28 March 2018

The ‘mad king’ conundrum

Clinical Ethics

Where were you when Donald Trump was elected President of the United States? I was at my desk. Work had ground to a halt, and I was feverishly hitting refresh on the New York Times election prediction barometer. The needle swung to 95% certainty, triggering the rumblings of a seismic political shift felt around the world.

Dr Bandy Lee, a forensic psychiatrist and violence expert at Yale University, found herself in centre of the emergency response.

“The day after the election, I was flooded with phone calls and emails from people and organisations that were afraid of the violence that was to come,” Dr Lee tells The Medical Republic.

Many people fear that President Trump isn’t exactly the “very stable genius” he claims to be.

“His impulsivity, recklessness, paranoid reactions, lack of empathy, loss of touch with reality, constant need to burnish a sense of power, attraction to violence –  these are psychological signs that point to dangerousness,” Dr Lee says.

As the election results rolled in, Dr Lee had a choice to make. Either she could abide by the new “gag rule” laid down by the American Psychiatric Association, or she could speak out.

“I had to ask myself, after devoting my entire career to preventing violence, do I turn away from the greatest violence we could possibly face?”

The association’s Goldwater Rule was expanded in March last year to prohibit psychiatrists from not just diagnosing, but from making any comments on the effect, behaviour or speech of public figures, even in an emergency.

It goes much further than the original Goldwater Rule, established in 1973, which allowed psychiatrists to share their expertise in general, so long as they did not actually diagnose a public figure without first examining them, and obtaining their consent.

Dr Lee is a proponent of the Goldwater Rule in its original form, but she believes the new rule asks psychiatrists to violate a higher principle of medical ethics: the protection of human health and wellbeing. This principle was clarified in the Declaration of Geneva adopted by the World Medical Association in 1948.

Most psychiatrists privately consider President Trump a threat to public health and safety, says Dr Lee. But few are willing to say this publicly, and none of Dr Lee’s colleagues would sign their name to a letter to Congress following the 2016 election.

“I thought that was odd,” she says. “I then decided to organise a conference to talk about it. No one would co-organise it with me and so I did it alone.” The conference took place in one of Yale’s 500-seat auditoriums. Only 20 people showed up.

Some of Dr Lee’s colleagues told her quietly that they were afraid of retaliation in the form of physical violence from Trump supporters, or legal action from the President himself.

The media caught wind of the Yale conference, and the international headlines that followed gave Dr Lee a way to connect with thousands of colleagues. Together, they formed the National Coalition of Concerned Mental Health Experts.

Twenty-seven of these psychiatrists and mental health professionals published their views in a damning treatise, The Dangerous Case of Donald Trump, in October last year.

The book, edited by Dr Lee, presents a laundry list of psychological issues that may explain President Trump’s seemingly difficult relationship with reality.

It didn’t directly diagnose President Trump, which would be in violation of the 1973 Goldwater Rule. But the book does provide education on narcissistic personality disorder, sociopathy, hedonism, paranoia, delusional disorder, cognitive impairment and dementia. You connect the dots.

This kind of information isn’t just relevant to the electorate, says Dr Lee. US legislators have the power to declare the President unfit and remove him from office under the 25th Amendment.

In early December, Dr Lee agreed to brief around a dozen members of the House of Representatives and the Senate who were worried about the president’s mental fitness. This meeting included one unnamed Republican senator.

While this may appear uncomfortably close to politics, Dr Lee says she abided by ethical guidelines, providing medical information in a politically neutral way. This is a public service similar to a psychiatrist commenting on a defendant in a court of law, she says.

While knowledge of psychiatric conditions can help legislators make a decision, the question of whether President Trump is fit for office is a political one, not a medical one, she says. Dr Lee says she would provide the same service in relation to a Democratic president.

Dr Lee is very strict when it comes to conflicts of interest.

Late last year, she received a series of unexpected phone calls from close associates of President Trump, who said the President was frightening them. “They used the word ‘unravelling’,” she says.

Dr Lee explained she could not adopt a treatment role while she was involved in public education and told them to call the local emergency room.

