On October 23, 2017, Sally Quinn, journalist and widow of former Washington Post executive editor Ben Bradlee, was on The Charlie Rose Show talking about her new book Finding Magic: A Spiritual Memoir. It was an engaging interview about a fascinating life, but like all conversations these days the conversation eventually turned to Donald Trump and the state of the presidency. Quinn ended the show saying that she hoped someone would find an “antidote” to the current state of affairs.
It was a curious choice of word from a journalist, herself a wordsmith. We administer antidotes to counteract poisons and reinstate health. It suggested to me that there was at least an inference by Quinn’s word choice that the state of political affairs might be a medical problem as much as a political one.
Her phrase led me to consider what medicine, and neuroethics particularly, might have to add in response to to Quinn’s quest for an “antidote.” In particular, I wondered whether the neuroethical concept of duty to warn might support the breach of the Goldwater Rule.  This rule was promulgated by the American Psychiatric Association (APA) in 1973 to guide psychiatrists in their public statements about public figures following more than 2,000 psychiatrists’ participation in a survey by Fact magazine in which a majority opined that Senator Barry Goldwater, the 1964 Republican presidential nominee, was unfit for office. Goldwater was subsequently successful in a libel suit against Fact.
The Genesis of the Goldwater Rule
In an issue of Fact —the irony of the magazine’s name is not lost in our alt-fact era—more than one-thousand psychiatrists of approximately 2,000 surveyed opined that Goldwater was psychologically unfit to be president in an article entitled, “The Unconscious of a Conservative: A Special Issue on the Mind of a Conservative.”  They worried Goldwater would ignite a nuclear war. He had voted against the nuclear test ban treaty and said that the U.S. should not fear war with the USSR.
Future-President and Goldwater opponent Lyndon B. Johnson exploited these fears with a controversial campaign ad against Goldwater—what many commentators think to be the first modern attack ad.  In the “Daisy” commercial, a little girl is plucking a daisy, counting as she removes the petals. When she gets to ten, a real countdown starts culminating in the fire and fury of a thermonuclear detonation. 
What those psychiatrists did may have been considered a professional breach, constituting a sort of ethical cul-de-sac. If any one of them had examined Goldwater—and presumably no one had done so—then it would have been a breach of professional duty to publicly disclose those privileged and confidential discussions. To comment without a proper exam was professionally irresponsible.
Dr. Herbert Sacks, a former APA president, recalled the events, “We are reminded of the 1964 Goldwater-Johnson election, when 1,189 American psychiatrists responded to an inquiry for their opinions of the candidates by a now defunct magazine (Fact magazine). The bulk of the political responses, couched in psychiatric terminology, were so unfair and so outrageous to Goldwater that he sued and won a substantial settlement. APA issued public statements decrying such analyses.”  With the drafting of The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry in 1973, the Goldwater Rule was added as follows:
On 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. 
For psychiatry (who some think to be a pseudoscience straddled as it is between the sciences and the humanities), there was also the question of the legitimacy of the profession. In his statement, Dr. Sacks added, “Psychobabble reported by the media undermines psychiatry as science.” 
The Spirit of the Rule
All this raises the question, what does the Goldwater Rule protect or sanction? Does it defend the psychiatric profession’s legitimacy against charges of quackery? Bioethicist Jonathan Moreno suggests as much, noting that the Goldwater Rule was promulgated when the dominant psychoanalytic approach to psychiatry “…had much to lose by being embarrassed by association with amateurish psychological assessments and poor political prognostication—not to mention a scurrilous publication like Fact.” 
Beyond its defense of organizational reputation, does the Goldwater Rule sanction unethical professionals? Or does it protect public figures who may become inadvertent patients subjected to one-sided scrutiny? It depends on the situation. One could argue that a psychiatrist was virtuous in the exercise of her professional expertise within public discourse and was thereby adding legitimacy to the profession. Such action could also be construed as ethical in light of public health concerns.
Of course, the opposite might be true as was the case with Goldwater. Goldwater had been mischaracterized in an ideological spasm by politicized psychiatrists. He sued Fact magazine and won. The rule was promulgated in 1973 and has carried his name ever since. Ironically, he was one of the distinguished legislators who went to the White House in 1974 to tell Nixon, who was reported to have been depressed and drinking , , that the gig was up. ,  In all, Goldwater repeatedly demonstrated his fitness to serve until his retirement in 1986.
The Goldwater Rule remains in force today, with the APA in March of 2017 reiterating that the 1973 prohibitions.  Paradoxically, the mischaracterization of Goldwater also perseveres. In a Nietzschean eternal recurrence, the Clinton campaign enlisted the child actress from the Daisy commercial to question Donald Trump’s fitness to be commander in chief. Monique Luiz, 46 years old, said, “This was me in 1964… the fear of nuclear war that we had as children, I never thought our children would ever have to deal with that again. And to see that coming forward in this election is really scary.” 
