The Goldwater Rule: Psychiatry, Power, and the Ethics of Silence Kindle Edition
by Timothy Lesaca MD (Author) Format: Kindle Edition
Link to book is below:
Preface
This is not a book arguing that psychiatrists should sit on television and diagnose every politician they dislike. It is not a plea for partisan psychoanalysis, nor a defense of the reckless, long-distance certainty that made the Barry Goldwater episode infamous in the first place.
The Goldwater Rule emerged for a reason. Psychiatry is supposed to be a disciplined profession, not a mood ring for elections. Its authority depends on methods such as examination, context, and humility. Lose those things, and the profession begins to sound like everybody else, only with a stethoscope in its pocket.
But rules, like institutions, can age badly. A doctrine designed to prevent misuse can decay into paralysis. A profession that once embarrassed itself by saying too much can, over time, begin protecting itself by saying too little.
And so, here we are. The modern Goldwater Rule, especially as the American Psychiatric Association has interpreted it in recent years, extends far beyond a ban on remote diagnosis. It discourages nearly all meaningful professional comment about the observable conduct of powerful public figures, even when that conduct is repeated, documented, consequential, and frightening. In today’s world, it looks like surrender.
This book argues that the Goldwater Rule has outlived its present form. It does so ethically, because silence is not always neutral. And it does so culturally, because the world that produced the rule in 1973 is not the world we inhabit now. We live in a media environment that records, amplifies, and monetizes political behavior at industrial scale. We live in a culture that often rewards performance over character and spectacle over judgment.
The old rule was built for a world of limited access and communication. But that world is now just a memory.
Chapter 1: The Age of Nerves
On September 7, 1964, a little girl counted daisy petals on American television. She counted badly, the way children do, and then the image shifted. A military countdown began. The screen closed in on the child’s eye. A nuclear explosion followed. Lyndon Johnson’s campaign aired the “Daisy” advertisement only once, but once was enough. The ad was replayed, dissected, and discussed across the country. America was still living in the aftershock of the Cuban Missile Crisis. The memory of those thirteen days in October 1962 had not receded into abstraction. The country had learned that the difference between ordinary politics and catastrophe could be the judgment of a few men in a single room.
That discovery changed the presidency.
In such a world, voters naturally began asking a question that would once have sounded indelicate, maybe even improper: what sort of mind should be trusted with the bomb? Later, in Goldwater v. Ginzburg, a federal court would make the point in stark terms, observing that in an age of nuclear, chemical, and biological weapons, the mental stability of presidential aspirants was a matter “crucial” to intelligent voting. That sentence is important because it clarifies what the later Goldwater debate has often obscured. The original issue was never whether a leader’s mental stability matters. It obviously does. The question was whether psychiatry could speak responsibly about that matter without examination and consent, or whether, in trying to help, it would end by degrading itself.
Barry Goldwater entered that atmosphere like a man walking into a room already full of fumes. He accepted the Republican nomination in San Francisco and declared, with a line that would define his campaign, that “extremism in the defense of liberty is no vice” and “moderation in the pursuit of justice is no virtue.” To his admirers, it was a sentence of conviction.
To his critics, it sounded like a permission slip for recklessness.
Lyndon Johnson sharpened the contrast with his own warning that “there is no such thing as a conventional nuclear weapon.” In another decade, these might have remained competing speeches in a routine ideological contest. However, in 1964, with Berlin, Cuba, China, Vietnam, and fallout all pressing on the public imagination, rhetoric about power and restraint took on a different force.
The election became not just a contest over government but over nerve.
The country was anxious for other reasons as well. John F. Kennedy had been assassinated less than a year earlier. Civil rights had split the nation and the parties. Johnson had just signed the Civil Rights Act of 1964, the most important civil rights law since Reconstruction. Goldwater voted against it on constitutional grounds, a decision that electrified conservatives but appalled many others. Martin Luther King Jr. opposed Goldwater in language that was unusually direct, saying that the prospect of his presidency threatened “the health, morality, and survival of our nation.” King did not accuse Goldwater of madness. He accused him of embodying a philosophy that, in King’s view, would deepen racial injustice and civic disorder. That distinction is meaningful because before psychiatrists entered the story, Americans were already making strong moral and political judgments. Psychiatrics merely added the claim of expert authority.