Psychiatrists speculating about the President’s mental state have been savaged by the psychiatric association, which declares this kind of “armchair psychiatry” unacceptable and unethical.

“Simply tawdry, indulgent, fatuous, tabloid psychiatry,” was how past president Dr Jeffrey Lieberman described Dr Lee’s book.

“Psychiatry has made too many past missteps to engage in political partisanship disguised as patriotism – witness its collusion in Nazi eugenics policies,” he warned.

But psychiatrists who believe they have an ethical obligation, and a legal right, to speak freely have pushed back.

The German Psychiatric Association said nothing during the rise of Hitler, psychologist Dr John Gartner, one of the 27 authors in Dr Lee’s book, said.

“Should they be our moral role models? As a Jew, I was raised with the mantra ‘never again’, which means it is a grave and terrible sin to be silent in the face of rising fascism.

“We are fiddling with the Goldwater Rule while the world burns.”

IS DISTANT DIAGNOSIS ACTUALLY POSSIBLE?

Making a diagnosis without personally examining a patient is forbidden under the Goldwater Rule, but researchers are beginning to question the science behind this prohibition.

The rule was created to prevent another major embarrassment to the profession, after more than 2,000 psychiatrists volunteered their opinion on presidential candidate Barry Goldwater in a survey by Fact magazine in 1964.

Without having so much as spoken to Mr Goldwater, let alone gaining his consent, psychiatrists incorrectly diagnosed him with chronic psychosis, megalomania, obsessive-compulsive disorder and paranoid schizophrenia.

Under the cloak of anonymity, psychiatrists falsely claimed that Mr Goldwater had been “scarred by his potty training” and had “the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders”.

After losing to Lyndon B. Johnson in the election, Mr Goldwater sued the magazine for $US75,000 in punitive damages and $US1 compensatory damages.

In the 1960s, psychiatry was caught in the “psychoanalytic zeitgeist”, which focused on how unresolved issues in childhood and other experiences influenced the unconscious mind. Diagnosis at a distance was virtually impossible at this time because much of the clinically relevant information was not in the public domain. Today, psychiatrists make diagnoses on the basis of behavioural patterns that match the DSM-5 criteria. And some psychiatrists believe they have access to more than enough information on the behaviour of a sitting president to start drawing diagnostic conclusions.

Dr John Gartner, who has observed hundreds of hours of Donald Trump’s behaviour, read thousands of his tweets, and heard from dozens of informants, believes he has a stronger basis for diagnosing Trump than most of the patients in his practice.

Interviews are the core tool for information extraction in psychiatry, but interviews have limitations, and in some cases they actually decrease the accuracy of clinical judgments, according to an analysis published last year in Perspectives on Psychological Science.

Psychiatric interviews often lack standardised questions and scoring criteria, which makes them unreliable, and susceptible to cognitive biases, the researchers argue.

Lifetime data is less likely than interviews to be compromised by a patient’s poor memory, blind spots, and lack of insight.

Archival data may actually be more telling than interviews for patients who are incentivised to deny or minimise psychopathology, such as politicians running for re-election. Self-reported data often fails to reveal disorders that are particularly worrying in those seeking public office, such as psychopathy.

The Goldwater Rule “accords false primacy” to the interview and should be abandoned, the researchers argue. Not only is it possible to correctly diagnose a public figure from a distance by analysing large volumes of data, but clinicians should be able to offer diagnoses in times of crisis when an individual has substantial power over others.

It seems reasonable that by choosing to have substantial power of thousands or millions of people, an individual forfeits their right to keep their mental health status private, Professor Scott Lilienfeld, a psychologist at Emory University in Georgia, says.

Moreover, a person who has already chosen to express themselves through tweets, radio interviews, television appearances, and political debates is unlikely to have the same expectations of confidentiality as a patient.

IS IT ETHICAL?

Psychiatrists break into two main camps on the ethics of speaking about President Trump’s mental state.

The first group believes that medicine is about doing no harm to the patient in front of you.

The only instances where confidentiality can be broken ethically are when there is imminent danger to the patient or others, or where the psychiatrist is sanctioned by a court.

