abnormal behavior, we don’t know what the underlying cause is and it probably doesn’t take a psychiatrist to note that the behavior is abnormal. If it’s obvious from watching someone on television or reading about them in the newspaper or listening to on the radio, it really doesn’t take a psychiatrist to figure out wow, that’s not usual behavior. And so in a way I would argue that the psychiatrist has nothing to add given that they can examine the person and come to a diagnosis.

Jeff Schechtman: For individual psychiatrists that may go on television and say something or write an article or do a blog post or whatever, how is that looked on by the American Psychiatric Association? Are there sanctions? Are there reprimands? How is that dealt with?

Dr. Oquendo: Well, we strongly discourage our members from doing that.

Jeff Schechtman: But suppose they do. Just curious what the procedure, what the process is, if any.

Dr. Oquendo: Well, certainly we have a way of managing ethical breaches that can be activated if there is a complaint filed, for sure.

Jeff Schechtman: Have you seen any cases of this recently? Has this come up in an active way?

Dr. Oquendo: I’m not aware of any ethical complaints that have been filed at this time.

Jeff Schechtman: Talk a little bit about whether or not there has been pressure at all in this campaign season because all this is certainly talked about a lot. There has been pressure that really sort of bubbled to the surface, sort of encouraging you to talk about this Goldwater Rule at this point.

Dr. Oquendo: I would say that there has been some pressure and there’s a lot of attention and concern. Just today in the papers you could see that there’ve been even very senior people within the Republican Party making statements, and so whenever there’s a situation like that, you know that there’s going to be pressure on people who are specialists in behavior to render opinions, even though in our view it’s not ethical to do so.

Jeff Schechtman: What impact does all that have in a broader sense? What impact do you think that has on psychiatry in general, that you get so many people chiming in where everybody thinks they can offer an opinion?

Dr. Oquendo: I think that I would respond to this sort of on a slightly different tack by stating that for psychiatrists, once we start making armchair diagnoses, I think that our credibility is at risk and I think that making sure that we safeguard the credibility of the profession as a profession that sticks with facts and thorough information before rendering an opinion is very important. And in a way it’s kind of interesting because of course, if you were to do an examination of a particular individual, then you would be duty bound to actually keep their confidentiality, so you really could only reveal it if they gave you permission.

Jeff Schechtman: How do you view it when biographers of people, famous people – and they don’t necessarily have to be politicians – but when biographers engage in kind of armchair psychiatry in the context of doing detailed biographies of people? Is that something that the Association looks at as well, or thinks about?

Dr. Oquendo: We don’t specifically focus on the behavior of other professions including writers or biographers or historians, but I would say that caution is the better part of valor in these kinds of situations and that certainly will not stop individuals from writing what they will about an individual who they’re writing a biography for.

Jeff Schechtman: Do you know that when the Goldwater Rule was adopted in ’73, was this something that was unanimous on the part of the Association or was there controversy about it?

Dr. Oquendo: I can’t speak to that because I was not even a physician yet.

Jeff Schechtman: I mean, is it your sense, talking to colleagues today, that this is something that is accepted practice or do you sense any pushback to it nowadays?

Dr. Oquendo: Well certainly there is some dissent about whether we are being too rigid by taking the stance that it’s unethical to ever make comments, but I think we’re very careful to revisit our position on a regular basis and in our latest review of this rule and in fact the chair of our ethics committee was recently interviewed about this, and it’s very clear that this is at this point in time, a very reasonable position for us to take.

Jeff Schechtman: Dr. Maria Oquendo, she’s the president of the American Psychiatric Association. I thank you so much for spending some time with us today here on Radio Whowhatwhy.

Dr. Oquendo: Thank you so much.

Jeff Schechtman: Thank you. Thank you for listening and joining us here on Radio Whowhatwhy. I hope you’ll join us next week for another Radio Whowhatwhy podcast, I’m Jeff Schechtman.

If you liked this podcast, please feel free to share it and help others find it by rating and reviewing it on iTunes. You can also support this podcast and all the work we do by going to whowhatwhy.org/donate.


Related front page panorama photo credit: Adapted by WhoWhatWhy from Barry Goldwater (Library of Congress / Wikimedia) and APA President-Elect Maria A. Oquendo, M.D. (American Psychiatric Association)

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