Bioethics Discussion Blog: President Trump:Diagnosis and, if Necessary Therapy: Doing it Ethically

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Monday, February 05, 2018

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

5 Comments:

At Thursday, February 08, 2018 12:03:00 PM, Blogger A. Banterings said...

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

 
At Thursday, February 08, 2018 1:46:00 PM, Blogger Maurice Bernstein, M.D. said...

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.

 
At Thursday, February 08, 2018 3:23:00 PM, Blogger A. Banterings said...

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

 
At Thursday, February 08, 2018 8:12:00 PM, Blogger Maurice Bernstein, M.D. said...

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.

 
At Saturday, February 10, 2018 3:26:00 PM, Blogger A. Banterings said...

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








 

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