Goldwater rule
Based on Wikipedia: Goldwater rule
In 1964, a magazine asked over twelve thousand psychiatrists whether Barry Goldwater—the Republican presidential nominee—was psychologically fit to have his finger on the nuclear button. Over two thousand responded, and many didn't hold back. They called him paranoid, grandiose, a dangerous lunatic who might trigger World War III. The magazine published these armchair diagnoses under the provocative title "The Unconscious of a Conservative"—a cheeky jab at Goldwater's bestselling book, The Conscience of a Conservative.
Goldwater lost the election in a landslide. But he won something else: a landmark lawsuit against the magazine that would reshape how mental health professionals talk about public figures for generations to come.
The Birth of an Ethical Firewall
The magazine in question was Fact, edited by Ralph Ginzburg—a provocateur who had previously tangled with obscenity laws. Goldwater sued Ginzburg and his managing editor Warren Boroson for defamation. In 1969, the courts sided with Goldwater, awarding him $75,000—equivalent to roughly $640,000 today.
The psychiatric profession was mortified. Here were credentialed doctors diagnosing a man they'd never met, based on television appearances and political speeches. The American Psychiatric Association, or the APA (the organization representing psychiatrists, not to be confused with the American Psychological Association, which represents psychologists—a distinction that becomes important later), decided to act.
In 1973, the APA codified what became known as the Goldwater rule into Section 7 of its Principles of Medical Ethics. The rule has two parts, and understanding both is crucial.
The first part establishes an affirmative duty: psychiatrists should participate in activities that improve public health and community wellbeing. They should speak up. They have expertise the public needs.
The second part, Section 7.3, adds a critical caveat: while psychiatrists can share general expertise about mental health topics, they cannot offer professional opinions about specific individuals unless they've conducted a personal examination and received proper authorization to speak publicly about it.
It's an elegant compromise. Speak to the issues, not the person. Explain what narcissistic personality disorder looks like in general, but don't declare that Senator So-and-so has it.
The Irony Behind the Rule
Here's a delicious bit of historical irony that often gets overlooked: the American Medical Association, which pressured the APA to adopt the Goldwater rule in the first place, had actively supported Barry Goldwater's presidential campaign in 1964. The AMA was one of the most politically active medical organizations of the era, deeply hostile to what would become Medicare and viewing Goldwater as their champion against socialized medicine.
So when psychiatrists embarrassed the profession by playing armchair analyst with their preferred candidate, the AMA had both ethical and political motivations to shut it down. The rule that emerged served multiple masters: professional decorum, patient privacy principles, and perhaps a bit of partisan score-settling.
Decades later, in fall 2017, the AMA would write its own version of the guideline, explicitly stating that physicians should refrain from making clinical diagnoses about public officials, celebrities, or newsworthy individuals they haven't personally examined.
What Makes Psychiatric Diagnosis Different
To understand why this rule matters, you need to understand what psychiatric diagnosis actually involves—and why it's fundamentally different from, say, a cardiologist observing that a politician seems short of breath.
Mental health diagnoses aren't based on blood tests or brain scans. They emerge from extended interviews, careful observation of behavior over time, gathering history from family members, and ruling out other explanations. A single manic episode doesn't make someone bipolar. A few grandiose tweets don't constitute narcissistic personality disorder. Context matters enormously.
Someone might display what looks like paranoia but actually be responding rationally to genuine threats. A person might seem emotionally flat on camera but be vibrant in private life. Politicians, in particular, perform versions of themselves calibrated for public consumption. Their public persona may bear little resemblance to how they think, feel, and relate in intimate settings.
There's also the matter of consent. The doctor-patient relationship is built on trust and confidentiality. Diagnosing someone without their knowledge turns psychiatric expertise into a weapon—one that carries enormous stigma and can't easily be refuted. How does a public figure prove they don't have a personality disorder? The accusation itself becomes the story.
The Trump Era Stress Test
For decades, the Goldwater rule operated as settled professional consensus. Then came 2016.
Almost immediately after Donald Trump's election, mental health professionals began breaking ranks. They described what they saw as grandiosity, lack of empathy, impulsivity, and something ominously called "malignant narcissism"—a term that sounds clinical but isn't actually in the diagnostic manual.
The debate wasn't merely academic. These were credentialed experts with institutional affiliations publicly declaring that the President of the United States had dangerous mental illness. They argued that staying silent was itself unethical—that their expertise obligated them to warn the public, not protect the profession's reputation.
Bandy X. Lee, a forensic psychiatrist at Yale School of Medicine, became the most visible face of this movement. She argued that diagnostic practices had evolved since the 1970s. Modern psychiatry, she claimed, relied more on observable behavior than on the patient interviews that the Goldwater rule presupposed. If you could watch hours of someone's public conduct—speeches, interviews, tweets, rallies—couldn't that constitute adequate observation?
Lee organized thousands of mental health professionals into the World Mental Health Coalition, explicitly positioning the group against what she characterized as the APA's abdication of its public health responsibilities. In December 2019, she led a group that urged the House Judiciary Committee to consider Trump's "brittle sense of self-worth" as relevant to impeachment proceedings.
John Gartner, a psychologist leading a group called Duty to Warn, put it bluntly: "We have an ethical responsibility to warn the public about Donald Trump's dangerous mental illness."
The Organizational Alphabet Soup
The controversy exposed something the public rarely notices: the mental health profession isn't monolithic. Different organizations have different rules, and the distinctions matter.
