"A Strong Statement": The APA Adopts the Goldwater Rule

When Ralph Ginzburg devoted a special issue of Fact magazine, “The Unconscious of a Conservative,” to the mental health of 1964 Republican presidential candidate Barry Goldwater, it was a daring step. Ginzburg had never interviewed Goldwater, but on the eve of the election, he flooded newspapers with full-page ads questioning Goldwater’s psychological fitness to be president.

In the issue itself, the flamboyant free-speech advocate offered the public a tendentious “survey” of American psychiatrists and a dramatic psychological profile. The survey came complete with juicy (and often “improved”) excepts from the psychiatrists’ generally hostile responses. The profile described Goldwater as having had two nervous breakdowns, a weak father, and a tearful wife. The candidate, alleged Ginzburg and many of the psychiatrists, needed to shore up a fragile sense of masculinity by acting very tough indeed.

Ginzburg was especially concerned about Goldwater’s alleged paranoia and impulsive aggression, which Ginzburg felt increased the risk of world destruction in the nuclear age. The Fact issue ended with an image of a mushroom cloud and the words “the End” set in bold type.

The American Psychiatric Association (APA), the nation’s largest organization of psychiatrists, was upset too—but for a different reason. It had quickly learned about the upcoming special issue when several vigilant APA members sent a copy of the Fact survey to APA headquarters.

The APA believed that Ginzburg’s survey and profile violated a basic canon of the profession—that a diagnosis rests on a personal interview. The APA’s medical director, Walter Barton, wrote Ginzburg that the group would “take all possible measures to disavow” the survey’s validity. APA president Daniel Blain said the special issue had “administered a low blow to all who would work to advance the treatment and care of the mentally ill in America.”

Ginzburg regarded Fact as a public service and simply ignored the objections. He serenely distributed 236,000 copies of his special issue to newsstands throughout the country.

After the election—Goldwater lost by a landslide and sued Ginzburg successfully for libel—the APA took further action. In a move that was characteristic of the group at the time, Blain noted publicly the alleged misbehavior of the group’s own members: “To the great embarrassment of our association some psychiatrists unwittingly replied to the [survey] question in their capacity as psychiatrists.” There was, in the APA’s view, no role for media comments about the President’s mental health.

At the time, the APA was working hard to reorganize itself into a more effective and efficient organization. One item on its agenda was the development of a formal set of ethics rules for its members. The episode involving Ginzburg and Goldwater was an impetus for that effort.

As its internal documents show, the APA viewed Ginzburg's “malicious mischief” as a major embarrassment to psychiatry. The group had reasons to worry. World War II had demonstrated the usefulness of psychiatric methods applied on a vast scale. After the war, there had been a vast expansion in medical specialization, professionalism, and NIH funding for psychiatry. In the mid-1960s, the development of Medicare put much new federal money into play. These developments gave psychiatry a new prominence—and a new professional image to protect. The group's leadership, as its archives show, emphasized not only ethical standards but the interrelated matter of psychiatry's public image.

"Every psychiatrist," said one draft APA internal document in 1969, "should be aware of his position as a representative of the profession to the general public and help portray the profession in its proper perspective." Proper, for this APA committee member, meant "thoughtful, dignified," and "always motivated to help human beings in distress." In all circumstances, harm should be avoided.

After the inauguration of Richard Nixon in 1969, things got worse rather than better for the APA. Nixon threatened to cut the federal budget for mental health. Hollywood films, once full of idealized portraits of psychiatrists, began to portray psychiatrists as self-interested and corrupt, and sometimes as mentally ill themselves. And the press began to report on sexual misconduct by psychiatrists.

When "adverse newspaper publicity" occurs, said medical director Barton in 1973, it would help to be able to tell reporters "that we already have a strong statement" on record.

After much discussion and behind-the-scenes work, the APA developed a formal set of ethics rules that included a ban on psychiatric diagnosis without interview and consent. Now diagnosis from a distance (at least if conducted by individual psychiatrists outside government) would be considered unethical. In theory, at least, APA members could be sanctioned if they violated the ban. In 1973, the APA Board of Trustees voted to make the provision official APA policy.

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Section 10.3 of the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry (later section 7.3) quickly became known as the Goldwater Rule. In the years since, the policy has been questioned many times, including by distinguished APA members who are concerned about the effect on the country of a mentally unstable president or candidate. At least one trustee voted against the rule in 1973. But the rule has remained a firm principle for the organization over time.

Public figures have noticed. Barry Goldwater, not surprisingly, was pleased that the APA had spoken out. The American Medical Association (AMA) also supported Goldwater: The AMA’s publicity director stayed in touch with Goldwater as the libel case worked its way through the courts. (The process was made easy by the fact that the publicity director was a former member of Goldwater’s staff). In a 1968 case involving Ginzburg and Lyndon Johnson, the president took careful notice of what the APA and AMA had to say about the ethics of commenting on public figures.

Ginzburg's high-minded effort was undermined by his own careless editorial methods. The publisher's provocation and the APA's response led to consequences that are still with us today.

Next time: The American Psychoanalytic Association (APsaA) develops a very different response to Ginzburg and Fact.