It was not some law that Noah broke but a social rule, something not written down in any code of justice anywhere in the United States. Thou shalt not raise thy voice in a Boeing 707. That is all Noah really did. … No question about it — he’d flipped his lid. … Yet who are these people who are making this judgement? There were no psychiatrists on the airplane. Not professionals, in other words, but everyday ‘normal’ people, police and passengers, decided he was crazy. Which is a way of saying that we — you and I, the public — made that diagnosis. … Let the psychiatrist decide whether it’s schizophrenia or involutional melancholia or some other arcana they suffer from. That’s the psychiatrist’s job. He confirms and refines what is fundamentally our diagnosis. He works for us. … The mental hospital is essentially what we want it to be, and we want an institution which will take disturbing people off our hands. … Only a change in attitude on our part will eliminate the need for such custodial institutions. — Lucy Johnstone

In the past few months, we have seen a resurgence of debate surrounding psychiatry’s Goldwater Rule. Here is how the American Psychiatric Association describes the rule in their “Principles” guidebook:

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.

And here are some examples from recent times.

Independent:

Donald Trump has a “dangerous mental illness” and is not fit to lead the U.S., a group of psychiatrists has warned during a conference at Yale University. Mental health experts claimed the President was “paranoid and delusional,” and said it was their “ethical responsibility” to warn the American public about the “dangers” Mr. Trump’s psychological state poses to the country.

The Telegraph:

Though they stopped short of making a psychiatric diagnosis they clearly imply that the (now) President suffers from Narcissistic Personality Disorder — recently described in the American Journal of Psychiatry as being associated with ‘significant functional impairment and psychosocial disability.’ There are apparently two variants with Trump being of the thick-skinned overt type who can be ‘socially charming despite being oblivious to the needs of others and interpersonally exploitative.’

Time:

It’s indeed impossible for anyone but a professional who is treating Trump to say with certainty what his clinical diagnosis is — if any. But when the mental health of one man can have such a profound impact on the lives of 323 million Americans — to say nothing of the 7.5 billion people living on the planet as a whole — it’s irresponsible to not at least have the conversation. And it’s a dereliction for the people who know the most — the doctors — not to lead it.

Psychology Today:

The group “Duty to Warn,” founded by influential psychotherapist Dr. John Gartner, has gathered nearly 60,000 signatures on a petition calling for the removal of Donald Trump from office due to “serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States.”

Rather than focus on the ethical issues surrounding the Goldwater Rule, I’d like to take a different approach on the subject.

The main argumentative strategy against publicly diagnosing Donald Trump has been on the basis that we lack sufficient information to make a clinical diagnosis.

Instead, I want to focus on the unreliability of psychiatric diagnoses as the reason why we should refrain from commenting on his mental health.

Most of the current debate surrounding the question of whether it’s morally permissible to diagnose a public figure like Donald Trump seem to simply assume diagnoses are reliable. If they didn’t think so, there’d be no point in arguing about it in the first place.

I want to undercut such arguments by challenging that assumption.

To start, here’s a chart with the results of the field trials for the DSM-5, alongside the results from previous editions of the DSM:

A score of .7 or higher used to be the gold standard, which the APA considered to signify “very good agreement.”

or higher used to be the gold standard, which the APA considered to signify “very good agreement.” Scores from .4 to .59 means “good agreement.”

to means “good agreement.” And scores from -.03 to .36 means “unacceptable.”

Higher scores are better. They signify the reliability of a diagnosis by providing us with a measure of the

degree to which two clinicians could independently agree on the presence or absence of selected DSM-5 diagnoses when the same patient was interviewed on separate occasions, in clinical settings, and evaluated with usual clinical interview methods.

Basically, it tells us how confident we are that two different doctors would arrive at the same diagnosis for the same patient if they both individually treated that patient under the usual conditions.

The original standard, .7, was lowered for the DSM-5 to .6.

Why is this a problem? To quote Allen Frances:

When DSM 5 failed to achieve acceptable reliability by historical standards, the DSM 5 leadership arbitrarily decided to move the goal posts in and lower the bar in defining what is ‘acceptable.’ In fact, only the 5 of the 23 DSM 5 diagnoses that achieved kappa levels of agreement between 0.60–0.79 would have been considered ‘good’ in the past. DSM 5 cheapens the coinage of reliability by hyping these merely okay levels as ‘very good.’ Then it gets much worse. The 9 DSM 5 disorders in the kappa range of 0.40–0.59 previously would have been considered just plain poor, but DSM 5 puffs these up as ‘good.’

Notice the score for depression? It has gone from a reliability of .81 back in the days of the DSM-III (1980s) all the way down to .32.

Our ability to reliably diagnose major depressive disorder has gone from .81 to .32 in the span of 30 years. We’ve gotten way worse at it. How is this even possible?

If reliability is this abysmally low under normal circumstances when a patient actually sits in front of a clinician and talks to them in person, why on earth should we expect that a diagnosis for someone as polarizing as Donald Trump to be remotely useful or accurate? Remember, this would be a diagnosis made by people who haven’t even met him.

In this era of fake news and “experts for hire,” what, if anything, do we think can be accomplished by weaponizing something as unreliable as a psychiatric diagnosis in the service of our political aims?

There are no biological tests for any mental illness; we have nothing but the judgment of the clinician to rely on. But there is no reason to assume clinicians are any better at setting aside their biases than the rest of the population.

There is simply no doubt, whatsoever, that the political affiliation of the mental health professional would color and shape the type of diagnosis, if any, that someone like Trump would be likely to receive.

This is the first argument that ought to be addressed before we even have to bother engaging with ethical considerations surrounding the Goldwater rule.

And I would hope it should go without saying that the strategy of employing the stigma of mental illness in order to discredit a political opponent is morally reprehensible. But if the immorality of the deed doesn’t convince you, then perhaps its being just bad science will.