It doesn’t take too much time on the internet to find people talking with some measure of incredulity about Donald Trump.\u00a0 Some of this talk takes the tone of horrified fascination; some of it is mocking (and is accompanied by correspondingly mocking images); and some people are wondering aloud about his mental health.\u00a0 In this last category, there’s a couple of sub-categories: sometimes, people are not really talking in earnest; sometimes, though, they are.\u00a0 What if the forty-fifth President of the United States of America has some kind of mental illness, or some kind of personality disorder?\u00a0 What if this affects his ability to make decisions, or increases the chance that he’ll make irrational, impulsive, and potentially dangerous decisions?<\/p>\n
This does raise questions about the proper conduct of the medical profession – particularly, the psychiatric profession.\u00a0 Would it be permissible for a professional to speak publicly about the putative mental health of the current holder of the most important political office in the world?\u00a0 Or would such action simply be speculation, and unhelpful, and generally infra dig<\/em>?\u00a0 More particularly, while the plebs might say all kinds of things about Trump, is there something special about speaking, if not exactly ex cathedra<\/em>, then at least with the authority of someone who has working knowledge of cathedrae<\/em> and what it’s like to sit on one?<\/p>\n As far as the American Psychiatric Association is concerned, the answer is fairly clear.\u00a0 \u00a77.3 of its Code of Ethics, which you can get here<\/a><\/span>, says that<\/p>\n [o]n 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.<\/p><\/blockquote>\n This rule is nicknamed the “Goldwater Rule”, after Barry Goldwater, the Senator who sued successfully for damages after a magazine polled psychiatrists on the question of whether or not he was fit to be President.\u00a0 Following the rule would appear to rule out making any statement about whether a President has a mental illness, a personality disorder, or anything else that might appear within the pages of the DSM<\/em>.<\/p>\n Over on the BMJ<\/em>‘s blog<\/a><\/span>, Trish Greenhalgh has been wondering about what a doctor may or may not do in cases like this:<\/p>\n I have retweeted cartoons that mock Trump, because I view satire and parody as legitimate weapons in the effort to call our leaders to account.<\/span><\/p>\n But as a doctor, should I go further? Should I point out the formal diagnostic criteria for a particular mental illness, cognitive condition, or particular personality disorder and select relevant examples from material available in the public domain to assess whether he appears to meet those criteria?<\/p><\/blockquote>\n Her post is long, but it does generate an answer:<\/p>\n I believe that on rare occasions it may be ethically justified to offer clinically-informed speculation, so long as any such statement is clearly flagged as such. […] I believe that there is no absolute<\/em> bar to a doctor suggesting that in his or her clinical opinion, it would be in the public interest for a particular public figure to undergo \u201coccupational health\u201d checks to assess their fitness to hold a particular office.<\/p><\/blockquote>\n Her phrasing is such as to leave no bet unhedged – she’s careful not to say that she’s talking about anyone in particular; but, beneath that, the message is clear: it might be justifiable to depart from the Goldwater Rule to some extent in certain hypothetical circumstances.<\/p>\n My post in response will also be long – in fact, it’s going to spread out over two posts.\u00a0 I think she’s plausibly correct; but the way she gets there is not persuasive.<\/p>\n<\/div>\n<\/div>\n<\/div>\n <\/p>\n First things first: here’s how Greenhalgh sets out her stall:<\/p>\n For some people, it would not be permissible to attempt to diagnose a public figure.\u00a0 If the figure is not the practitioner’s patient, there’ll be insufficient evidence; if the figure is<\/em>, then there’ll be breach of professional confidentiality.\u00a0 “This,” she says, “is known by medical ethicists as the deontological<\/em> position (the doctor\u2019s over-riding duty is to the individual whose putative illness is in question).”\u00a0 On the other hand, one might be more utilitarian, and appeal to the optimific outcomes that one hopes to derive from maintaining or breaching confidentiality on a case-by-case basis.<\/p>\n OK: now I’m going to interject here, wave my medical ethicist flag, and point out that many deontologists think that maintaining confidentiality is morally required.\u00a0 So it could be a<\/em> deontological position.