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