In the year since the 2016 election, the Goldwater Rule has been in the news regularly, , with arguments both to uphold its provisions and to violate the professional norm, as well as evidence for and against psychiatric diagnosis.,   In response to a Democratic bill introduced in the House to establish an oversight commission to assess presidential capacity under the 25th Amendment,  Peter Kramer and Sally Satel, psychiatric commentators on both sides of the aisle, agreed that medicalizing a political question is perilous.  Others have seen this as a viable option.  Just months ago, the conservative New York Times columnist Ross Douthat saw the 25th Amendment as a “solution” to this presidency, noting Mr. Trump’s “…incapacity to really govern, to truly execute the serious duties that fall to him to carry out, is nevertheless testified to daily—not by his enemies or external critics, but by precisely the men and women whom the Constitution asks to stand in judgment on him, the men and women who serve around him in the White House and the cabinet.” 
The usual rectitude of the senate has even been breached. One senator in the president’s own party worried about a nuclear apocalypse save for the adults in the room and characterizing the White House as a day care center.  Another has announced he will not seek reelection, whether or not a viable option, because he did not want to be complicit.  Those same senators have said on record that their colleagues on both the right and left have—off the record—questioned the psychiatric fitness of Donald Trump to serve as president.
But is it proper for doctors to weigh in? Let us consider the precedent and long history of psychiatrists working in the service of intelligence agencies seeking to profile world leaders’ vulnerabilities and proclivities.
Russian intelligence agencies have reportedly used psychological profiling to inform their strategies with the president and other world leaders. Former Acting CIA Director Michael Morell has said that former KGB agent and Russian President Vladimir Putin “was playing” Trump, making him an unwitting agent given his psychological needs. 
The Russian intelligence services use psychological profiles and so does the United States. The CIA’s Center for the Analysis of Personality and Political Behavior generates data on world leaders that is fed to senior U.S. leadership prior to summits and other key meetings. Presumably most of this data is generated without conducting direct therapy sessions with world leaders. The Center’s founder and former director, Dr. Jerrold Post, was instrumental in developing the “Camp David profiles” of Sadat and Begin prior to the Camp David Accords. Post, a psychiatrist, is in residence as a professor of psychiatry, political psychology and international affairs at George Washington University after his career at the CIA.  Interestingly, Post is a Life Fellow of the American Psychiatric Association, the same APA that has promulgated the Goldwater Rule.  This forensic practice may be mitigated by the official context of the work as well the methodological limitations that are ethically embedded in this practice genre of psychiatry. Furthermore, these reports are not meant for public consumption and thus not a breach of the Goldwater Rule which speaks to public statements and not just evidentiary standards related to a psychiatric examination.
Even before Post and his work at the CIA, the predecessor of the CIA known as the Office of Strategic Services (OSS) profiled world leaders. R.C. Baker in The Village Voice recently penned an article entitled, “Before the ‘Goldwater Rule’: Profiling Hitler in 1943.”  The OSS Report described therein, “A Psychological Analysis of Adolf Hitler: His Life and Legend,” was written by the psychoanalyst Walter Langer. The use of psychiatric evaluation of world leaders’ mental health to facilitate the Camp David Accords and the defeat of Nazi Germany may presumably establish favorable precedent for doing so in service to the public good.
“The Dangerous Case of Donald Trump”
More recently, a new anthology entitled The Dangerous Case of Donald Trump was recently authored by Bandy Lee, a Yale psychiatrist.  In the book, written following the “Yale Duty to Warn Conference,” twenty-seven psychiatrists and mental health professionals engaged the Goldwater Rule prohibition with some asserting a duty to warn and others making more generic comments about the issues related to presidential fitness. It is a forceful book, albeit with an obvious ideological tinge. There are persuasive arguments about the danger posed by this presidency. Some contributors call for the invocation of Section IV of the 25th Amendment which deals with the inability of the president to discharge his duties. In the forward, Robert J. Lifton cautions against the “malignant normality” of our times, and advocates for the role that “witnessing professionals” must assume to identify its trajectory and counter this trend.
What are we to make about the neuroethics of all this? Should psychiatrists break the rules of the APA? Is there a First Amendment, free speech, academic freedom issue here that should not constrain the free exchange of information? If one were a psychiatrist, under what circumstances would one be obliged to speak out, invoking a Tarasoff-like duty to warn thus breaching the confidentiality of the doctor-patient relationship? 