\u00a0 But there’s nothing in the very structure of deontology to say that we must maintain confidentiality: the form and content of a moral theory are not the same.\u00a0 Deontology doesn’t tell us what to do any more than Pythagoras’ theorem tells us that the hypotenuse is 7.3cm long.\u00a0 Like a mathematical theorem, a moral theory tells us how to think about a problem; nothing more.\u00a0 And, working the other way, it’s perfectly possible for non-deontologists to think that one should always maintain confidentiality.\u00a0 There’re perfectly good utilitarian arguments to that effect.\u00a0 For that reason, the idea that utilitarians look at things case-by-case is also mistaken.\u00a0 Some might.\u00a0 Others might be rule-utilitarians.<\/p>\n Neither is it a matter of confidentiality.\u00a0 No confidence has been given.\u00a0 There is no relationship – as far as we know – between Trump and the pundits.\u00a0 Thus the question is not one about maintaining confidentiality: it’s about speculating based on publicly-observed behaviour.\u00a0 That might be infra dig<\/em> in many cases; but whatever we happen to think about the scope of duties of confidentiality, it won’t apply here.\u00a0 This is important, because you can’t give a decent answer to a moral question unless you’ve identified the terms of the debate correctly.\u00a0 What we’re talking about in this kind of case is not a breach of confidentiality, but about speculation.\u00a0 Note, too, that when it comes to what medics – specifically, psychiatrists – may or may not do in cases like this, it’s not just any old speculation: it’s informed<\/em> speculation.<\/p>\n That might yet be morally iffy; but it might not.<\/p>\n One final point on confidentiality: the convention that’s grown up after Tarasoff<\/em> is that an HCP may breach confidentiality if and only if the patient poses an identifiable threat to an identifiable person.\u00a0 That’s fine in most cases.\u00a0 But it doesn’t seem to fit particularly well when it’s a Head of State who’s the source of concern.\u00a0 In cases like that, we may not be able to identify particular people who’re at threat in identifiable ways: we may be able to do no more than wave vaguely out of the window, or mutter about future generations.\u00a0 That’s precisely because the potential threat is so huge.\u00a0 Yet it’d be very odd to say that we couldn’t raise the alarm because the thing about which we’d be raising it is too significant to relate to particular persons.\u00a0 Therefore the Tarasoff<\/em> convention doesn’t really fit.<\/p>\n As Greenhalgh admits, there may be several reasons to err on the side of saying nothing about whether or not Trump or someone like him would fit in any of the\u00a0DSM<\/em>‘s categories.\u00a0 For example, there’s a long an unfortunate history of people being labelled as mentally ill when they became politically inconvenient.\u00a0 It’s a favourite trick of totalitarians the world over.\u00a0 For that reason, maybe we should fight shy of calling political foes mentally ill.<\/p>\n This is fair enough on the face of it – but there’s an important difference between calling someone mentally ill because he’s a political opponent, and suggesting that a political opponent might be mentally ill (or has a personality disorder, or whatever).\u00a0 Correspondingly, it’s fallacious to think that because some people used mental health as a cover for political Machiavellianism, everyone who talks about mental health in a political context is behaving in the same way.\u00a0 Note too that there’s a power dynamic involved in the grimmer historical examples that isn’t at play here.\u00a0 Stalin could label his opponents as mentally ill and get rid of them that way, but Stalin was Stalin.\u00a0 He had the power.\u00a0 In our current case, it’d be a stretch to think that the power dynamic is even vaguely similar.\u00a0 Take heed of the warnings from history – but apply them with discrimination.<\/p>\n Here’s another reason to steer clear of speculating about Trump’s mental health: that it’s stigmatising.\u00a0 The “dangerous lunatic” caricature makes life unnecessarily difficult for those who have a mental illness and those around them, and reduces the chance that the sufferer is going to seek help for it.\u00a0 If your only image of mental illness is an image of a padded cell, you’d be have to be nuts to see your doctor.<\/p>\n Again, though, I don’t think that this concern need carry much weight in this case.\u00a0 Presumably, the worry is that Trump might be showing signs of the kind of thing that’d make serious errors of judgement more likely.\u00a0 And it’s at least possible that the worries are on to something.