In response, the A.P.A. issued “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.

To diagnose conditions in someone we’ve never met — let alone offer treatment recommendations — is fraught both ethically and scientifically. Assessing patients face to face and finding out their experiences and history, much of which is private, and has perhaps never been disclosed to anyone, is essential. Otherwise, we risk making big errors and fostering confusion.

Psychiatric diagnoses are after all stigmatized (calling someone “narcissistic,” “psychotic” or “in denial” is commonly a denigration), and are frequently misunderstood. Insurance companies still grossly underfund mental health treatment, leaving millions of seriously ill Americans without care. These restrictions reflect, partly, widespread biases that psychiatric diagnoses (e.g., depression) are not “real problems” warranting insurance coverage. Hence, to legitimize psychiatric disorders and treatment is important. Doctors who loosely and freely offer diagnoses for individuals they have never interviewed threaten to make these terms cheap and ubiquitous, fueling misperceptions.

Over the 50 years since the Goldwater incident, researchers have thus conducted careful studies to make psychiatric diagnoses clearer and more precise, advancing scientific understanding and treatment. Since the Hippocratic oath, physicians have also sought to act professionally, to follow very high moral standards and respect privacy and confidentiality, partly to gain and preserve patients’ trust.

Nonetheless, many mental health providers have challenged the Goldwater Rule. Psychologists (with Ph.D.s, as opposed to psychiatrists, with medical degrees) argue that this principle does not fully apply to them, and that offering diagnoses of public figures can be in the national interest. Recently, several psychologists ranked all of the presidents in order of narcissism (L.B.J., Nixon and Teddy Roosevelt scored on top), and argued that this trait helped in persuading the public and advancing legislation, but could also lead to rigidity and impeachment.