Dr. Lee takes this tack. She notes that she respects the Goldwater Rule as a “norm of ordinary practice” and urges her contributors to honor it. But in making that argument, she also acknowledges the need for conscientious objection when professionals feel obliged to speak out “to protect the public.” She notes that a “defect” of the Goldwater Rule is that it does not have a “countervailing rule, as does the rest of professional ethics, that directs what to do when the risk of harm from remaining silent outweighs the damage that could result from a public figure—which, in this case, could be the greatest possible harm.”  It is an argument about supererogatory obligations.
If we were to analogize from questions about an individual to the broader body politic about a duty to warn, proportionality would hinge on the quality of the evidence, the gravity of the threat, and its imminence. In a normal doctor-patient encounter, the psychiatrist would bring both expertise and private knowledge of a patient’s risk to bear in invoking a Tarasoff-like warning. In this case, mental health professionals do not have information that the rest of us are not privy to from the public record. We have all seen the president on TV, read his tweets and viewed his interactions with his subordinates. The question, therefore, hinges on the second element that mental health professionals would bring to a duty to warn determination and that is expertise. Would a psychiatrist understand what she or he sees differently, and draw different conclusions, based on their training and expertise?
Let us consider these two central questions in turn with respect to Dr. Lee’s claims regarding the threat presented by President Trump. The quality of the evidence is inferential without a formal clinical evaluation. Although we see the president’s personality revealed each day in the media and in tweets, the question remains of whether this is revelatory of his true self or a political façade. The gravity of the threat is beyond words if we think of North Korea and potential nuclear apocalypse. So too are threats of escalation with respect to tensions on the Korean peninsula. Are the president’s statements evidence of disinhibition or a negotiation tactic? Finally, in terms of imminence, we have seen actions thus far that seem reckless, unrestrained, and impulsive. Are they truly bad political decisions or could these acts be indicative of what some commentators have called a pathological narcissism or sociopathy?
Dr. Lance Dodes seeks to answer this question in his contribution to The Dangerous Case of Donald Trump. In his chapter about sociopathy, Dr. Dodes asks, “Crazy like a fox or just crazy?”  He maintains that, “…a person who is repetitively immoral—who cons others, lies, cheats, and manipulates to get what he wants, doesn’t care who he hurts, just as long as he is gratifying himself,” is emblematic of sociopathy as delineated as antisocial personality disorder in the current DSM.
Dodes’ compelling argument provides the medical heuristic called for by Sally Quinn’s appeal for an antidote. Without diagnosis in medicine, there can be no hope for containment of the threat posed by illness. Diagnostic thinking helps to interpret symptomatology, understand its origins, and develop a plan for effective treatment. If we fail to diagnose, or at least appreciate the possibility and elements of a diagnosis, we leave ourselves unprepared to recognize, identify and respond to patterns of behavior that would otherwise seem random and not consistent with a diagnostic pattern of behavior. As the Spanish philosopher José Ortega y Gasset put it, the uneducated eye does not see. 
In the context of the president’s personality, it is not an outright diagnosis that is needed per se but a public appreciation of what sociopathy is that can help inform a response. Medical diagnosis demands a high evidentiary standard. In the public sphere, mere knowledge of what sociopathy entails may enable the requisite scientific literacy for the citizenry to decide if observed behaviors fit a discernable pattern of psychiatric diagnosis that has a bearing on an ability to govern. This knowledge is especially important in sociopathy, which by its nature can obscure and seduce the observer. Human nature is drawn to sociopathy and vulnerable to its charm. Public awareness of sociopathy’s existence and nature is thus vital to deliberative democracy. This knowledge becomes a component of basic scientific literacy for deliberative democracy. Having said this, this knowledge need not require understanding at the level of clinical nosology. It may constitute essential knowledge like the germ theory of disease: even if they can not diagnostically distinguish an errant gastroenteritis caused by E. Coli or Salmonella, the public knows enough to engage in personal hygiene and perhaps avoid potato salads simmering in the sun at a summer picnic. Public knowledge about sociopathy has a similar utility: it can help guide behaviors and inform responses by our political leaders and journalists in the Fourth Estate as they do their work.
A very useful book on sociopathy is The Sociopath Next Door, by Harvard psychologist Martha Stout.  Her vignettes of sociopathy from actual case histories are reminiscent of some of the traits and actions we have seen during Trump’s presidential campaign and first year in the White House. Stout speaks of how sociopathic individuals bring people around them down in ruin. Stout’s message: sociopaths destroy others to survive without compunction and without a conscience.