\u00a0 Is this stigmatising of all mental illness?\u00a0 Not in itself: the stigma is already there.\u00a0 And the worry about stigma is a slightly strange one to raise if the claim about mental health is made in good faith.\u00a0 Indeed, to refuse to ring a warning bell that in this case may be appropriate because one is concerned about attitudes to mental illness in the world at large is to allow those with stigmatising attitudes to set the terms of the debate – not just in this case, but in all cases.\u00a0 In other words, it may perpetuate the stigma that one is aiming to avoid.\u00a0 And, though it’s probably not decisive here, the stigmatisation point is hard to separate from the fact that many people with mental illness are, or end up, socially marginalised.\u00a0 The billionaire President of the most powerful nation on the planet is not in a comparable position.<\/p>\n Still: that these concerns aren’t wholly convincing won’t generate a reason to diagnose.\u00a0 The default is still saying nothing.<\/p>\n But it seems to me that those with medical insight possibly shouldn’t feel bound by the Goldwater Rule.\u00a0 For one thing, as I hope is clear, I think that there’s a world of difference between the PotUS – or, really, any head of government – and a normal mortal.\u00a0 For my money, medical diagnoses shouldn’t be publicly accessible or publicised; but there might be good reasons to breach this rule on occasion.\u00a0 I’m a big fan of the principle that exceptio probat regulam in casibus non exceptis<\/em>: being prepared to draw an exception from a rule proves that the rule does hold in unexcepted cases.\u00a0 Sometimes these reasons’ll be for the good of the patient; sometimes for the good of a third party.\u00a0 When it comes to the PotUS, like Greenhalgh, I’m open to persuasion, but my gut feeling is that there’s a reason to speak that doesn’t apply in normal cases.\u00a0 Everyone on the planet has a very strong interest in the PotUS not being a paranoid narcissist.\u00a0 If the PotUS is showing all the signs of paranoia and a narcissistic personality disorder…\u00a0 Well…<\/p>\n And so I’m with Greenhalgh in the claim that what medics should do is qualify their statements: to make it clear that they are not offering a diagnosis in the normal sense, based on case history and consultations with the patient, and that they’re simply bringing a professional eye to publicly-observable behaviour.\u00a0 They should make it clear which role they’re currently occupying.\u00a0 Nevertheless, they can still say that there is, in their professional judgement, reason to think that such-and-such is the case.\u00a0 To that extent, it’s not particularly different from someone who’s employed as a public hygiene inspector deciding not to order food from a certain pub, and warning others not to, based on the appearance of the place and years of experience.<\/p>\n (Going back to the point about speaking ex cathedra<\/em>, the seat from which the pundit is speaking is not that of Trump’s physician.\u00a0 Whether Trump’s physician should speak out is a further question; depending on the diagnosis, he or she might.\u00a0 So, for example, if a President or military leader is showing signs of some kind of paranoia, that is very likely in the public interest.\u00a0 If it’s a manageable case of depression, it isn’t.\u00a0 Of particular relevance here is a report<\/a><\/span> about Trump’s former physician saying that he takes Propecia, a baldness treatment that is associated with mental confusion.\u00a0 Is knowing that in the public interest?\u00a0 It might be.\u00a0 It certainly seems reasonable to think that someone holding the highest public office ought to discount the importance of thinning hair if the preferred treatment for it impairs mental function; and it’s not self-evidently unreasonable to think that the public has a right to know about the President’s priorities, especially since going bald is not an illness that one would normally have the right to keep private.)<\/p>\n Besides: there might also be psychiatrists who’d be prepared to go on record to say that he’s probably not mentally ill, or doesn’t have a personality disorder.\u00a0 Maybe this is Trump sane<\/em>.<\/p>\n Now there’s a scary thought.<\/p>\n","protected":false},"excerpt":{"rendered":" It doesn’t take too much time on the internet to find people talking with some measure of incredulity about Donald Trump.\u00a0 Some of this talk takes the tone of horrified fascination; some of it is mocking (and is accompanied by correspondingly mocking images); and some people are wondering aloud about his mental health.\u00a0 In this […]<\/p>\n