Diagnosing Trump

It doesn’t take too much time on the internet to find people talking with some measure of incredulity about Donald Trump.  Some of this talk takes the tone of horrified fascination; some of it is mocking (and is accompanied by correspondingly mocking images); and some people are wondering aloud about his mental health.  In this last category, there’s a couple of sub-categories: sometimes, people are not really talking in earnest; sometimes, though, they are.  What if the forty-fifth President of the United States of America has some kind of mental illness, or some kind of personality disorder?  What if this affects his ability to make decisions, or increases the chance that he’ll make irrational, impulsive, and potentially dangerous decisions?

This does raise questions about the proper conduct of the medical profession – particularly, the psychiatric profession.  Would it be permissible for a professional to speak publicly about the putative mental health of the current holder of the most important political office in the world?  Or would such action simply be speculation, and unhelpful, and generally infra dig?  More particularly, while the plebs might say all kinds of things about Trump, is there something special about speaking, if not exactly ex cathedra, then at least with the authority of someone who has working knowledge of cathedrae and what it’s like to sit on one?

As far as the American Psychiatric Association is concerned, the answer is fairly clear.  §7.3 of its Code of Ethics, which you can get here, says that

[o]n occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

This rule is nicknamed the “Goldwater Rule”, after Barry Goldwater, the Senator who sued successfully for damages after a magazine polled psychiatrists on the question of whether or not he was fit to be President.  Following the rule would appear to rule out making any statement about whether a President has a mental illness, a personality disorder, or anything else that might appear within the pages of the DSM.

Over on the BMJ‘s blog, Trish Greenhalgh has been wondering about what a doctor may or may not do in cases like this:

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?

Her post is long, but it does generate an answer:

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. […] 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.

Her phrasing is such as to leave no bet unhedged – she’s careful not to say that she’s talking about anyone in particular; but, beneath that, the message is clear: it might be justifiable to depart from the Goldwater Rule to some extent in certain hypothetical circumstances.

My post in response will also be long – in fact, it’s going to spread out over two posts.  I think she’s plausibly correct; but the way she gets there is not persuasive.

First things first: here’s how Greenhalgh sets out her stall:

For some people, it would not be permissible to attempt to diagnose a public figure.  If the figure is not the practitioner’s patient, there’ll be insufficient evidence; if the figure is, then there’ll be breach of professional confidentiality.  “This,” she says, “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).”  On the other hand, one might be more utilitarian, and appeal to the optimific outcomes that one hopes to derive from maintaining or breaching confidentiality on a case-by-case basis.

OK: now I’m going to interject here, wave my medical ethicist flag, and point out that many deontologists think that maintaining confidentiality is morally required.  So it could be a deontological position.  But there’s nothing in the very structure of deontology to say that we must maintain confidentiality: the form and content of a moral theory are not the same.  Deontology doesn’t tell us what to do any more than Pythagoras’ theorem tells us that the hypotenuse is 7.3cm long.  Like a mathematical theorem, a moral theory tells us how to think about a problem; nothing more.  And, working the other way, it’s perfectly possible for non-deontologists to think that one should always maintain confidentiality.  There’re perfectly good utilitarian arguments to that effect.  For that reason, the idea that utilitarians look at things case-by-case is also mistaken.  Some might.  Others might be rule-utilitarians.

Neither is it a matter of confidentiality.  No confidence has been given.  There is no relationship – as far as we know – between Trump and the pundits.  Thus the question is not one about maintaining confidentiality: it’s about speculating based on publicly-observed behaviour.  That might be infra dig in many cases; but whatever we happen to think about the scope of duties of confidentiality, it won’t apply here.  This is important, because you can’t give a decent answer to a moral question unless you’ve identified the terms of the debate correctly.  What we’re talking about in this kind of case is not a breach of confidentiality, but about speculation.  Note, too, that when it comes to what medics – specifically, psychiatrists – may or may not do in cases like this, it’s not just any old speculation: it’s informed speculation.

That might yet be morally iffy; but it might not.

One final point on confidentiality: the convention that’s grown up after Tarasoff is that an HCP may breach confidentiality if and only if the patient poses an identifiable threat to an identifiable person.  That’s fine in most cases.  But it doesn’t seem to fit particularly well when it’s a Head of State who’s the source of concern.  In cases like that, we may not be able to identify particular people who’re at threat in identifiable ways: we may be able to do no more than wave vaguely out of the window, or mutter about future generations.  That’s precisely because the potential threat is so huge.  Yet it’d be very odd to say that we couldn’t raise the alarm because the thing about which we’d be raising it is too significant to relate to particular persons.  Therefore the Tarasoff convention doesn’t really fit.

