President Trump:Diagnosis and, if Necessary Therapy: Doing it Ethically
An excellent article written by physician-ethicist Joseph J. Fins in Harvard Medical School Bioethics Journal and it is my reading that he suggests when it comes to the psychiatric fitness of Donald Trump to be the United States President, it should not be a psychiatric diagnosis (such as "sociopathy") from afar but should be the education of the public in a clinical non-partisan fashion by the psychiatrists of the symptoms of disease and it will be the public and their government to prescribe and carry out the appropriate treatment.
In Dr. Fin's words:
In the context of the
president’s personality, it is not an outright diagnosis that is needed per se
but a public appreciation of what sociopathy is that can help inform a
response. Medical diagnosis demands a high evidentiary standard. In the public
sphere, mere knowledge of what sociopathy entails may enable the requisite
scientific literacy for the citizenry to decide if observed behaviors fit a
discernable pattern of psychiatric diagnosis that has a bearing on an ability
to govern. This knowledge is especially important in sociopathy, which by its
nature can obscure and seduce the observer. Human nature is drawn to sociopathy
and vulnerable to its charm. Public awareness of sociopathy’s existence and
nature is thus vital to deliberative democracy. This knowledge becomes a
component of basic scientific literacy for deliberative democracy. Having said
this, this knowledge need not require understanding at the level of clinical
nosology. It may constitute essential knowledge like the germ theory of disease:
even if they can not diagnostically distinguish an errant gastroenteritis
caused by E. Coli or Salmonella, the public knows enough to engage in personal
hygiene and perhaps avoid potato salads simmering in the sun at a summer
picnic. Public knowledge about sociopathy has a similar utility: it can help
guide behaviors and inform responses by our political leaders and journalists
in the Fourth Estate as they do their work.
So read the entire but
brief article and return with your idea of the role, if any, for the
psychiatrists in relation to the American public with regard to President
Trump. Remember, this thread is
not about presidential policies but about how to make a psychiatric diagnosis
and who should be supervising any treatment.
..Maurice.
GRAPHIC: From Google Images
posted by Maurice Bernstein, M.D. @ 11:51:00 AM
12 comments
12 Comments:
This is reminiscent of NJ Governor Chris Christie and Dr. Connie Mariano:
I find it fascinating that a doctor in Arizona who has never met me, never examined me, never reviewed my medical history or records, knows nothing about my family history, could make a diagnosis from 2,400 miles away. She must be a genius, Christie said, adding: My children saw that. Source:New Jersey’s Christie fires back at ‘hack’ doctor over weight comments
Then there is 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 authorization for such a statement. Source: Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry The Goldwater Rule: Why breaking it is Unethical and Irresponsible
Even though this applies to psychiatrists, they are also physicians and have special expertise in psychiatry. Note that the title of the article is Especially Applicable to Psychiatry and NOT solely limited to psychiatry.
One of the issues brought up by Governor Christie is potential liability for misdiagnosis if his physician (psychiatrist) were to refute Dr. Mariano.
There is really no debate here; physicians need to follow the ethical standards of their profession.
Of course it is a funny coincident that the 3 most famous cases (Goldwater, Christie, and Trump), all apply to Republicans. I know that we are not discussing politics, but an unbiased scientist must ask the question if there is a political bias in the profession?
-- Banterings
Banterings, thanks for your posting. With regard to Governor Christie, it is interesting that in February 2013, apparently shortly after his response to the 'hack, former Presidential physician, Christie had lap-band weight loss surgery: https://www.nbcnews.com/health/health-news/still-not-skinny-christie-cheered-weight-loss-surgery-success-n33191
What his decision had to do with her prognosis is unknown but despite his angry public response, it provided education.
certainly an action "public education" (including Christie)consistent with the Goldwater Rules.
"Public knowledge" about disorders as provided by a learned individual or 200 individuals certainly is what medical professionalism is all about. ..Maurice.
Maurice,
First off Christie has always said, but most notably at a press conference on shortly after that he and his doctors did have a plan for his health, and "whether it'll be successful or not, you'll all be able to notice." Source: CNN
I would argue you that the ethics of the Goldwater Rule were followed. Someone with her political contacts could have easily called him directly and expressed concern. I believe that that was probably more for her 15 minutes of fame which would help promoter her book, The White House Doctor: My Patients Were Presidents: A Memoir.
That leads to the ethics of using her license as a doctor to hock products. Dr. Oz has been accused of this and ethical questions have arose.
If you are saying that it has educational purposes and that Dr. Mariano is exempt? That is the same justification used at UPMC over the genital photos being posted on FB.
What she did was fat shaming. There is no place for this in society, but ESPECIALLY in medicine it has NO place. See:
2017 KMD - Doctors must stop fat shaming their patients
Professor: Doctors Telling Obese Patients To Lose Weight Is 'Medical Fat-Shaming'
Fat Shaming in the Doctor's Office Can Be Mentally and Physically Harmful
-- Banterings
Shame is not a technique to teach to my medical students. It is harmful to a doctor-patient relationship. It is not even therapeutic. The alternative is empathy.
"empathy and shame are on opposite ends of a continuum. Shame results in fear, blame (of self or others), and disconnection. Empathy is cultivated by courage, compassion, and connection, and is the most powerful antidote to shame."
Should Trump be shamed for any sociopathic behavior he is said by psychiatrists to demonstrate? Should the physicians and the public demonstrate empathy toward President Donald Trump? Without getting primarily political in answering this question, which approach for someone with such behavior would be the most therapeutic? ..Maurice.
Maurice,
We bothe agree about shame. My point was that Dr. Mariano did this in a public forum. If her motives were truly about Govenor Christie's health, she could have called him personally (with her political connections).
