And I don’t even like Trump
So yesterday, this happened.
https://www.statnews.com/2017/07/25/psychiatry-goldwater-rule-trump/
Yep. The American Psychoanalyst Association (APsA—not to be confused with the APA—American Psychiatric Association) yesterday relieved its members of what’s known as “the Goldwater rule” against making statements about the mental health of public figures.
I think that was a bad move.
You might ask as my people might: What’s your own, since you’re Nigerian? Well, for one, I was actually asked to comment.
https://twitter.com/iam_sola/status/889846577388507138
But also, let’s face it, it’s a smaller world than ever, and events and opinions anywhere, and especially in America, can affect events and opinions anywhere, for good or ill. I think it’s for ill in this case.
First off, though, what exactly is the Goldwater rule?
Named after Barry Goldwater, an American presidential candidate who had the misfortune to be declared mentally unfit via a poll of psychiatrists in 1964, the rule states that…
Psychiatrists may share expertise about psychiatric issues in general but…it is unethical for a psychiatrist to offer a professional opinion about an individual based on publicly available information without conducting an examination.
—Section 7.3, The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Full document here (PDF).
I responded to the request to comment (see the first tweet in the thread below)—but I thought the whole thing was worth unpacking here.
So, would I offer a professional opinion on Trump?
I'd say no. Anyone, medical or not, can offer an opinion, but can one call it "professional" if it's not—you know—PROFESSIONALLY obtained? https://t.co/iMBNzqudMf
— Dọ́kítà Ayọ̀mídé ✊🏾 (@DocAyomide) July 25, 2017
And, believe me (as Trump would say), it’s not for any lack of appeal in the prospect of doing so. But that’s the thing: the fact that it’s so appealing is the more reason to take a closer look at it. After all, professionals should be driven by the helpfulness of things, not just their appeal, right?
So yes, it certainly is tempting to offer an opinion on Trump, and while we’re at it, on Nigerian politicians. But overall, it’s more harmful. To clarify why, allow me to back up and explain something about how medicine works.
The inescapable guesswork in medicine
See, there’s something about medicine, and what doctors do, that many people don’t fully grasp. It is this: making a diagnosis is basically making a very highly educated guess, which is very often spot on, but it’s still a guess. And before you go all, “I knew it! Doctors don’t know jack!” let’s be clear: it’s not a guess because a doctor is being careless. It’s a guess because the system of systems that is the human body and mind is so complex, not guessing is literally impossible (and also why computers haven’t replaced us yet). So don’t go all, “I know doctors don’t know jack,” just yet.
But that’s not all. You see, this complexity isn’t just in the symptoms you have and how the same sets of symptoms can often mimic absolutely diverse conditions. It’s also in how each patient reports those symptoms, depending on their educational level, social class or cultural background. Every doctor has had patients telling them about symptoms they knew but in ways the doctor didn’t recognise because of the person’s way of describing it! (And, oh yeah, it’s also why, as convenient as it is to Google your symptoms, it’s a far cry from actually seeing a doctor who’s trained to interpret them.)
Like I said, very complex.
Doctors are like detectives
Think of medicine as detective work, where health conditions are the crimes, and your body as the crime scene. You are the main witness, and the physical examination and lab investigations are all in search of clues.
But there’s one thing any good detective knows: you don’t name suspects as criminals without proper trial.
Well, in medicine, “proper trial” means the medical consultation. You know, where you and the doctor sit down and talk about what you’re feeling, and maybe poke around your body a bit, and take blood samples and all.
Yeah, that.
What’s all this detective stuff got to do with commenting on Trump?
Everything.
You know that highly educated guesswork I spoke of? Well, to offer “diagnoses” or other kinds of “professional opinions” without consultation is to risk turning educated guesswork into just guesswork.
And this is in a world where it’s already typical for people to make pronouncements about their mental health all the time (I’m so OCD, I act so bipolar, I’m so depressed!, and such). We also very freely make declarations about the mental health of people we don’t like (he’s such a retard, she’s so schizophrenic, he’s insane), and of public figures (like, say, Kanye). But even setting aside the danger from normalising these “professional” opinions, dropping the Goldwater rule as an ethical guideline puts us all at risk of three great dangers.
Danger #1: Overconfidence
If public figure diagnosing becomes a thing, best believe the media will increasingly request it. In fact they already do, but to a limited degree. Removing the limits means you may expect full diagnoses, complete with predictions about outcomes and things. The present exception will become the future norm.
It’s not like we don’t talk about public diagnoses in private, but not with some sense that it’s all speculation. Put a media spotlight on that and you can be sure that sense will start to fade, because, human nature. And the reluctance to diagnose at a distance that every doctor learns early on will be replaced by a confidence in their ability to do so.
But remember we’re like detectives. A detective too eager to incarcerate suspects as criminals, without trial, is a potentially dangerous detective. (Except you’re Batman.)
Danger #2: Stigma
It’s bad enough how people just use one symptom to label people (including themselves): self-diagnosed “OCD”, “anxiety,” and such are everywhere, in our movies, music and real life. But lack of validity of these “diagnoses” aside, there is a more subtle danger: underlying them is the misconceived idea that psychiatric diagnoses are obvious, something anyone can identify with a bit of knowledge.
Think about it: how readily do people pronounce others to have physical health conditions? Not so much, because there’s a sense in which the average person understands that it’s not that easy. But perhaps because mental health problems often have behavioural components, there’s a sense of popular comfort with making them, and thereby labelling people.
Which is basically what stigma is all about.
But the behavioural components are exactly why this should be avoided, because behaviours in themselves are often nonspecific: they can be influenced by anything and mean anything.
So freely offering “professional” opinions will only reinforce an idea that any detective worth their salt knows and avoids: the idea that it’s okay to skip trial and just shoot suspects on sight based on what you “know.”
It’s not. (Unless, again, you’re Batman.)
Danger #3: Disrepute
Perhaps worst of all: this can only help discredit mental healthcare as a profession. Some historical context is necessary here. Psychiatry as a medical field is fairly new (dating only to about mid-19th century), whereas the history of stigma against mental illness is older than medicine itself. So it’s hardly surprising that the early days of the specialty were tragically marked by the use of psychiatrists to label people who were in disfavour with larger society or the ruling powers.
The labelling itself wasn’t new: what was new was the possibility of adding a professional veneer to it. And psychiatry is inherently prone to this kind of abuse by virtue of being the only specialty requiring involuntary admission of people. The line is thin, and we don’t need to blur it out any further. On top of that, all the work psychiatry has done to become more scientific has yet to grant it full recovery in the public eye from the stain of its shady history (more at Wikipedia’s political abuse of psychiatry article).
And we want to risk throwing all that away just because of Trump? Fine. Keep in mind, though: it might be Trump today.
But what if the tables turn tomorrow? What then?
For more on the APA’s decision to stand by the Goldwater Rule, and their well-thought through responses to the commonest objections, read this (PDF).
Update
There’s a fourth danger, described well by Alysha Fung Koehler in a comment:
https://www.statnews.com/2017/07/25/psychiatry-goldwater-rule-trump/