Johnson went on to crush Goldwater in the general election, winning 61.1 percent of the popular vote and 486 electoral votes to Goldwater’s 52. But the size of the defeat can obscure what made the election historically significant. Goldwater lost, yet he also marked a realignment. He carried Arizona and five Deep South states, split the Republican Party, and helped turn modern conservatism from a faction into a movement. The Senate’s own historical office later observed that, although he was “soundly defeated,” his leadership helped fuel conservative victories in the years ahead, especially in 1980. Goldwater, in other words, was not a cautionary tale from a frightened season. He was a hinge figure.
The country did not only reject him. It also absorbed him.
That is one reason it is so important not to reduce him to a one-dimensional villain. Goldwater frightened many Americans, and maybe for good reason. But fear alone does not explain his place in history. He mattered because he represented a different style of politics which was harder-edged, more ideological, less embarrassed by conflict, and less respectful of the older bipartisan tone. The Cold War made that style feel dangerous. The future of the Republican Party made it feel prophetic. The more voters sensed those two truths at once, the more the election took on an atmosphere of high alarm.
And so the ground shifted. The ordinary political uncertainty of what does this man believe began to slide toward a more intimate and more dangerous one.
What sort of man is he?
Once that happens in a democracy, psychiatry is never far behind.
A columnist can say a candidate seems unstable. A psychiatrist, it is assumed, can say whether he is.
In 1964, the temptation became irresistible.
Across the country, psychiatrists opened their mail and found a question that would follow their profession for the next half century.
Chapter 2: Barry Goldwater Before the Rule
Barry Goldwater was born on New Year’s Day in 1909, three years before Arizona became a state. That detail helps explain the mythology that clung to him later. He belonged to a place that still felt rough-edged, young, and unhousebroken to the eastern political establishment. The Senate’s historical office describes him as a man who loved exploring and photographing the rugged southwestern landscape, often piloting his own plane and carrying a camera. One does not have to romanticize this to see the appeal. Goldwater looked and sounded like the sort of American character novels used to produce with some regularity: sunburned, impatient, and independent. By the standards of midcentury liberal Washington, he could appear aggressively unpolished. By the standards of a large part of the country, that was his charm.
His path into politics was not originally straight. He considered a military career, but his father’s poor health forced him into the family business, Goldwater’s Department Store. He later turned to local politics, won a seat on the Phoenix City Council in 1949, and in 1952 defeated Ernest McFarland, the Senate Democratic floor leader. That upset alone made him more than a regional curiosity. In Washington he quickly became the clearest national voice of a new conservatism that was suspicious of centralized power, adamantly anti-communist, and openly hostile to the managerial drift of New Deal liberalism. His 1960 book, The Conscience of a Conservative, became a manifesto. The Senate’s historical office notes that it is now regarded as a landmark in the development of modern conservatism.
Goldwater’s creed was not particularly obscure. He favored limited federal government, a stronger national defense, and a politics of individual responsibility over administrative expansion. What made him disruptive was not merely the content of those beliefs but the manner in which he held them. He seemed to relish clarity where others preferred calibration. Moderates within his own party found him alarming. Conservatives found him liberating. When the Republican establishment hesitated, Goldwater supporters often behaved like revolutionaries of the respectable class. They had the zeal of people who believed they had discovered not simply a candidate but a country.
None of this makes him a psychiatric case. In fact, one of the enduring absurdities of the later survey is how badly it flattened an obviously substantial life. Goldwater managed a business, served as a transport pilot in World War II, retained an Air Force Reserve commission, and won repeated election to the Senate. The APA’s own retrospective account of the controversy notes that some psychiatrists at the time pushed back precisely on those grounds. Thomas Stach called the survey an insult to the profession. Joseph Schachter admitted that Goldwater frightened him politically but refused to say he was psychologically unfit. Wilbert Lyons, who had served as a flight surgeon, argued that Goldwater could not have been a jet pilot if he were emotionally unstable. Those responses remind us that the scandal of 1964 did not arise from a complete absence of professional judgment. It arose because some people kept their judgment and others lost theirs.
Goldwater himself was not without humor about the whole thing. The Senate history page records his later remark that “the whole campaign was run on fear of me.” It also records the better line: “If I hadn’t known Goldwater, I’d have voted against the s.o.b. myself.” A self-aware politician is not necessarily a safe one, but the line does tell us something about his intelligence and his sense of his own effect. Goldwater knew that his manner unsettled people. He knew that his bluntness, his severity, and his refusal to soften his themes for television gave adversaries material. One can hear, in that joke, a trace of admiration for the ferocity of the case against him. One can also hear the beginnings of the whole Goldwater paradox. He was alarming enough to frighten the country, but not so simple as the frightened country wanted him to be.
