JUDITH LEWIS HERMAN, M.D., AND BANDY X. LEE, M.D., M.DIV.
Professions can create forms of ethical conversation that are impossible between a lonely individual and a distant government. If members of professions think of themselves as groups … with norms and rules that oblige them at all times, then they can gain … confidence, and indeed a certain kind of power.
Timothy Snyder, On Tyranny: Twenty Lessons from the Twentieth Century (2017)
Soon after the presidential election of 2016, alarmed by the apparent mental instability of the president-elect, we both separately circulated letters among some of our professional colleagues, expressing our concern. Most of them declined to sign. A number of people admitted they were afraid of some undefined form of governmental retaliation, so quickly had a climate of fear taken hold. They asked us if we were not wary of being “targeted,” and advised us to seek legal counsel. This was a lesson to us in how a climate of fear can induce people to censor themselves.
Others who declined to sign our letters of concern cited matters of principle. Psychiatry, we were warned, should stay out of politics; otherwise, the profession could end up being ethically compromised. The example most frequently cited was that of psychiatrists in the Soviet Union who collaborated with the secret police to diagnose dissidents as mentally ill and confine them to prisons that fronted as hospitals (Medvedev and Medvedev 1971).
This was a serious consideration. Indeed, we need not look beyond our own borders for examples of ethics violations committed by professionals who became entangled in politics. We have recently witnessed the disgrace of an entire professional organization, the American Psychological Association, some of whose leadership, in cooperation with officials from the U.S. military, the CIA, and the Bush White House, rewrote its ethical guidelines to give legal cover to a secret government program of coercive interrogation and to excuse military psychologists who designed and implemented methods of torture (Hoffman et al. 2015; Risen 2014).1
Among the many lessons that might be learned from this notorious example, one in particular stayed with us. It seemed clear that the government officials responsible for abusive treatment of prisoners went to some lengths to find medical and mental health professionals who would publicly condone their practices. We reasoned that if professional endorsement serves as important cover for human rights abuses, then professional condemnation must also carry weight.
In 2005 the Pentagon organized a trip to the Guantánamo Bay detention camp for a group of prominent ethicists, psychiatrists, and psychologists. Participants toured the facility and met with high-ranking military officers, including the commanding general. They were not allowed to meet or speak with any of the detainees.
Dr. Steven Sharfstein, then the president of the American Psychiatric Association, was one of the invited guests on this trip. Apparently, what he saw and heard failed to convince him that the treatment of detainees fell within the bounds of ethical conduct. “Our position is very direct,” he stated on return. “Psychiatrists should not participate on these [interrogation] teams because it is inappropriate” (Lewis 2005). Under Dr. Sharfstein’s leadership, the American Psychiatric Association took a strong stand against any form of participation in torture and in the “interrogation of persons held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere” (American Psychiatric Association 2006).
Contrast this principled stand with the sorry tale of the American Psychological Association. Its involvement in the torture scandal illustrates how important it is for leaders in the professions to stand firm against ethical violations, and to resist succumbing to the argument that exceptional political circumstances, such as “the war on terror,” demand exceptions to basic ethical codes. When there is pressure from power is exactly when one must abide by the norms and rules of our ethics.2
Norms and Rules in the Political Sphere
Norms and rules guide professional conduct, set standards, and point to the essential principles of practice. For these reasons, physicians have the Declaration of Geneva (World Medical Association 2006) and the American Medical Association Principles of Medical Ethics (2001), which guide the American Psychiatric Association’s code for psychiatry (American Psychiatric Association 2013). The former confirms the physician’s dedication to the humanitarian goals of medicine, while the latter defines honorable behavior for the physician. Paramount in both is the health, safety, and survival of the patient.
