Trish Greenhalgh: “Do doctors have a duty to hold their silence or to voice concern about Donald Trump’s health?”

Donald Trump may or may not have a mental illness. As a doctor, it would be unprofessional of me to comment on that question. Or would it?

Like many liberal-minded people, I find Trump’s opinions and actions abhorrent. I have joined in social media condemnation of his policies and questioned his personal integrity. I have retweeted cartoons that mock Trump, because I view satire and parody as legitimate weapons in the effort to call our leaders to account.

But as a doctor, should I go further? Should I point out the formal diagnostic criteria for a particular mental illness, cognitive condition, or particular personality disorder and select relevant examples from material available in the public domain to assess whether he appears to meet those criteria? As a medical academic with an interest in evidence-based medicine, should I summarise research evidence for and against allowing someone with said illness or disorder to hold senior public office?

I put this question out on Twitter. Of my 25,000 followers, many are doctors or psychologists. They were divided in their responses.

Some responders took the absolute position that no doctor should ever pass any comment on the health of a public figure because either a) they do not know all the medical details or b) if they did, they would be bound by professional confidentiality. This is known by medical ethicists as the deontological position (the doctor’s over-riding duty is to the individual whose putative illness is in question). It was the implicit basis of Hannah Jane Parkinson’s recent Guardian piece. “No-one should be diagnosed at a distance—even Donald Trump.” Parkinson quoted Sir Simon Wessely, president of the UK Royal College of Psychiatrists, saying that psychiatrists would deserve to be “struck off” the medical register if they ventured a clinical opinion on Trump’s mental state (Wessely later clarified to me that he was referring to those in a clinical role when he used the words “struck off,” and not to those who may speculate from a distance).

Others who responded to my Twitter question took a more nuanced view. One distinguished between “speculating on media celebrity and [advocating] serious caution re fascist leaders.” Another said “We mustn’t speculate about health of friends or neighbours. But [what] if [they] seem visually impaired and drive a school bus?”. These are examples of a utilitarian ethical position, which justifies the means with reference to a (hoped-for) better ending for the majority.

Journalists in the USA, for example Susan Milligan, have cited clinical opinion that Trump may be dangerously mentally ill and implied that there is an over-riding moral requirement to formalise this diagnosis and if necessary remove him from office for the greater public good.

Some responders to my tweet felt that whatever Trump’s mental state, its nature was clear enough to the people voting for him and that he therefore has a mandate to exercise the level of personal integrity and quality of judgement for which the American people voted. Trump, said one responder, “is a political, not a psychiatric problem.” Several people quickly replied that (in their view) he is both.

Some felt that there were more pragmatic reasons not to venture psychiatric diagnoses. They argued that unless made with the individual’s own health needs as the prime purpose, such diagnoses do not help achieve the public-interest objective (because there are more effective ways of restraining Trump in the event that he oversteps his brief), and may serve to increase the stigma carried by those with mental health conditions (because they conflate “bad” with “ill”).

One doctor took the view that we should never use mental health diagnoses in jest or as part of a satirical critique. If I want to use humour to highlight the absurdity of Trump’s rise to power, I can tweet about his impetuous sex drive, his comb-over, and his lack of diplomacy, but not about a (hypothetical) DSM-5 diagnosis. This, surely, is an important rider even to a utilitarian argument.

Joking aside, what would be the grounds for a serious commentary, by a doctor, on the possibility of Trump being unfit to serve as President on medical grounds? As Hannah Jane Parkinson pointed out, US psychiatrists are professionally barred from doing this by the so-called Goldwater rule (“it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement”). This recommendation followed a 1964 legal case brought by a contender for the US presidency who lost the election after more than 1000 psychiatrists responded to a survey by declaring him mentally unfit to serve.

As a UK doctor, I am bound by a different set of professional principles—specifically, the General Medical Council’s (GMC’s) Duties of a Doctor, which—to my surprise—does not explicitly cover the question of a doctor’s duty towards a public figure who is not his or her patient.  The GMC guidance conveys a general expectation of professional decency and restraint, including but not limited to the use of social media. It also says (paragraph 4) that You must use your judgement in applying the principles to the various situations you will face as a doctor… [and] be prepared to explain and justify your decisions and actions.