A recent example of this, what we might call the contagion of sociopathy, is the experience of White House Chief of Staff John Kelly. A distinguished four-star Marine general, aide to Leon Panetta at the Pentagon, and Gold Star father, Kelly shared his most private loss in defending his president, only to get embroiled in a political cauldron that will forever be part of his biography.  Writing of John Kelly, New Yorker columnist Ryan Lizza commented upon the “dangerous moral calculus of working for Trump.” 
Stout’s advice on how to contain the destructive threat of sociopathy is instructive for individuals and the political process. Her recommendations are the elusive antidote that Sally Quinn seeks, still unaware that what she has observed as a citizen might coalesce into a diagnostic framework that could lead to a constructive response. A case in point: Dr. Stout writes of the peril of any one individual taking on a sociopath. This approach creates vulnerability and immediate vicious attack. We have seen how Senators Robert Corker and Jeff Flake, for example, have been excoriated after their comments in the media, or how Trumpian opponents were labeled, belittled, and demeaned in the presidential debates. Stout’s advice is to form a group, encircle and expose the sociopathic behaviors, the distortions and the lies. Imagine if all seven Republican candidates collectively had done that in the primaries? Having a better understanding of sociopathy, which by its nature is hard to identify and acknowledge, can help inform political leadership, the media, and the public in their response.
A Way Forward
Unlike some of the authors of the Yale anthology, The Dangerous Case of Donald Trump,  I do not think that the 25th Amendment should be invoked. I question the feasibility of a panel to psychiatrically assess the president in order to advise the Vice President and the Cabinet in pursuing such a course of action. No sane president, especially one “clever as a fox”, would ever submit to such an examination. The stigma of mental illness is too strong. Think of the political toxicity of Thomas Eagleton’s nomination by George McGovern during the 1972 campaign.  I believe that the only way to remove the president would be through the political process: impeachment or the 2020 elections. The provisions of the 25th Amendment are not likely to be helpful with respect to any kind of characterological psychiatric impairment. The process, outlined in Section 4 of the 25th Amendment, stipulates:
Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.
This would require the vice president and a majority of the cabinet, or a body designated by Congress, to first identify the sociopathy and act upon it. This seems highly unlikely and a Fabian dream. Such a determination, with its implications for presidential succession, amounts to much more than a medical judgment. It is a political and legal determination that would only take place in the political arena via an impeachment by the House and trial in the Senate or through the natural course of an election in which the electorate would make a collective judgment of the candidate’s ability to govern. This section of the 25th Amendment did not envision removal for a psychiatric condition but a more clear-cut medical incapacity, like the stroke sustained by President Woodrow Wilson. 
Medical knowledge can inform the political process but it cannot—and should not—dictate its outcome. That would be an overreach and a medicalization of a political process. Instead, a psychologically informed perspective should help inform political, journalistic, and investigative strategies undertaken by House and Senate Committees, the press, and the special counsel, and ultimately decisions made by the electorate. Such knowledge is essential to the scientific literacy necessary for the exercise of deliberative democracy. The medical profession can serve this end through its educative role, which is distinct from the public pronouncement of psychiatric diagnoses. Such public education would at least be consistent with any reading of the Goldwater Rule.
Of course, this is only true if public education is undertaken with impartiality and in a bipartisan fashion, as was the case during Watergate.  These issues transcend the incumbent presently in office. One could envision a president of the other party who might one day raise concerns about fitness, so this should not be a partisan affair. When we speak about presidential fitness, a respect for constitutional government and our democratic traditions must be our ethical North Star. It is this objective which supersedes any professional mandate or prohibition about bringing to bear our expertise in medicine, neurology, or neuroethics so long as the public exchange of information is not motivated by partisanship. Of course, it is difficult to judge intent or motivations. We will need to act in good faith and know that history, one of those neglected humanities amidst our focus on the sciences, will have the final word and be the judge of our actions.
Joseph J. Fins, M.D., M.A.C.P, can be reached at jjfins (at) med.cornell.edu.
Joseph Fins is The E. William Davis, Jr. M.D. Professor of Medical Ethics, Professor of Medicine, and Chief of the Division of Medical Ethics at Weill Cornell Medical College. He co-directs, the Consortium for the Advanced Study of Brain Injury (CASBI) at Weill Cornell Medicine and The Rockefeller University. At Yale Law School, he is the Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law.
The author is grateful to Kate Crikshank archivist of the Birch Bayh Senatorial Papers at the University of Indiana and Jason Berman, former chief of staff to Senator Bayh for their generous assistance. An earlier version of this talk was presented as part of a panel entitled, “Neuroscience, Communication, and Public Engagement” at the annual meeting of the International Neuroethics Society. American Association for the Advancement of Sciences. Washington, D.C. November 9, 2017. The opinions expressed are those of the author and not of any organization with which he may be affiliated.
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