Hollywood scriptwriters could not have imagined a better drama than the emerging legal battle between Yale University and renegade psychiatrist Bandy X. Lee, who was fired after Harvard Law Professor Alan Dershowitz complained that Dr. Lee violated professional standards in January 2020, when she accused him of suffering from a “shared psychosis” with other supporters of Donald Trump.
The standard in question — known colloquially as the “Goldwater rule” — is an ethical principle of the American Psychiatric Association (APA) dating back to 1973. It prohibits psychiatrists from commenting publicly on the mental health of individuals they have not personally examined. In contrast, psychologists are not bound by the same code, so Mary Trump has been able to diagnose her uncle with impunity.
Dr. Lee, a longtime critic of both the rule and Mr. Trump, was serving as a voluntary faculty member at Yale’s medical school in 2017 when she began warning the public about Mr. Trump’s alleged psychiatric instability. She ultimately edited a bestselling collection of essays, “The Dangerous Case of Donald Trump,” in which prominent mental health professionals asserted a duty to warn the public against the perils of Mr. Trump’s mental state — akin to similar professional duties to notify potential victims of threats made by violent patients. In response to the “shared psychosis” claim on Twitter, Mr. Dershowitz asked Yale to investigate Dr. Lee for publicly diagnosing him based upon his “legal and political views.” According to a lawsuit filed last week, Dr. Lee alleges that Yale fired her for breaching the Goldwater rule with regard to both Messrs. Trump and Dershowitz.
Whether or not Dr. Lee has a persuasive legal claim is a matter for the courts. But as an academic psychiatrist — and, for full disclosure, an APA member in good standing — the basis for Dr. Lee’s termination, if accurate, is deeply concerning.
Some background is helpful here: The APA is a voluntary professional association, albeit a highly respected one; it is not a licensing or credentialing organization. It is my profession’s equivalent to the Knights of Columbus or the Elks. Membership is not required to practice psychiatry. So, while the APA’s ethical principles often reflect professional consensus, they are generally not binding on nonmembers. Dr. Lee has not belonged to the APA since 2007.
The Goldwater rule arose in response to a controversial survey conducted by Fact magazine editors Ralph Ginzburg and Warren Boroson of APA members during the 1964 presidential election. They asked: “Do you think that [Republican candidate] Barry Goldwater is psychologically fit to serve as President of the United States?” When 1,189 psychiatrist declared Goldwater unfit — and some publicly diagnosed the distinguished senator as psychotic and schizophrenic — the APA leadership was mortified. Under additional pressure from the American Medical Association (which had shared Goldwater’s opposition to Medicare and Medicaid), the APA adopted the gag rule.
Unlike some professional principles — like confidentiality or prohibitions on sex with patients — the Goldwater rule remains controversial. In recent years, it has been questioned by leading figures in the profession. It has also drawn considerable criticism for constraining the ability of psychiatrists to educate the public about the apparent psychiatric illnesses of perpetrators in high profile mass shootings. Of course, the APA is welcome to make its own rules and expel members for violating them. In contrast, a university terminating a prominent professor for violating an APA rule threatens a chilling effect upon freedom of expression in clinical medicine.
The larger problem is that most academic physicians, even those at higher ranks, lack the protections of tenured status that shield their colleagues in the humanities and basic sciences. Even those who do have tenure at medical schools can lose their hospital appointments, and hence most of their income, for speaking out on controversial issues. I imagine many of my psychiatric colleagues are now thinking: Dr. Lee today, me tomorrow. The self-censorship that results will prove far more hazardous than any breach of APA ethics.
Jacob M. Appel (email@example.com) is director of Ethics Education in Psychiatry at the Icahn School of Medicine at Mount Sinai. He is the author of “Who Says You’re Dead?” a collection of ethical conundrums.