So, what was the motivation?
Hocking her book? Political?
I ask the same of the Trump "diagnosis: What is the motivation?
Even phrasing the issue as "fitness for office" has political motivations (it is NOT protecting the public). The US Constitution has built in checks and balances, including fitness for office. In addition to impeachment (Article II, Section 4), the 25th Amendment allows for removal for fitness of the office.
The 25th Amendment to the Constitution was ratified in 1967, prompted by the assassination of President John Kennedy. Its purpose was to provide for the orderly transfer of power when the president dies, resigns or is incapacitated. So far Section 3 of the Amendment has only been used in cases where the president was physically incapacitated.
Section 4 of the amendment has never been used and it opens up a gray area around presidential capacity. The wording leaves open the possibility that mental incapacity could become grounds for removing a president.
Section 4. Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.
If fitness for office was the real reason and the President exhibited signs of a psychiatric pathology AND was unfit for office, he would be removed.
What makes this political is the fact that Vice President Pence would assume the office and he is even less desirable to the Democrats.
As to shaming patients, you may not teach it, but physicians learn it (the hidden curriculum perhaps), AND fat shaming by physicians IS a problem AND presents dangers to patients.
See:
Fat-Shaming by Doctors Happens Way More Often Than You Think (sources cited)
Lies in the Doctor-Patient Relationship
Denial of Treatment to Obese Patients—the Wrong Policy on Personal Responsibility for Health
Impact of weight bias and stigma on quality of care and outcomes for patients with obesity
-- Banterings
So the profession wants to change the rules to make it what they want. They forget that they do not exist in a vacuum, but rather in society. Society has certain expectations from medicine (which it must conform to). The Goldwater Rule is one such example.
Clinical Psychiatry News: Goldwater Rule should be modified, debate audience at The College agrees
-- Banterings
Banterings, thanks for the link to the Goldwater Rule debate and conclusion by the America College of Psychiatrists at their annual meeting. Where do you put the Goldwater Rule relative to the First Amendment to the American Constitution? ..Maurice.
Maurice,
I believe that in a free society, we are all truly free. That does not mean that we are immune to consequences. For instance read
Dad Shoots And Kills His Son's Rapist. Even though the father was free (and some would argued justified), it does not make him immune to the consequences.
The categories of speech that fall outside of the protection of free speech are obscenity, child pornography, defamation, incitement to violence and true threats of violence. Even in those categories, there are tests that have to be met in order for the speech to be illegal.
The Goldwater Rule would apply because the speech would be defamation because it is being made publicly. There are checks and balances in place if the President or other elected officials were truly incompetent including ways to privately report the suspected incompetence.
Comments made by experts carry different weight than other citizens due to the potential consequences of their statements. One could be convicted of the felony of terroristic threats for saying to someone in anger (even justified anger) "I'll kill you."
The defamation would amount to slander or liable. Both could cause civil and/or criminal implications. The most obvious being malpractice.
I believe that psychiatrists are free to say what ever they want, that does not mean they are immune to the consequences. Then comes the ethical question of what is the responsibility are the members of a profession to place the integrity of the profession and the interests of clients above your own interests, act with integrity, competence, and respect. Seems like a no brainer for those of us on a blog titled Bioethics Discussion Blog. Yet in the article I linked above:
...Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to "make the profession look good,,"...
Short answer: Free speech does not apply because the publicly saying it amounts to defamation.
-- Banterings
Banterings, as an internal medicine physician what am I publicly allowed to say based on my medical education allowed or not allowed to say publicly about the President's mental behavioral state based only on my TV inspection? If I didn't indicate publicly my profession, would that make a difference in what I was allowed to say? ..Maurice.
Maurice,
Any doctor will be publicly identified as a physician and therefore subject to the Goldwater Rule. Scope of practice does not matter because physicians are trained in all aspects of healthcare, including psychiatric.
More so if you identify yourself as "Doctor" or even (the famous ) Maurice Bernstein, who would be recognized as a public figure (moderator of the Bioethics Discussion Blog) and a physician.
Of course, unless you were a physician, that is an expert, you would not be on the news and people would not give more weight to your opinion.
I would also ask your opinion of what duty YOU have to the profession in making public statements?
-- Banterings
Banterings, wait! Do you mean by me being a physician and "speaking for myself", I cannot express my personal mental state evaluation and my own diagnosis of the President in any public manner ethically or even legally?
Those in politics and who have allowed themselves to be voted into office have no right under the Constitution to prevent a voter from making an evaluation of the personality, behavior or mental state as well as the political aspects of the politician. We vote for more than "promises"..we vote for the person who is to occupy the political office. Right? ..Maurice.
Maurice,
But you are a practicing physician and have the legal ability to diagnose. So if you make a public statement, how does one know if it is a diagnosis or something else? Is not a diagnosis an opinion?
There are also special laws that protect ANY person from falsely claiming that a person has a loathsome disease (medical conditions have a special requirements in society).
You are absolutely free to do such a thing. You are also free to drive a car without a license while under the influence of alcohol. In both situations you are also NOT immune to consequences.
The person that you opine on may have their physician who examined them come up with a different diagnosis sue you for malpractice for misdiagnosis, HIPAA violations for public disclosure of his personal protected health information. You may face being charged with defamation of character and/or threats against the person.
When the public decries your actions and blames medicine as a whole for doing something irresponsible, you may be facing the licensing board over complaints from colleagues who are bearing the backlash you brought upon them.
If you want to speak your mind with immunity under the First Amendment, then voluntary turn in your license. After all, being a licensed physician is like driving a car, it is a PRIVILEGE, it is NOT a RIGHT! With the privilege also comes responsibility.
-- Banterings
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