An Old Dilemma Rears Its Head in the Age of Trump: Client-patient Privilege or the Fate of the World?

The United States has been bothered by the question whether Donald Trump is mentally ill ever since the 2016 presidential election

President Donald Trump a rally in Phoenix, Arizona, August 22, 2017.
Alex Brandon/AP

Since Donald Trump arrived in the White House, the press has held a lively debate about his state of mental health. Politicians and publicists, as well as famous psychologists and psychiatrists, attribute a psychological disturbance to the 45th U.S. president. Given growing public criticism, the American Psychiatry Association affirmed in March that the 1973 Goldwater rule, which forbids members from diagnosing a public figure based on their public appearances, was still in effect.

Is psychological assessment a valid tool within a political struggle, or is there more going on here? Is client-patient privilege absolute, even when the fate of the nation, and the entire world, are at stake? Relations between doctors and leaders often create important and dramatic case studies in the conflict between the obligation of the doctor to his patient and his obligation to society.

Barry Goldwater was an Arizona senator who won the Republican nomination for the presidency in 1964. The magazine Fact published a poll it had taken during the campaign of APA members, asking them to evaluate Goldwater’s psychological fitness. The response from 1,189 APA members held that he was not psychologically fit to be president. Some of the respondents even added insulting comments to their answers, like “I believe Goldwater has the same pathological make-up as Hitler, Castro, Stalin and other known schizophrenic leaders.”

Goldwater suffered a bitter defeat to Lyndon Johnson. He later sued the magazine for libel. A court awarded him $75,000, and the magazine shut down. In the wake of the incident, the APA issued the Goldwater rule, forbidding its members from diagnosing public figures. This rule was dead for years, but returned to the spotlight when Trump declared his candidacy in 2015 and has become a hot topic since his election.

Barry Goldwater. The response from 1,189 APA members held that he was not psychologically fit to be president.
Marion S. Trikosko / U.S. News &

Prominent members of the mental health profession have appeared for over a year on media channels, telling the public that Trump suffers from a serious mental illness. Some of them classify him as suffering from a narcissistic personality disorder. Others call him paranoid and delusional, and there are those who agree that his mental state prevents him from being fit to serve as president or in any other senior position.

John Zinner, a psychiatrist from Maryland, told The New Yorker recently that as doctors who are sworn to protect their patients, psychiatrists are obliged to take action to limit Trump’s access to nuclear weapons. To wit – Trump’s latest threats against North Korea, which have aroused widespread anxiety over the prospect of nuclear war. The obligation to speak out, according to Dr. Zinner, supersedes the profession’s ethics rules.

However, in March the APA’s ethics board affirmed the Goldwater rule and even expanded it. The board put a general ban on members publicly issuing a professional opinion about anyone. Psychiatric evaluation, according to the board, includes diagnosing and a functional evaluation based on a personal, detailed interview made with the agreement of the patient and subject to complete immunity. Leaders of the association warned that violating these principles is liable to undermine public faith in psychiatry, which in any event is not at its peak.

Winston Churchill. Doctor Charles Wilson avoided telling Churchill and the world about the patient’s medical condition.
ANONYMOUS/AP

After the psychiatric establishment “saved” the profession’s reputation, what about saving the world? On this question, Dr. Mark Komrad, a staffer at Johns Hopkins Hospital, told The New Yorker that diagnosing Trump brings no added value. “You don’t need a doctor to tell you that the guy on the plane with a hacking cough is sick,” he said. Meanwhile, Dr. Allen Frances, who chaired the task force that published the fourth edition of the Diagnostic Manual of Mental Illnesses, said that the cure to Trump is politics, not psychology.

Trump’s unusual behavior creates a feeling of urgency and deep fear about world stability, but it turns out there is nothing new under the sun. A 2006 article in the Journal of Nervous and Mental Disease surveyed 37 presidential biographers who had written about all of the presidents from George Washington to Richard Nixon. Certain passages from the biographies were given to experienced psychiatrists, who were asked to diagnose the subjects based on their behavioral patterns and symptoms. About half of the presidents, 18, fulfilled the criteria for psychological disorders under DSM guidelines. The most common disorders among the presidents were depression, anxiety, bipolarity or alcoholism. Ten of them were found to have evidence of mental disorder they suffered during their term in the White House, which hurt their ability to function in most cases.

Doctor of the entire world

On May 10, 1940, Winston Churchill entered 10 Downing Street at the age of 65. The cabinet decided at its very first meeting to appoint a personal doctor for Sir Winston, expressing the great importance they attributed to the fitness of a prime minister during wartime. Charles Wilson, 1st Baron Moran, a reputable doctor who had been dean of the school of medicine at St. Mary’s Hospital for 25 years, took the job unenthusiastically, by his own account. However, he stayed in the job 25 years until the death of the British leader. A year after Churchill’s death, Wilson published a book based on his personal diaries, in which he revealed much about the British prime minister’s health, over the staunch objections of Churchill’s family and despite sharp criticism by the medical establishment.

In December 1941, about two weeks after the United States declared war on the Axis powers, Churchill went to the United States to meet with President Franklin Delano Roosevelt and to deliver a speech to Congress. Wilson describes in his book the events of the night after the speech, about which Churchill told him. It was oppressively hot in the room, Churchill said, and he had to use great force to open a window. Just then, he suffered from shortness of breath and a terrible pain above his heart, which spread to his left arm.

While listening to his heart, Wilson had a few thoughts: There is a reasonable suspicion of a heart attack. He needs an EKG to support the diagnosis. The very knowledge that an EKG was brought into Churchill’s room is liable to start rumors about his illness, and if he did indeed suffer a heart attack I have to order him to lie in bed six weeks (the standard practice of the day) and to issue a press release. Such an announcement, at the critical moments of World War II, could have a destructive impact on the public and on the prime minister himself. If I ignore the symptoms Churchill reported, and he suffers another attack that is fatal, the entire world will blame me for his death. When he removed the stereoscope from Churchill’s chest he had to inform him of his decision. The event isn’t serious, he told Churchill. Continue your work as usual.

Wilson asserted that he bore the fate of the world on his shoulders. He expanded the principle of medical secrecy to include the patient himself. To hide Churchill’s condition from the masses, who saw him as the ultimate savior, the doctor avoided telling Churchill and the world about the patient’s medical condition. He would rather endanger Churchill to maintain the morale of the prime minister, the British public and the entire world. He was completely committed to the allies’ war effort.