Psychiatrists’ codes of ethics derive directly from these principles. In ordinary practice, the patient’s right to confidentiality is the bedrock of mental health care dating back to the ethical standards of the Hippocratic Oath. However, even this sacrosanct rule is not absolute. No doubt, the physician’s responsibility is first and foremost to the patient, but it extends “as well as to society” (American Psychiatric Association 2013, p. 2). It is part of professional expectation that the psychiatrist assess the possibility that the patient may harm himself or others. When the patient poses a danger, psychiatrists are not merely allowed but mandated to report, to incapacitate, and to take steps to protect.
If we are mindful of the dangers of politicizing the professions, then certainly we must heed the so-called “Goldwater rule,” or Section 7.3 of the APA code of ethics (American Psychiatric Association 2013, p. 6), which states: “it is unethical for a psychiatrist to offer a professional opinion [on a public figure] unless he or she has conducted an examination and has been granted proper authorization for such a statement.” This is not divergent from ordinary norms of practice: the clinical approaches that we use to evaluate patients require a full examination. Formulating a credible diagnosis will always be limited when applied to public figures observed outside this intimate frame; in fact, we would go so far as to assert that it is impossible.
The Goldwater rule highlights the boundaries of practice, helps to preserve professional integrity, and protects public figures from defamation. It safeguards the public’s perception of the field of psychiatry as credible and trustworthy. It is reasonable to follow it. But even this respectable rule must be balanced against the other rules and principles of professional practice. A careful ethical evaluation might ask: Do our ordinary norms of practice stop at the office of president? If so, why? If the ethics of our practice stipulate that the health of our patient and the safety of the public be paramount, then we should not leave our norms at the door when entering the political sphere. Otherwise, a rule originally conceived to protect our profession from scandal might itself become a source of scandal. For this very reason, the “reaffirmation” of the Goldwater rule in a separate statement by the American Psychiatric Association (2017) barely two months into the new administration seems questionable to us. The American Psychiatric Association is not immune to the kind of politically pressured acquiescence we have seen with its psychological counterpart.
A psychiatrist who disregards the basic procedures of diagnosis and treatment and acts without discretion deserves reprimand. However, the public trust is also violated if the profession fails in its duty to alert the public when a person who holds the power of life and death over us all shows signs of clear, dangerous mental impairment. We should pause if professionals are asked to remain silent when they have seen enough evidence to sound an alarm in every other situation. When it comes to dangerousness, should not the president of a democracy, as First Citizen, be subject to the same standards of practice as the rest of the citizenry?
Assessing dangerousness is different from making a diagnosis: it is dependent on the situation, not the person. Signs of likely dangerousness due to mental disorder can become apparent without a full diagnostic interview and can be detected from a distance, and one is expected to err, if at all, on the side of safety when the risk of inaction is too great. States vary in their instructions. New York, for example, requires that two qualifying professionals agree in order to detain a person who may be in danger of hurting himself or others. Florida and the District of Columbia require only one professional’s opinion. Also, only one person need be in danger of harm by the individual, and the threshold is even lower if the individual has access to weapons (not to mention nuclear weapons).
The physician, to whom life-and-death situations are entrusted, is expected to know when it is appropriate to act, and to act responsibly when warranted. It is because of the weight of this responsibility that, rightfully, the physician should refrain from commenting on a public figure except in the rarest instance. Only in an emergency should a physician breach the trust of confidentiality and intervene without consent, and only in an emergency should a physician breach the Goldwater rule. We believe that such an emergency now exists.
Test for Proper Responsibility
When we circulated our letters of concern, we asked our fellow mental health professionals to get involved in politics not only as citizens (a right most of us still enjoy) but also, specifically, as professionals and as guardians of the special knowledge with which they have been entrusted. Why do we think this was permissible? It is all too easy to claim, as we did, that an emergency situation requires a departure from our usual practices in the private sphere. How can one judge whether political involvement is in fact justified?
We would argue that the key question is whether mental health professionals are engaging in political collusion with state abuses of power or acting in resistance to them. If we are asked to cooperate with state programs that violate human rights, then any involvement, regardless of the purported justification, can only corrupt, and the only appropriate ethical stance is to refuse participation of any sort. If, on the other hand, we perceive that state power is being abused by an executive who seems to be mentally unstable, then we may certainly speak out, not only as citizens but also, we would argue, as professionals who are privy to special information and have a responsibility to educate the public. For whatever our wisdom and expertise may be worth, surely we are obligated to share it.