In clinical practice, the justification for breaking confidentiality is that the psychiatrist may be the only person who knows about the danger, says Assistant Professor Arash Javanbakht, a psychiatrist at Wayne State University.

In the case of President Trump, there is no doctor-patient relationship. Psychiatrists do not have special access to privileged information, and therefore they do not have a duty to warn the public.

“The psychiatrists who got involved in this have too much faith in themselves,” Professor Javanbakht says.

“The behaviour that they are observing is observable by everyone. It’s not like we see something that other people don’t see.”

Weaponising mental health diagnoses to attack political figures, even in the name of public safety, seriously damages mental health advocacy, he says.

By associating an unpopular president with certain mental health diagnoses, psychiatrists are stigmatising citizens living with these conditions.

Upholding the political neutrality of the profession also has benefits. Trump supporters may not want to visit a psychiatrist if the profession gets a reputation as a “bunch of entitled liberals” pushing their own political agenda, Professor Javanbakht says.

Personal regret is another good reason for zipping your lips. Howard Gardner, an adjunct professor of psychology at Harvard University, had to public withdraw his comments after he was quoted calling Donald Trump “remarkably narcissistic”.

“I should have anticipated the ways in which my words could have been cited and accordingly declined to utilise any words that smacked of diagnosis whatsoever,” he wrote in a blog post.

The second group of psychiatrists believe that do no harm calls on the medical profession to have a social conscience. Psychiatrists can’t just shut out the external world and attend to the needs of the individual patient because they have a broader civic duty to warn. Ethical rules are never absolute and meeting the humanitarian goals of medicine sometimes means infringing an individuals’ right to privacy.

The justification for commenting on President Trump’s mental health is that the psychiatric profession has centuries of accrued knowledge about the human mind and may see things that the public can’t.

Insights from psychiatry allow for the prediction of behaviour. Had psychiatrists spoken out sooner, they may have tempered false hopes that Donald Trump would become more presidential following election, says Dr John Gartner. People with malignant narcissism become even more grandiose, reckless and aggressive after victories, he says.

WHO IS RIGHT?

To answer that question, a little distance from the debate raging in in the US is useful.

Dr Chris Rudge (PhD), a postdoctoral researcher in psychiatry, literature, and law at The University of Sydney, says that psychological analysis of current political leaders can be done in an ethical way, but that clinical psychiatrists have professional duties that prevent them from providing that commentary.

Some psychoanalysts and psychological scientists have been writing psychobiographies about political figures in recent decades. One reason for this may be that these professionals are not bound by the same ethical standards as psychiatrists.

Given their different training and ethical guidelines, commentators such as these might be better placed to enlighten the public about what is going on in President Trump’s head than practising psychiatrists.

Last year, for instance, the American Psychoanalytic Association sent a letter to its members saying that they were permitted, within some limits, to comment on the mental state of public figures, including the president.

“By issuing this letter, the American Psychoanalytic Association isn’t disobeying the Goldwater Rule; it’s just that psychoanalysts have very different traditions and professional responsibilities to psychiatrists,” says Dr Rudge. “Psychiatrists are doctors whereas psychoanalysts are usually not, and so different ethical guidelines will generally apply,” he says.

The Royal Australian and New Zealand College of Psychiatrists doesn’t have a “down under formulation” of the Goldwater Rule and we probably don’t need one, says Michael Robertson, a psychiatrist and associate professor of mental health ethics at The University of Sydney,

The separation of powers is much more robust in a Westminster system like Australia’s, so it is unlikely that we will ever face the “mad king” drama unfolding in the US.

However, psychiatrists function in a political matrix, and cannot be completely agnostic to the political system, even in Australia.

“When the machinery of the state starts falling in lockstep with the malignant aims of the totalitarian regime, that’s where we need to raise alarm because that’s how genocide happens. That’s how holocausts happen, that’s how the persecution of the disabled happens,” says Professor Robertson.

Psychiatrists have a duty to protect social institutions because these are what stop a power grab by political leaders with extreme ideologies, he says.

And perhaps that’s why psychiatrists in the US are so conflicted. The president is a social institution, so the inner workings, and seeming dysfunction, of President Trump’s mind may have a direct bearing on public safety.