As Greenhalgh admits, there may be several reasons to err on the side of saying nothing about whether or not Trump or someone like him would fit in any of the DSM‘s categories.  For example, there’s a long an unfortunate history of people being labelled as mentally ill when they became politically inconvenient.  It’s a favourite trick of totalitarians the world over.  For that reason, maybe we should fight shy of calling political foes mentally ill.

This is fair enough on the face of it – but there’s an important difference between calling someone mentally ill because he’s a political opponent, and suggesting that a political opponent might be mentally ill (or has a personality disorder, or whatever).  Correspondingly, it’s fallacious to think that because some people used mental health as a cover for political Machiavellianism, everyone who talks about mental health in a political context is behaving in the same way.  Note too that there’s a power dynamic involved in the grimmer historical examples that isn’t at play here.  Stalin could label his opponents as mentally ill and get rid of them that way, but Stalin was Stalin.  He had the power.  In our current case, it’d be a stretch to think that the power dynamic is even vaguely similar.  Take heed of the warnings from history – but apply them with discrimination.

Here’s another reason to steer clear of speculating about Trump’s mental health: that it’s stigmatising.  The “dangerous lunatic” caricature makes life unnecessarily difficult for those who have a mental illness and those around them, and reduces the chance that the sufferer is going to seek help for it.  If your only image of mental illness is an image of a padded cell, you’d be have to be nuts to see your doctor.

Again, though, I don’t think that this concern need carry much weight in this case.  Presumably, the worry is that Trump might be showing signs of the kind of thing that’d make serious errors of judgement more likely.  And it’s at least possible that the worries are on to something.  Is this stigmatising of all mental illness?  Not in itself: the stigma is already there.  And the worry about stigma is a slightly strange one to raise if the claim about mental health is made in good faith.  Indeed, to refuse to ring a warning bell that in this case may be appropriate because one is concerned about attitudes to mental illness in the world at large is to allow those with stigmatising attitudes to set the terms of the debate – not just in this case, but in all cases.  In other words, it may perpetuate the stigma that one is aiming to avoid.  And, though it’s probably not decisive here, the stigmatisation point is hard to separate from the fact that many people with mental illness are, or end up, socially marginalised.  The billionaire President of the most powerful nation on the planet is not in a comparable position.

Still: that these concerns aren’t wholly convincing won’t generate a reason to diagnose.  The default is still saying nothing.

But it seems to me that those with medical insight possibly shouldn’t feel bound by the Goldwater Rule.  For one thing, as I hope is clear, I think that there’s a world of difference between the PotUS – or, really, any head of government – and a normal mortal.  For my money, medical diagnoses shouldn’t be publicly accessible or publicised; but there might be good reasons to breach this rule on occasion.  I’m a big fan of the principle that exceptio probat regulam in casibus non exceptis: being prepared to draw an exception from a rule proves that the rule does hold in unexcepted cases.  Sometimes these reasons’ll be for the good of the patient; sometimes for the good of a third party.  When it comes to the PotUS, like Greenhalgh, I’m open to persuasion, but my gut feeling is that there’s a reason to speak that doesn’t apply in normal cases.  Everyone on the planet has a very strong interest in the PotUS not being a paranoid narcissist.  If the PotUS is showing all the signs of paranoia and a narcissistic personality disorder…  Well…

And so I’m with Greenhalgh in the claim that what medics should do is qualify their statements: to make it clear that they are not offering a diagnosis in the normal sense, based on case history and consultations with the patient, and that they’re simply bringing a professional eye to publicly-observable behaviour.  They should make it clear which role they’re currently occupying.  Nevertheless, they can still say that there is, in their professional judgement, reason to think that such-and-such is the case.  To that extent, it’s not particularly different from someone who’s employed as a public hygiene inspector deciding not to order food from a certain pub, and warning others not to, based on the appearance of the place and years of experience.

(Going back to the point about speaking ex cathedra, the seat from which the pundit is speaking is not that of Trump’s physician.  Whether Trump’s physician should speak out is a further question; depending on the diagnosis, he or she might.  So, for example, if a President or military leader is showing signs of some kind of paranoia, that is very likely in the public interest.  If it’s a manageable case of depression, it isn’t.  Of particular relevance here is a report about Trump’s former physician saying that he takes Propecia, a baldness treatment that is associated with mental confusion.  Is knowing that in the public interest?  It might be.  It certainly seems reasonable to think that someone holding the highest public office ought to discount the importance of thinning hair if the preferred treatment for it impairs mental function; and it’s not self-evidently unreasonable to think that the public has a right to know about the President’s priorities, especially since going bald is not an illness that one would normally have the right to keep private.)

Besides: there might also be psychiatrists who’d be prepared to go on record to say that he’s probably not mentally ill, or doesn’t have a personality disorder.  Maybe this is Trump sane.

Now there’s a scary thought.