It doesn’t take a psychiatrist to notice that our president is mentally compromised. Members of the press have come up with their own diagnostic nomenclature, calling the president a “mad king” (Dowd 2017), a “nut job” (Collins 2017), and “emotionally unhinged” (Rubin 2017). Conservative columnist George Will (2017) writes that the president has a “disorderly mind.” By speaking out as mental health professionals, we lend support and dignity to our fellow citizens who are justifiably alarmed by the president’s furious tirades, conspiracy fantasies, aversion to facts, and attraction to violence. We can offer a hand in helping the public understand behaviors that are unusual and alarming but that can all too easily be rationalized and normalized.
An important and relevant question that the public has been asking is this: Is the man simply crazy, or is he crazy like a fox? Is he mentally compromised or simply vile? When he lies, does he know he is lying, or does he believe his own lies? When he makes wild accusations, is he truly paranoid, or is he consciously and cunningly trying to deflect attention from his misdeeds?
We believe that we can help answer these questions by emphasizing that the two propositions are not mutually exclusive. A man can be both evil and mentally compromised—which is a more frightening proposition. Power not only corrupts but also magnifies existing psychopathologies, even as it creates new ones. Fostered by the flattery of underlings and the chants of crowds, a political leader’s grandiosity may morph into grotesque delusions of grandeur. Sociopathic traits may be amplified as the leader discovers that he can violate the norms of civil society and even commit crimes with impunity. And the leader who rules through fear, lies, and betrayal may become increasingly isolated and paranoid, as the loyalty of even his closest confidants must forever be suspect.
Some would argue that by paying attention to the president’s mental state, we are colluding with him in deflecting attention from that by which he should ultimately be judged: his actions (Frances 2017). Certainly, mental disturbance is not an excuse for tyrannical behavior; nevertheless, it cannot be ignored. In a court of law, even the strongest insanity defense case cannot show that a person is insane all the time. We submit that by paying attention to the president’s mental state as well as his actions, we are better informed to assess his dangerousness. Delusional levels of grandiosity, impulsivity, and the compulsions of mental impairment, when combined with an authoritarian cult of personality and contempt for the rule of law, are a toxic mix.
There are those who still hold out hope that this president can be prevailed upon to listen to reason and curb his erratic behavior. Our professional experience would suggest otherwise; witness the numerous submissions we have received for this volume while organizing a Yale conference in April 2017 entitled “Does Professional Responsibility Include a Duty to Warn?”3 Collectively with our coauthors, we warn that anyone as mentally unstable as Mr. Trump simply should not be entrusted with the life-and-death powers of the presidency.
Judith Lewis Herman, M.D., is Professor of Psychiatry at Harvard Medical School. She is a renowned expert in the traumas of interpersonal violence and author of the now-classic Trauma and Recovery. She is a cofounder of the Victims of Violence Program in the Department of Psychiatry at Cambridge Health Alliance, a Distinguished Life Fellow of the American Psychiatric Association, and the recipient of numerous awards, including the Lifetime Achievement Award from the International Society for Traumatic Stress Studies.
Bandy X. Lee, M.D., M.Div., is Assistant Clinical Professor in Law and Psychiatry at Yale School of Medicine. She teaches at Yale Law School, cofounded Yale’s Violence and Health Study Group, and leads a Violence Prevention Alliance collaborators project for the World Health Organization. She is the author of more than one hundred peer-reviewed articles, editor of eleven academic books, and author of the textbook Violence.
Acknowledgments
We thank Nanette Gartrell, Dee Mosbacher, Gloria Steinem, Robin Morgan, Jaine Darwin, Frank Putnam, and Grace Lee, for their helpful editorial comments and assistance in the preparation of this Prologue.
References
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