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Opinion When is it okay to say the president might be nuts?

On Saturday, President Trump gave an angry, rambling speech to his supporters in which he obsessed over perceived enemies in the media and elsewhere. Recently he insisted he won’t “stand by anything” in his accusations about alleged wiretapping by President Barack Obama, yet argued that his case has been “proven very strongly.” (In reality, the entire national security community has rejected it, as have the chairmen and ranking minority-party members of House and Senate committees.) He said of President Andrew Jackson:

I mean, had Andrew Jackson been a little later, you wouldn’t have had the Civil War. He was a very tough person, but he had a big heart. And he was really angry that — he saw what was happening with regard to the Civil War. He said, “There’s no reason for this.” People don’t realize, you know, the Civil War — if you think about it, why? People don’t ask that question, but why was there the Civil War? Why could that one not have been worked out?

Jackson was a slave owner and was responsible for the “Trail of Tears,” which killed thousands of Native Americans. And of course, every grade-schooler knows that the Civil War was about slavery and the inevitable clash between America’s “original sin” and the promise of the Declaration of Independence. As The Post’s Aaron Blake put it, this “is just a completely bizarre claim that, once again, suggests a president who speaks loudly and confidently about things he simply doesn’t understand.” Apparently, Trump learned nothing from his visit to the National Museum of African American History and Culture.

Trump has praised the dictator of North Korea, Kim Jong Un, as a “smart cookie.” He insisted the health-care bill that the House is struggling to pass does not say what it does and is still changing (although Gary Cohn insists there are likely votes for it). Politico quotes a senior GOP aide as saying of Monday’s interviews, “He just seemed to go crazy today.”

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During his many television interviews, President Trump often leaves his interviewers with more questions than answers. (Video: Jenny Starrs/The Washington Post, Photo: CARLOS BARRIA/The Washington Post)

Is Trump nuts, ill-informed or a liar — or all three?

Until now, people who could have shed light on a president’s mental state were professionally hindered from doing so. The so-called Goldwater Rule — named for the late Sen. Barry Goldwater, whom some psychiatrists took to calling crazy because of his foreign policy views — admonishes medical professionals not to opine on the mental health of people whom they had not examined. In the context of Trump, however, there has been some buzz about doing away with the rule on the grounds that psychiatrists should be able to give their best medical judgment to “warn” the public.

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Evan Osnos in the New Yorker waded into that debate in a piece questioning whether Trump might be removed under the 25th Amendment:

Lance Dodes, a retired assistant clinical professor of psychiatry at Harvard Medical School, believes that, in this instance, the Goldwater rule is outweighed by another ethical commitment: a “duty to warn” others when he assesses that a person might harm them. Dodes told me, “Trump is going to face challenges from people who are not going to bend to his will. If you have a President who takes it as a personal attack on him, which he does, and flies into a paranoid rage, that’s how you start a war.”
Like many of his colleagues, Dodes speculates that Trump fits the description of someone with malignant narcissism, which is characterized by grandiosity, a need for admiration, sadism, and a tendency toward unrealistic fantasies. On February 13th, in a letter to the [New York] Times, Dodes and thirty-four other mental-health professionals wrote, “We fear that too much is at stake to be silent any longer.” In response, Allen Frances, a professor emeritus at Duke University Medical College, who wrote the section on narcissistic personality disorder in the Diagnostic and Statistical Manual of Mental Disorders—IV, sought to discourage the public diagnoses. Frances wrote, “He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder. . . . The antidote to a dystopic Trumpean dark age is political, not psychological.”

Well, as the letter to the New York Times illustrates, mental health professionals can challenge or defy the Goldwater Rule. It’s up to medical associations to enforce professional ethics. We are going to hear a lot more from such people, I suspect, as Trump displays his temperament in high-pressure situations.

There are myriad problems with diagnoses by doctors not treating a patient. We saw during the campaign how unfounded speculation about Hillary Clinton’s health got out of hand. Supporters and critics of an incumbent president (not to mention psychiatrists) are unlikely to agree. And in any event, it is not clear that a finding that “the president is suffering from a narcissistic personality disorder” can be used to invoke the 25th Amendment.

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U.S. President Donald Trump, center, signs an executive order at the Department of Homeland Security (DHS) in Washington, D.C. U.S., on Wednesday, Jan. 25, 2017. Trump acted on two of the most fundamental -- and controversial -- elements of his presidential campaign, building a wall on the border with Mexico and greatly tightening restrictions on who can enter the U.S. Photographer: Chip Somodevilla/Pool via Bloomberg (Chip Somodevilla/Bloomberg)

There are, however, a few points on which many Americans can agree. First, there is a fundamental difference between calling someone “crazy” because of his views, for example, on the Vietnam War and questioning someone’s mental stability based on his behavior, speech and other observable factors. Second, Congress could try to pass a law requiring an annual physical and mental checkup for the commander in chief, although it would have to get past a likely veto. Congress would also need to figure out how to enforce such a requirement and tackle the issue of doctor-patient confidentiality. All of that seems a bit much to overcome. Third, in an era when anyone has access to social media, we are going to see professional and unprofessional voices eager to assess a president whose behavior seems out of the ordinary.

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From our vantage point, the issue, we think, is not about getting a medical diagnosis. Assessing the president’s mental, temperamental and physical fitness is what voters do. They judge for themselves based on all the evidence they wish to consider (they can look up the DSM-5 for themselves). It’s perfectly valid for them to look at Trump’s short attention span as well as his lack of coherence, self-control, rationality, steadiness and ability to process information. In 2016, enough voters thought he passed muster. However, in 2020, they will have to make that judgment all over again unless Trump chooses not to run. This time they will have witnessed how he functions, listened to him speak and observed how he makes decisions. They may well conclude that he’s too erratic, self-absorbed, dishonest, confused and ignorant to be president. They won’t need a doctor to tell them that.

The Sullivan Ballou letter would have sounded a little different. Cue the sad violins. (Video: Adriana Usero/The Washington Post)