The Ethical Malpractice of Silence

The consideration of what constitutes an ethical law dates back thousands of years, spanning the globe from Plato to Confucius. While our records of studying the human mind are less ancient, certainly human psychology, even if not overtly referred to in this manner, is an age-old discipline. The last 100 years, especially, have yielded breathtaking advances that allow us to understand the mind, both “healthy” and “unhealthy”, in amazing new ways.

This knowledge is what we make use of in our day-to-day work as psychiatrists, when we must assess patients in crisis and decide whether or not they constitute enough of a danger to themselves or to the community that we are justified in admitting them involuntarily to an inpatient psychiatric unit. The responsibility granted us by society—to take away an individual’s freedom—is not a duty we take lightly, and an awesome charge because of the nature of mental illness. When patients are mentally impaired, they may make choices that are harmful to their own interests—indeed their own or others’ survival—and are the last to recognize that they need help. Indeed, they may resist any kind of help and may need to have it forced on them. However, the reason mental health professionals are allowed the extraordinary exception of curtailing others’ civil liberties is because, once patients are treated and feeling better, they recognize that they needed the help and often thank their caregivers. In fact, “freeing” patients from the grip of illness, even against their will, is called “right to treatment.”

As psychiatrists, we may desire a patient to receive treatment, but we usually wait until the patient poses an imminent risk to justify our taking away the basic right to self-determination. This is called “the least restrictive modality of care.” It gets more complicated when a patient states that he or she is going to hurt a specific person. A specific case in California, where a person who had told a therapist he was going to kill someone and followed through on the threat, led to a “duty to warn” individuals who are threatened. This has then further expanded to a “duty to protect.” These are situations where the risk is so pressing that one must override the ethical duties to self-determination and confidentiality.

On the other side of the scale is the prevention of psychiatrists using their powers indiscriminately to influence when it is not necessary. Fifty-four years ago, when there was far less knowledge about the brain, psychiatrists—who mostly utilized very inexact concepts of psychoanalysis—“analyzed” presidential candidate Barry Goldwater. While only 10 percent of psychiatrists surveyed spoke irresponsibly, the tabloid magazine that conducted the survey sensationalized the results and embarrassed the profession. In the aftermath, the American Psychiatric Association came up with the so-called Goldwater rule, which says that no psychiatrist should diagnose a public figure without a formal interview. Note, of course, that this rule was implemented at a time when diagnoses were not made on objectively observable behavior, as they are now, and when high-quality data such as videos, transcripts of interviews, reports by family members and co-workers, and moment-to-moment updates on public figures were not as available.

Yet, there was no pressing reason to reexamine this rule—until Donald Trump announced his candidacy for president. This was a man who illustrated dangerous pathology in behavior and words more obviously than any interview could provide (Healy and Haberman, 2015). But few people stood up to longstanding rules instituted by major organizations, especially as the American Psychiatric Association expanded the rule so that no one could speak about the president in any manner, under any condition.

When the book The Dangerous Case of Donald Trump followed what ethical principles and psychiatric ethics ordinarily do, that is, weigh competing guidelines to follow the greater good, the decision was clear: Mental health professionals needed to warn of the acute dangers that Trump posed. There was clear objective evidence, based on psychological signs and professional knowledge about the brain. Yet, despite the fact that Trump, in tweets, gave the country an unprecedented look into his mind, our own professional organization muzzled us from doing our duties to assess imminent dangers to the community and to warn and to protect the public against those dangers.

How are psychiatrists to react at this rule, which we believe requires us to be derelict of our professional duties? History has taught us that laws are not always ethical, and that sometimes they are blatantly unethical. The horrific laws of Nazi Germany and the laws in so many countries that codified slavery are but a few. It thus follows that, while law is generally to be respected, if it leads to the detriment of even one person, or one society, or the whole world, it is our duty to reconsider it. This principled action is what also protects the integrity and reputation of the profession.

From Bill Maher to Morning Joe, many experienced observers openly acknowledge that, when it comes to Trump’s words and behavior, something is rotten in Denmark. A recent anonymous op-ed in The New York Times has made clear that people have found Donald Trump so disturbing that they considered invoking the 25th Amendment. If we were scientists specializing in global warming, we would never ask politicians to consider legislation regarding climate change without doing everything in our power to give them all the information they need. And similarly, if we were prescribing a medication for a patient, it would be malpractice to not discuss the full risks and benefits with the patient.

And so we believe that it is ethical malpractice to continue to be silent regarding the danger this country, and this world, faces, because of the clear pathology in thinking and subsequent action, that Donald Trump has displayed. To ask our media to muse on its own about his psychopathology, and our politicians to seek guidance desperately on just “what is wrong” with the president, and what can be done about it, is the greatest malpractice we could commit at this time. And to just walk away, with “professional ethics” as our excuse, puts all of us at unconscionable risk.

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Co-authored with David Schatz, M.D.

David Schatz, M.D., is a forensic psychiatrist who graduated from the University of Pennsylvania School of Medicine and completed his psychiatric training at Stanford University Hospital and Clinics. He currently splits his time between John George Psychiatric Emergency Services and Santa Rita Jail.