My reading of the GMC guidance is that in extreme circumstances, even acknowledging the expectation of how doctors should normally behave, it may occasionally be justified to raise concerns about a public figure (for example, when the individual is relentlessly pursuing a course of action that places many lives at risk). Expressing clinical concern in such circumstances seems to involve a comparable ethical trade-off to the public interest disclosure advice (Duties of a Doctor paragraphs 53-56) that breach of patient confidentiality may be justified in order “to prevent a serious risk of harm to others.”

That said, it is important to recognise that the two situations—stating that one’s own patient is medically ill and wondering whether a public figure may be medically ill—are not the same. The former is an informed clinical opinion; the latter is clinically-informed speculation. And here’s where I differ from the deontologists: I believe that on rare occasions it may be ethically justified to offer clinically-informed speculation, so long as any such statement is clearly flagged as such. Note the school bus analogy above—the tweeter is concerned that the driver seems visually impaired, not that they have been definitely diagnosed as visually impaired. Is it more ethical to raise a concern, or to fail to raise it?

I am a general practitioner, not a psychiatrist. Uncertainty is my stock-in-trade, and hedging is often my preferred communicative genre. When referring a patent to a hospital colleague, for example, I do not declare that patient X is suffering from disease Y; rather, I propose that the signs seem to point in that direction and that I would value an expert opinion and specialist diagnostic tests.

Any statement of clinical concern must be clear about its own provenance. In particular, the limitations of press reports and (for example) tweets emanating from an account attributed to the individual must be acknowledged. Clinical equipoise must be maintained (I have much sympathy with the tweeter who warned that “calling people mentally ill because you disagree with them has a long and shameful history”). But with those caveats, I believe that there is no absolute bar to a doctor suggesting that in his or her clinical opinion, it would be in the public interest for a particular public figure to undergo “occupational health” checks to assess their fitness to hold a particular office.

When this issue took off on Twitter, it took me a while to decide which side of the fence to come down on. I’ve enjoyed an exchange of tweets with doctors, psychologists, and mental health service users who disagree with me. I wrote this blog to promote further debate on the topic and invite the GMC to clarify its position on it. I may yet be persuaded to change my mind.

Trish Greenhalgh is Professor of primary care health sciences at the University of Oxford.

Twitter: @trishgreenhalgh

  • Tom Woodcock

    Will you allow Donald Trump to read your tweets / blogs and comment on your mental health in return? IMHO you are abusing your professional privilege. Really want to know what GMC thinks? Publicise your diagnosis of Mr Trump and self-refer to MPTS.

  • JC

    Not sure I have understood which side you are on? As a Mental Health Act Manager I have often grappled with what behaviour is perceived as threatening and what is real. Just because we have different values to some about cleanliness, ideology, values or behaviour doesn’t mean it is wrong. In the case of a world leader the judgement must be made by those closest to him who have no particular axe to grind. In this case I think Donald Trump is exposing very challenging behaviour for a President but is it so for a business man? Like you I am very alarmed at what has been happening over the last 7 days the like of which we have never witnessed with a new President in the White House. But with my Mental Health Act Managers hat on I am not sure this should be described in the terms of illness. I may be wrong and where does that leave us?

  • David Pilgrim

    Thanks Trish for raising this matter and offering your own view. I write as a clinical psychologist and critical realist. I reject the scientific legitimacy of all psychiatric diagnoses in principle. However, I do not reject the claims that the individual aspects of conduct that those diagnoses subsume are real. People do hear voices, have low mood, are scared etc. In the case of Trump the contention is not whether he is mentally disordered or not (in orthodox terms he might fulfill criteria for narcissistic personality disorder or even psychopathy- by the way neither are even included in DSM/ICD for now) but whether the specific aspects of his conduct are deemed to be self-centred and dangerous. The latter are (to my mind valid) ordinary moral judgments and do not require medical expertise at all. He is a selfish and nasty bully who also holds misogynistic and racist views.. So the question for me is less his mental state (even if it is important) but the social processes whereby the guy has got elected. It is the complicity of half the US voters that is at issue here. Narcissist individuals are ten a penny (look at who runs any organisation or wants to be a politician or likes the role of ‘president’ of anything). The socio-political question is why people like him and are complicit in his indecent intentions. Then we get into psychological aspects of authoritarianism in general and fascism in particular That is really important: the diagnosis debate can distract us from it.

