President Donald J. Trump, the ultimate conversation starter or completely the other way around, had his white house physical exam in January, 2018. Among all the regular items, his “cognition abilities” was especially brought to the public attention. On the official report of this physical exam,the physician to the president, Dr. Ronny Jackson, specifically mentioned that Mr. Trump voluntarily took a Montreal Cognitive Assessment test, MoCA, and passed with perfect score, 30/30. Though I would argue against using only a MoCA to evaluate one’s cognitive abilities, it is nevertheless very interesting to have a look at the whole mental fitness discussion around Mr. Trump eventually leading to the first ever cognition test performed on the president of the US.

“Trump is unfit!”

From what I could recall, the mental fitness, or rather, “unfitness”, arguments were brought onto the table during the 2016 election campaign. Clinton and Trump attacked each other with health issues, including mental health. They kept the use, or I would say abuse, of psychiatry to a relatively minimal level and refrained from commenting on each other’s health issues at a later stage. Around the same time, Duty to warn, was founded by Dr. John Gartner, who also started a petition on change.org which has already gathered over 70,000 petitions (as of 02.03.2018). Both request the removal of Mr. Trump from the office. More serious academic discussions, was led by Dr. Bandy Lee, a forensic psychiatrist from Yale University, who convened a conference “Duty to Warn” at Yale University and later edited the book “The Dangerous Case of Donald Trump”. Not surprisingly, their arguments suggests serious mental illness in Mr. Trump and are based on his behaviors on media reports and tweets. The situation was brought to the climax when Mr. Trump tweeted about his “bigger and more powerful” nuclear weapon button than North Korea. Numerous articles and discussion centered Mr. Trump’s mental health followed this tweet and posed pressure on the white house to respond on speculations on Mr. Trump’s mental situations, leading to mental state exam. Despite that MoCA is not the exam the opposition psychiatrists have fought for, the discussion quickly cooled down.

“Did the liberals forget about the Goldwater Rule?”

It is quite obvious that the Goldwater rule has been broken. The Goldwater rule is a nickname of Section 7.3 of the APA (American Psychiatric Association, not to be confused with American Psychological Association, although they have a similar rule) ethics code and concerns the incident which took place during 1964 US election. Fact magazine surveyed psychiatrists with astonishingly inappropriate methodology, and delivered the message that Barry Goldwater was “unfit to be president”, leading to his landslide lose. This section in the code of conduct was taken as APA’s formal response to the incident. The rule basically states that psychiatric diagnostic information should not be used imprudently in speculative and personal attacks. This rule has been the common sense for most psychiatrists around the globe and it is also applicable to figures in high offices, which should include Mr. Trump.

However, he is a very controversial figure and the controversies also suggest clear flaws in the Goldwater rule. Some, such as Dr. Bandy Lee have argued that the Goldwater rule is simply not absolute. She tried to circumvent the ethics code by claiming to be warning about the danger of violence. I find her arguments relatively weaker than proposals of Dr. Kroll and Dr. Pouncey, who went further and pointed out a crucial dilemma of the Goldwater rule: the dilemma for the mental health professionals to speak their conscience. There is no doubt that the anti-trump psychiatrists are acting out of their conscience, but the current system offers few opportunity for them to act on it. I would also add, that such dilemma is hindering a consensus on the issue. I believe the voice of psychiatrists should not be absent from the debate over politician’s mental health. I believe the debate should be a joint, continuing, and interdisciplinary discussion where experts from not only psychiatry and clinical neuroscience, but also the public media, applied ethics, sociology and every person who cares about their future should participate in. The Goldwater rule forbids almost any public discussion from the perspective of psychiatrists and therefore seems to be didactic. In short, it needs revision.

So can psychiatrists say anything now?

Of course NO. I have to clearly point out that though I too speculate Mr. Trump might be suffering from mental illnesses, I would not support any speculative diagnosis. Apart from the ethics code, there are some more obvious flaws in those speculations. First off, the frequent term that opposition psychiatrists refer to, “the duty to warn”, would not suffice to justify their grounds to make speculative diagnosis. “Duty to warn” is a common term for specific articles in US state-specific laws, which allows or mandates psychiatrists to violate the confidentiality of their patients, when this person has a clear intention and ability to harm anyone. Since Mr. Trump is not their client, they should not bear a duty to warn in legal terms. On the other hand, the duty to warn comes with the “duty to protect” the patient from possible harm, too. Since these psychiatrists do not exercise the duty to protect, they do not have a legal duty to warn either.

What’s more, it is still very much unclear whether tweets suffice as basis for diagnosis. There are recent attempts by social media companies equipped with deep learning techniques, which aim to flag out early signs of mental conditions from posts and tweets that could shed light on this topic. Deep learning algorithms are very powerful and could potentially provide us with important insights. However, the algorithms are still under development and not very reliable. It would be hard to judge if tweets can be taken as direct evidence for psychiatric diagnosis, especially since he is, you know, also a president and his tweets can carry underlying political messages.

After reading extensively on the criticisms around Mr. Trump’s mental health, I began to feel we might be seeing a possible case of political abuse of psychiatry. First of all, it is clear that all those speculations on Mr. Trump’s mental illness are aimed to, directly or indirectly, remove him from office. Second, those speculations are used as powerful weapons by opposition politicians, as to show the growing interests to remove Trump from office. Political abuse of psychiatry is not unusual and very powerful when used against someone: how could a crazy person prove that he is not crazy? We have witnessed numerous cases of such abuses: the aforementioned Mr. Goldwater is an unfortunate victim. The psychiatrists might be also threatening with their “big red button on the table”: the expertise to diagnose a person’s mental health and the trust of the general public in their expertise. This is the very reason why APA also wrote against violating the Goldwater. Also, the abuse of psychiatry downplay the previous efforts to reduce the stigma around mental illnesses. The psychiatrists have worked hard to spread the message that mental illnesses are not “craziness”, but rather more of an analogy to a “hidden common cold”. If we are openly suggesting Mr. Trump is unfit and should leave the office, are we suggesting that patients with similar illnesses should quit their job as well?

What’s next?

As I follow the debate and go down the rabbit hole, I feel more and more challenged on my view of psychiatry and politics. I do not believe one should simply ignore the general code of conduct, yet under the current system, there is almost no way to publicly address a psychiatrist’s political oppositions. Perhaps, only when the stigma around mental health is finally reduced and we can look at mental illnesses the same way as physical problems, we might be finally able to crack this ethical dilemma.

The feature image by johnhain(CC0 1.0). Thanks to the authors of the images used.