Does the Goldwater Rule Still Apply?

The Origin of the Goldwater Rule

In the heat of the 1964 presidential contest between Lyndon Johnson and Barry Goldwater, FACT magazine surveyed psychiatrists for their opinion of whether Barry Goldwater had the mental fitness required to be President. Many physicians in this survey felt he did not. In the aftermath, Goldwater sued the magazine and won.

In 1973, the American Psychiatric Association codified this sensible and fair guideline and named it the Goldwater Rule.

What the Rule Actually Says — and Why It Matters

Simply stated, the rule prohibits psychiatrists from offering opinions on the mental health of public figures whom they have not personally examined and without patient consent. It has been in place ever since, with little push by psychiatrists to speak out clinically about a public figure in a non-clinical setting.

That is — perhaps — until now.

When the Psychiatrist Is in the Room

We certainly see and hear more from Donald Trump than we ever did from Barry Goldwater. I’ve attended recent social gatherings where, invariably, the president’s perceived troubled mental state has come up. And as the Shrink in the room, I feel all eyes focused on me. Thank you, Mr. Goldwater.

Discussing a President’s personal characteristics is part and parcel of American democracy. President Trump’s tendency to oddly go off topic, make inaccurate or simply false statements (such as repeatedly calling Greenland Iceland), and directly express hostility toward some individuals seems a little different from most of his predecessors.

It is true that Joe Biden’s slowed and apparent diminished cognitive capacity — including his unfortunate reluctance to bow out of the race — was widely recognized and likely contributed to Donald Trump’s victory. In my experience, there was no shortage of psychiatric opinion about Biden, although none to my knowledge that broke the Goldwater Rule.

Observing Behavior Without Assigning Diagnosis

As a psychiatrist, non-linear speech — such as is often the case with President Trump — catches your eye, or rather your ear, since it can be associated with significant mental disorders.

Responding to criticism by throwing back nastier criticism is not only reminiscent of middle school; it also speaks to what is often referred to as pathologic narcissism, in which a troubled sense of self is intertwined with alternating vulnerability and grandiosity.

It’s important to remember, though, that narcissism itself is not always bad. It can provide sturdiness and useful drive toward achievement. Has there ever been a President without a healthy dose of narcissism?

Pathological narcissism, on the other hand, is rarely — if ever — of benefit.

Transparency and Presidential Health

There is no guideline or rule that compels a President’s physician to provide a thorough and accurate accounting of the President’s health, although what is presented should be accurate, timely, and complete. I don’t know a single physician who has confidence that President Trump’s full medical history has been thoroughly or accurately presented to the public.

On the other hand, there have certainly been other Presidents whose illnesses or mitigating medical issues were understated. President Franklin Roosevelt avoided being seen and photographed standing with leg braces, and this was viewed as an accepted and even comforting move for a population under enormous stress during the Great Depression and later World War II. There was very little detail provided regarding Roosevelt’s health in his final presidential terms.

Bruises, Cognitive Tests, and Medical Speculation

It doesn’t take a medical degree to know that President Trump’s “moving” hand bruises are not consistent with the side effects of daily aspirin use and frequent hand shaking, as we have been told. Some medical colleagues suggest these bruises are more likely from recent intravenous treatments — also accompanied by MRIs — another topic in the president’s recent medical history.

Nurses, who often have the most grounded instincts in these matters, have their own opinions.

I have “enjoyed” hearing President Trump declare on multiple occasions that he “aced” administered cognitive tests. I have administered, or been present during, numerous administrations of such tests and have never heard — from either a patient or a physician — of someone “acing” the test. Although, of course, we understand what he means.

The Constitutional Safeguard

There is, of course, a protective measure the Founding Fathers put in place to handle the mental or physical decline of a President. The 25th Amendment, Section 4, provides steps to remove a President when the Vice President and a majority of the Cabinet determine that the President is unable to perform his duties due to physical or mental incapacity.

Don’t hold your breath. I don’t see that coming any time soon.

Where Observation Ends and Diagnosis Begins

Observation and comment about a leader’s speech and behavior are — in my judgment — an acceptable side effect of being a psychiatrist. Making observations is not the same as assigning a diagnosis.

It is simply hard to ignore non-linear communications, especially multidirectional exchanges of information without clear sequential context. It is even harder to ignore false statements that flow into one another, and grandiose remarks.

Not Everything Is Pathological

Not all of the president’s behavior looks pathological. I have enjoyed seeing him appear to offer spontaneous warmth to his children.

And as a golfer, I must admit that I have occasionally nudged my ball to a better lie and visibly enjoyed a good shot — rare as they are for me. So I personally give the President some room on the golf thing.

Performance Versus Governance

President Trump’s State of the Union Address on February 24, however, seemed more like a hosted television show than the most important address of the year. This reflects as much about the president’s attitude toward politics as it does about his mental state.

On the other hand, he got through it reasonably well — inaccuracies and attacks notwithstanding — considering that the speech became one of the longest in history.

So — Does the Goldwater Rule Still Apply?

Yes, I still believe the Goldwater Rule is a good one.

Should the situation and behavior require something more, bring in the Shrink. I’ll leave it up to him or her to decide what to tell the public.

All of us will be watching.

That’s our responsibility.