The American Psychiatric Association (the APA that promulgated the Goldwater rule) represents psychiatrists—medical doctors who specialize in mental health and can prescribe medication.
The American Psychological Association (confusingly, also abbreviated APA) represents psychologists—professionals with doctoral degrees in psychology who typically provide therapy but generally can't prescribe drugs. This second APA doesn't have a Goldwater rule per se, though its leadership has argued that various provisions in its ethics code would apply to armchair diagnoses of public figures.
Then there's the American Psychoanalytic Association, abbreviated APsaA (note the lowercase "s" and additional "a"), which represents psychoanalysts—practitioners of the talk-therapy tradition descended from Sigmund Freud. Psychoanalysts can be psychiatrists, psychologists, or social workers; it's a theoretical orientation rather than a degree.
In June 2017, APsaA published a letter emphasizing that it had never adopted the Goldwater rule and didn't consider political commentary by its members to be an ethical matter. This created a media frenzy. Stat published an article with the headline "Psychiatry Group Tells Members They Can Defy 'Goldwater Rule' and Comment on Trump's Mental Health."
Critics pointed out this framing was misleading. APsaA wasn't changing any policy—it had never had the rule. And while individual APsaA members could offer personal opinions about politicians, the organization itself unanimously agreed it would only speak to issues, not specific political figures. The crack in the professional consensus was narrower than the headlines suggested.
The Man Who Wrote the Criteria
Into this heated debate stepped Allen Frances with a peculiar authority. Frances had chaired the task force that created the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders—the DSM-IV—which means he literally wrote the diagnostic criteria for narcissistic personality disorder.
In February 2017, Frances wrote a letter to The New York Times with a blunt message: Trump doesn't meet the criteria for narcissistic personality disorder. The diagnosis requires that the traits cause significant distress or impairment in functioning. Whatever else you might say about Trump, Frances argued, the man seemed to be functioning rather well—he'd just won the presidency, after all.
This created an awkward situation. The APA had to point out that saying someone doesn't have a mental illness is also a professional opinion about their mental state. Frances had violated the Goldwater rule while trying to defend Trump from psychiatric labeling.
The episode illustrated something important: the rule isn't just about protecting individuals from stigmatizing diagnoses. It's about keeping psychiatry out of political disputes altogether. The diagnosis and the rebuttal are both forms of professional opinion that the rule seeks to prevent.
When Experts Speculate Anyway
In September 2017, Jeffrey Lieberman—a past president of the American Psychiatric Association itself—published an article that began by affirming his commitment to the Goldwater rule and then proceeded to extensively speculate about Trump's mental state anyway. He arrived at a working theory of "incipient dementia."
Lieberman faced no professional sanctions.
This points to one of the rule's awkward realities: it's largely unenforceable. The APA can't revoke medical licenses; that power belongs to state medical boards. The worst the APA can do is expel a member from the organization. For prominent psychiatrists with established practices, this is more an embarrassment than a career-ender.
Critics of the APA during this period raised another uncomfortable question: conflict of interest. The APA receives federal funding for various programs, and that funding had increased after actions taken under the Trump administration. Was the organization's insistence on the Goldwater rule principled neutrality, or was it protecting its financial interests?
The Deeper Question
Strip away the partisan heat, and the Goldwater rule forces us to confront something fundamental about expertise and democracy.
On one hand, mental health professionals have specialized knowledge the public lacks. If they see warning signs of dangerous instability in someone with nuclear codes, shouldn't they speak up? The ethical principle of "duty to warn"—which requires therapists to alert potential victims if a patient threatens violence—suggests that some obligations override confidentiality and professional decorum.
On the other hand, psychiatric diagnosis carries enormous stigma and is easily weaponized. Throughout history, political dissidents have been labeled mentally ill to discredit them. Soviet psychiatry infamously diagnosed opposition to communism as a form of schizophrenia. The appearance of scientific objectivity makes psychiatric labels particularly powerful—and particularly dangerous when applied to delegitimize political opponents.
There's also the question of what professionals actually contribute. When a psychiatrist says a public figure displays narcissistic traits, are they offering expert insight unavailable to ordinary observers? Or are they just putting a clinical gloss on impressions anyone could form from watching the news? If it's the latter, the professional credential adds false authority without adding genuine knowledge.
Beyond Goldwater
The rule's namesake died in 1998, but his ghost haunts every election cycle. Each time a controversial figure rises to prominence, the same debate resurfaces. Should mental health experts weigh in? Are they helping the public or just playing politics?
The rule itself remains in effect as of this writing, but its status is contested. Those who defend it argue that professional restraint protects both the integrity of psychiatry and the rights of individuals—even famous individuals, even powerful individuals—not to be publicly diagnosed by strangers. Those who oppose it argue that it places professional etiquette above public safety and creates a perverse situation where experts must stay silent precisely when their expertise matters most.
Neither side has won definitively. What's clear is that the 1964 magazine survey—with its lurid speculations about Barry Goldwater's unconscious—created a wound the profession is still trying to heal. The attempt to use psychiatric authority as a political weapon backfired spectacularly then, discrediting both the specific claims and the idea that such claims were appropriate at all.
Whether that lesson applies equally to every era and every candidate remains the question. The Goldwater rule says yes: the line between clinical expertise and political opinion is too easily blurred, and the profession should stay behind that line. Its critics say no: some situations are dangerous enough that silence itself becomes complicity.
The debate continues. It probably always will.