  • Rob Poole

    I was the “Trump is a political, not a psychiatric problem.” responder. It is relevant that I am a psychiatrist and an unapologetic socialist. To me there are two overwhelming arguments for declining to see Trump as “unwell” or “disordered”. Firstly, he is a horrible and, in all likelihood, bad man. This is not a symptom of mental disorder. Generally speaking, from McNaughton onwards, it has been recognised that when people with mental disorders behave badly, it is because their ability to make a proper judgement is impaired. Badness, in itself, cannot be a criterion for mental disorder. This kind of politically normative diagnosis happened in the Soviet Union with respect to dissidents, and British, US and world psychiatry fought hard against it. People with personality disorders and mental illnesses are not like Mr Trump, and it really distresses them to suggest that they are. Secondly, let’s examines consequences. So…stigmatising and counter productive. Don’t do it.

  • Patricia Hughes

    ‘Diagnosing’ personality disorder in individuals whose behaviour is antisocial or erratic does not generally help displace them. Better to wait till they do something so unacceptable or even criminal that there are legal grounds to take action. In the situation of employment, if a psychiatrist has examined a person and given a diagnosis of personality disorder, that person may (and often will) argue that under the disability discrimination act they cannot be dismissed. Not a route to follow if it can be avoided.

  • Christina Glaser Hall

    I read with great interest Dr. H’s position as well as all comments. I am glad this forum exists.
    As a US RN for 20+ yrs and member of the healthcare community currently.
    It boils down to whether he is incompetent in my view, a very difficult thing to prove. I believe it’s harmful, distracting and not in our best interest to waste time debating over whether he has a mental illness or personality disorder. Half of America has and the other half are certainly developing anxiety disorders with all of this as we speak!
    I do think ” diagnosing from afar” is a very slippery slope and should not be done.
    Isn’t there some mechanism to simply necessitate a mental health evaluation? This ongoing debate can distract of from other issues…..

  • David Pilgrim

    Hi Rob I agree with your conclusion but not with the logic of how you got there. You say that ‘badness in itself cannot be a criterion for mental disorder’ but surely if you are committed to nosologies like ICD or DSM (I am not but you are!) then what of ‘dissocial PD’ or anti-social PD’? The notion of ‘malignant narcissism’ mainly derived from psychodynamic reasoning then sets up the older diagnosis of ‘psychopathy’ from Cleckley’s ‘Mask of Sanity (1941), which until recently was codified in sections of the British MHA. One way out our ambivalence is to operate an analog logic-we are all more or less self-centered and anti-social. That line of reasoning is psychological not psychiatric and can be found in Robert Hare’s work who, against the trend of ICD and DSM, keeps the tradition of Cleckley going but turns a categorical judgment into one of a continuum. Shall we agree that Trump is at one end of that continuum? There we are simply talking of nasty self-absorbed people who use others as a means to an end not an end in themselves thus violating one aspect of Kant’s categorical imperative. Trump is certainly one of them-we can all agree on that surely…..

  • GCW Cooper

    Completely unprofessional. This would be an abuse of the power you have as a doctor to further your own political thought. Claiming to be able to give an accurate mental diagnosis on such a public figure with such media bias and blurring of the facts from both sides is absurd. Making such a claim public is unethical. Simple logic. Feel free to express your political views, but using your power as a doctor in this arena is quite frankly disgusting.

  • exomike

    Am I still being moderated?

  • UKRegulator

    An excellent piece Trish. It will be interesting to watch the debate develop.

  • UKRegulator

    How exactly has Trish abused her professional privilege? What has she said or done that constitutes a breach of her professional obligations?

  • Rob Poole

    Hi Dave yes, we agree on that. I am always troubled by this idea that I, or the majority of psychiatrists, are “committed” to ICD or DSM and that these are our defining texts. They are not. Training as a psychiatrist, I was not taught to diagnose, I was taught to formulate. Of course the internet twitter debate has moved on to whether it is ethical to formulate Trump, and that is equally inappropriate in my view. It would be nice if people who see tyranny for what it is, and those of us who understand the most important mental health issue as inequality and adversity, could stop squabbling and pull together. PS my contribution was heavily moderated, and made more sense before that!