Intended for healthcare professionals

Feature

Do doctors have a “duty to warn” if they believe a leader is dangerously mentally ill?

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1087 (Published 09 March 2017) Cite this as: BMJ 2017;356:j1087
  1. Jeanne Lenzer, associate editor, The BMJ
  1. jlenzer{at}bmj.com

Jeanne Lenzer explores the debate among healthcare professionals about whether to make public their concerns over Donald Trump’s mental health

US healthcare professionals are not supposed to comment on patients they have not examined themselves, and they can only discuss their patients with others if they have the patient’s consent or consider that a patient is a threat to someone else.

But in recent weeks, debate has raged within the profession about whether, if experts believe US president Donald Trump is mentally ill, they have a duty to inform the public. Many who choose to speak out opine that he has the traits of a sociopath that fall under the diagnosis of narcissistic personality disorder.12

Two rules govern US healthcare professionals and patient confidentiality.

The Goldwater rule states that it is unethical for psychiatrists to diagnose mental illness in people they haven’t examined and whose consent they have not obtained. The rule was issued by the American Psychiatric Association in 1973 after it surveyed its members about Senator Barry Goldwater, then Republican nominee for president.3 Nearly half of the responding psychiatrists said he was mentally ill, and some described him as “paranoid” and “grossly psychotic.” Goldwater successfully sued Fact, the now defunct magazine that published the results of the survey, for libel. The rule does allow psychiatrists to talk to the media about the general traits of an illness an individual not in their care is said to have. The American Psychological Association’s code of ethics similarly states that psychologists “should not offer a diagnosis in the media of a living public figure they have not examined.”

The Tarasoff rule established that healthcare professionals have a “duty to warn” if they believe a patient in their care may be a threat to others. This rule grew out of a civil suit filed by the relatives of Tatiana Tarasoff, a student at the University of California who was stabbed to death by Prosenjit Poddar, a fellow student who had been stalking her.4 Tarasoff’s family successfully sued the therapist for failing to warn them after Poddar had confided he was planning to kill her.

Since the Tarasoff ruling, depending on the state in the US, health professionals are required by law to warn people (and/or law enforcement) if a patient makes serious threats of harm against them.5

But these laws do not give health professionals any responsibility for warning the public about people who are not their patients. And the Goldwater rule specifically says that they should not. Psychiatrists who violate the rule risk suspension or expulsion from their professional association. Yet growing numbers are finding they feel a stronger ethical duty to warn the public about Trump than to follow the rule. A group of 35 psychiatrists, psychologists, and social workers has written a letter to the New York Times warning that Trump is dangerous, and one psychologist, John Gartner, has launched a petition entitled “Mental health professionals declare Trump is mentally ill and must be removed” which has gathered over 27 000 signatures (though not all from health professionals). Another petition calling for Trump’s mental health to be formally examined has gathered 36 000 signatures.

Gartner, a clinical psychologist and former Johns Hopkins professor, argues that Trump is “dangerous,” and that his attacks on the Muslim parents of a fallen soldier, his bragging about sexual assault and other behaviours are manifestations of a “serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States.”6

Other psychiatrists wrote that Trump has an “apparent inability to distinguish between fantasy and reality” and called for him to submit to a full medical and neuropsychiatric evaluation by impartial investigators.”7

Bandy Lee, a psychiatrist specialising in preventing violence and Yale professor, and Gartner say a large proportion of mental health professionals agree that Trump is showing signs of mental illness, although they differ somewhat in the next step. Some, like Gartner, think the remedy lies in the 25th amendment to the constitution with a direct appeal to Congress to remove Trump because of impairment, a process allowed under the amendment.

Others, like Lee, say therapists cannot diagnose Trump without examining him and call for an independent assessment. Lee told The BMJ that current practice in all US states is such that “if someone shows signs of mental illness and is dangerous even to just one person, and if the person refuses to be evaluated, then detaining him or her is permitted because it is an obligation of health professionals to prevent harm,” which, she says, “is an obligation that overrides all others.”

However, other mental health professionals object to labelling Trump as mentally ill. Citizen Therapists, an organisation of psychotherapists, states that it is “alarmed by the rise of the ideology of Trumpism,” but nonetheless concludes: “arguing about a mental health diagnosis for a public figure risks “weaponizing” diagnosis … with every candidate for president being subjected to ‘partisan diagnosis.’”

Allen Frances, professor emeritus at Duke University, North Carolina, and former chair of the task force for the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, which defines the criteria for narcissistic personality disorder, says Trump is “bad not mad.” “He may be a world class narcissist, but this doesn’t make him mentally ill because he does not suffer from the distress and impairment required to diagnose mental disorder,” Frances wrote in a letter to the New York Times. “Psychiatric name-calling is a misguided way of countering Mr Trump’s attack on democracy… His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.”8

Footnotes

  • See also the blog by Trisha Greenhalgh “What should UK doctors say about Trump?” http://bmj.co/trump_health.

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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