Should mental health professionals comment in the media about the mental health of politicians or other public figures? Are there any circumstances in which psychiatrists or psychologists should publicly express their views that a given public figure appears to be mentally ill?
This question is controversial but it is not new. In 1964, during the US presidential race between Barry Goldwater and Lyndon Johnson, Fact magazine asked 12,356 psychiatrists: "Do you believe Barry Goldwater is psychologically fit to serve as president of the US?"
The subsequent article was highly critical of Goldwater. It caused a furore. Daniel Blain, president of the American Psychiatric Association (APA), described the piece as "a hodge-podge of the personal political opinions of selected psychiatrists speaking as individuals". Dr Blain added that "the replies to the question have no scientific or medical validity whatsoever". The magazine's editor, Ralph Ginzburg, was successfully sued for libel.
As a direct consequence of these events, the first edition of the APA's Principles of Medical Ethics in 1973 included the 'Goldwater Rule': "On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement".
In other words, psychiatrists can comment in public about mental illness in general, but should refrain from offering professional opinions about a specific public figure unless they have examined the public figure and have been given permission for public statements.
Last year, the American Medical Association wrote a similar guideline into its code of ethics, stating that doctors should refrain "from making clinical diagnoses about individuals (eg public officials, celebs, persons in the news) they have not had the opportunity to personally examine."
But are there ever times when these guidelines should be violated? Are there extreme circumstances in which the health and safety of specific people, or entire communities, are at risk? And could that risk be mitigated by public diagnosis of mental illness?
It is very difficult to identify any such circumstances. Diagnosis is always a challenging task, even when the patient is sitting right in front of you. Several meetings may be needed, along with further assessments and information from family and friends. Diagnosis is never simple or quick.
So, what should a healthcare professional do if they believe a public figure might be seriously ill? For example, a dermatologist might see that a news reader has a particular rash. Or a GP might notice that a weather forecaster has the characteristic features of another illness of some sort. In those circumstances, the ethical course of action is to contact the newsreader or weather forecaster in question, advise them of the concern, and recommend that they see a doctor. There is no role for public pronouncements.
Is it different for mental illness? Essentially, no. Most people with mental illness recognise that they are unwell and can be advised privately to seek assistance. And if a person with mental illness lacks insight into their condition, and they are seriously unwell, most jurisdictions (including Ireland) have legal arrangements to facilitate care.
Once again, going public does not have a role in this chain of events. First, the person themselves is contacted privately. If that is not fruitful, contact can be made with family or friends privately. They may have more information to bring to bear and are likely in a much better position to decide on a course of action.
Finally, what if the behaviour of a public figure is so frankly alarming that some mental health professionals feel there is a duty to warn the public in the media about perceived risks to others resulting from mental illness? Again, there are many problems with the idea that the best thing to do here is to make a public diagnosis, even in an extreme circumstance.
First, it is impossible to diagnose a mental illness from afar, so the basic premise of this duty to warn publicly is fundamentally flawed. Without careful examination and engagement, there is no way of knowing if someone's behaviour is underpinned by mental illness or not.
Second, even a duty to warn does not necessarily involve a duty to warn publicly. There are always more discreet ways of proceeding. And third, any intervention by any healthcare professional needs to based on the idea that the positives exceed the negatives. Making a public diagnosis patently fails to meet this test.
Diagnosis is a powerful step, potentially helpful but also potentially harmful. Discretion is advised. Primum non nocere: first, do no harm.
* Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and Consultant Psychiatrist at Tallaght Hospital