He also carried contradictions that later disappeared beneath the legend. He opposed the Civil Rights Act in 1964, a vote that did lasting political damage and helped drive many Black voters and civil rights leaders into open opposition. Yet he was not easily folded into crude racial caricature, and later in life he became markedly more libertarian on some social questions, including gay rights and the religious right. The point is not to rehabilitate him. It is to understand him.
Goldwater was not a cartoon of evil from a Johnson television spot, nor was he merely a sage victim of liberal panic. He was a hard, ideological, historically important politician whose temperament and rhetoric collided with a moment of extraordinary national anxiety.
That collision is what made psychiatry possible as a political instrument.
Chapter 3: The Magazine, the Survey, and the Smear
The publication that detonated the crisis was Fact magazine, edited by Ralph Ginzburg, a publisher with a taste for provocation and little reverence for decorum.
In the fall of 1964, Fact produced a special issue devoted to Barry Goldwater’s mind. It wore its intentions on the cover. Time later recalled the issue’s flamboyant headline:
“1,189 Psychiatrists Say Goldwater Is Psychologically Unfit to Be President!”
The whole enterprise was built around the title “The Unconscious of a Conservative,” which tells you almost everything about the mood in which it was assembled. It was a political intervention dressed in psychological confidence. Even its wording contained a kind of sneer. Goldwater was not merely to be criticized, but interpreted, excavated, and reduced.
The mechanics were as simple as they were destructive. The magazine sent questionnaires to 12,356 psychiatrists asking whether Goldwater was psychologically fit to serve as President of the United States. Of the 2,417 who responded, 1,189 said no. Those numbers have become famous because they were so useful to everyone involved. They gave Fact a sensational cover. They gave the public the impression of expert consensus. They gave the psychiatric profession a humiliation that would take years to codify into a rule.
And they gave Barry Goldwater a grievance substantial enough to carry into court.
The quotations were worse. One psychiatrist declared Goldwater was suffering from “a chronic psychosis.” Another described him in terms of “megalomaniacal” grandiosity. Another suggested he was “basically a paranoid schizophrenic.” Another, reaching for historical company, claimed Goldwater had the same pathological makeup as Hitler, Castro, and Stalin.
The issue’s rhetorical power came not merely from the hostility of these judgments but from the way they were printed: as professional opinions offered by psychiatrists. Had a newspaper columnist written that Goldwater was frightening, reckless, or unstable, readers would have understood the genre. Fact invited readers to believe that medicine had entered the chat and delivered a verdict.
That is what made the affair institutionally dangerous.
Yet the survey was never as unified as the cover suggested. Some psychiatrists refused the premise outright. Thomas Stach wrote that the inquiry itself was “an insult.” Joseph Schachter, while personally disapproving of Goldwater and finding him “somewhat frightening,” said he could not honestly conclude that Goldwater was psychologically unfit. Others simply declined to answer because no examination had taken place. These dissenters matter greatly because they expose the lie lurking beneath the scandal’s retrospective simplicity. It was not that all psychiatrists in 1964 lacked an ethical compass and the APA later discovered one. The compass existed. Many doctors knew immediately that the request was professionally unserious. The scandal came from the number who answered anyway.
The ethical problem was clear even then. A psychiatric diagnosis is supposed to rest on examination, history, collateral information, and clinical method. The survey dispensed with all of that. Goldwater had not been interviewed. He had not been examined. He had not consented. Public speeches, campaign advertisements, news accounts, and partisan fear were treated as if they formed a clinical record.
What Fact offered instead was the authority of the profession divorced from the discipline of the profession.
The American Psychiatric Association recognized the danger almost at once. Long before the rule itself existed, the Association was already trying to distance itself from the spectacle. Walter Barton warned Fact that if it published the survey, the APA would “take all possible measures to disavow its validity.” Daniel Blain, then APA president, condemned the published responses as a “hodge-podge” of personal political opinions and said they had “no scientific or medical validity whatsoever.” Those phrases reveal a profession that understood it had been lured into something demeaning.
Psychiatry had not simply been made partisan.
It had been made sloppy.
If there is intrigue in the episode, it lies here. The public thinks of the Goldwater affair as a story about whether doctors should talk about politicians. In fact it was also a story about how badly politics wanted doctors to validate what politics already felt. That desire has never gone away. A democracy frightened by a leader will always be tempted to ask medicine to supply the last degree of certainty. