Fending off allegations in the Jeffrey Epstein scandal, he said publicly that he had a “perfect” sex life. That prompted Yale psychiatrist Bandy Lee to note that Dershowitz’s language was similar to the way Trump had described his “perfect” phone call with Ukrainian President Volodymyr Zelensky. Given “the severity and spread of ‘shared psychosis’ among just about all of Donald Trump’s followers,” she tweeted, it was quite possible that Dershowitz’s comment about perfection demonstrated his similarity to Trump. Dershowitz, she asserted, had the same lack of empathy and “grandiosity and delusional-level impunity” as his client.
Dershowitz labeled these accusations “absurd.” He also claimed Lee’s behavior was “unethical” and violated the American Psychiatric Association’s (APA) Goldwater Rule, which prohibits psychiatrists from commenting on the mental health of, or diagnosing, public figures without examination and consent. Lee equivocated on whether she was making a diagnosis and on what she meant by psychosis, but she stood her ground on her duty to call out the behavior of ill and unsafe public figures. But Lee shouldn’t have to fear repercussions. Nor should other psychiatrists who want to speak out in the Trump era. The Goldwater Rule, adopted to protect public figures and the image of psychiatry, needs to be changed to protect psychiatrists of conscience.
Is it ethical for a psychiatrist to comment on the mental health of a public figure? The question is far from new.
During World War II, psychoanalysts Erik Erikson and Walter Langer assessed Hitler for the Office of Strategic Services to assist the fight against Nazism. Although Langer conscientiously noted the limits of his ability to diagnose from a distance, he said Hitler had a sexual perversion and a messiah complex and could well die by suicide if cornered by the Allies.
“That might well have been the last situation,” said psychiatrist Robert Jay Lifton when the profile became public, “in which an American scholar could surrender his product [to the government] so unquestioningly without surrendering his integrity as well.”
During the 1964 presidential election, controversy erupted again. Publisher Ralph Ginzburg of Fact magazine (“not for squares”) ran a provocative profile of Republican candidate Barry Goldwater, asserting he was paranoid and unfit for office. Ginzburg surveyed every psychiatrist in the United States and published a selection of responses.
Most of them bashed Goldwater as unfit. His “proneness to aggressive behavior and destructiveness,” said one, “indicates an attempt to prove his manliness.” “He is a mass-murderer at heart and a suicide,” said another. As became clear when Goldwater brought a libel suit, Ginzburg had heightened the impact of many of the psychiatrists’ responses by editing them.
Goldwater saw the profile and the survey as gross violations not only of libel law, but also of medical ethics. He hoped to prevent scurrilous attacks on future politicians, especially conservatives. The APA also objected to Ginzburg’s effort.
These objections led to significant consequences: Goldwater won his libel suit, and after a lengthy internal process the APA adopted its “Goldwater Rule” in 1973. Throughout the process there was internal disagreement about the rule; one APA trustee proclaimed one cannot “legislate against stupidity.” The APA should have listened more closely to such dissenting opinions. By adopting a rigid prohibition, the organization overreached, preventing comments that sometimes can be morally and ethically sound.
For one thing, the rule only limited comment in the media. That generally meant comment initiated by individual psychiatrists of conscience concerned for the national welfare. In contrast, the APA never intended to prevent CIA psychiatrists from creating profiles of foreign leaders without interview or consent — even as part of war efforts that could lead to the foreign leader’s death.
Government profiling has other hazards. In 1971, as the APA was formulating the rule, President Richard Nixon grew furious at antiwar activist Daniel Ellsberg for his leak of the Pentagon Papers. Nixon’s staff pressured CIA psychiatrists to discredit Ellsberg by creating a psychological profile of him, for the purpose of “trying Ellsberg in public.” When the profile instead became a public scandal, the APA issued general statements about the risks of profiling but did not respond publicly to the profile, even though a prominent member had asked the group to censure the CIA psychiatrist responsible.
This was starkly different from the reaction to the Goldwater case. In 1975 the APA actually tightened the ban on media comment by individual psychiatrists, while continuing to regard profiling for government agencies as ethically acceptable. The APA says it aims to protect public figures, and it sees psychiatric work commissioned by the government as having a legitimate foundation — but given the risks of government profiling, it is hard to avoid the impression of a double standard.
In the 1990s, when psychiatrists were tempted to comment on Bill Clinton or on the suspected perpetrators of mass shootings, the organization issued reminders to avoid media comments. In the early 2000s, however, psychiatrist Jerrold Post challenged his organization’s thinking, making the argument that in circumstances of national danger created by an ill public figure, it may actually be unethical to withhold comment. Nonetheless, the rule stayed in place.
In the Trump era, it has faced challenge anew. Two prominent psychiatrists — Judith Herman, a trauma expert, and Lifton, an expert on how German physicians adapted to Nazism — have developed Post’s notion that in morally urgent circumstances, a psychiatrist’s obligation to society can override the rule. Lifton argues for a concept he calls “malignant normality,” in which a tyrant’s rise slowly erodes society’s usual moral norms and followers lose their ability to appreciate what is right. Then more than ever, he believes, it is important for professionals to speak out about the dangers evident in the tyrant.
Lee is not a member of the APA, so technically her recent comments on Dershowitz and Trump don’t violate the Goldwater Rule. But the rule sets the tone for ethics guidelines in psychiatry at large and in other mental health professions. Lifton, Herman and Post have joined Lee in the argument that President Trump has created a situation of malignant normality in collaboration with his misguided followers — an argument that may inform Lee’s comment about “shared psychosis.” From this point of view, it is important to challenge misguided government officials, not to collude with them.
The APA has done much good and, I believe, sincerely intends its rules to be helpful (I myself am a member). But the Goldwater Rule was flawed from the beginning. Its rigid approach has at the very least now outlived its usefulness.
Lee’s assertion that Trump and most of his followers are psychotic will strike many as naive, but it is not unethical. Psychiatrists have the right, and even a responsibility, to speak out thoughtfully in circumstances that they believe jeopardize the safety of the nation — and to speak out without fear of ethical retribution.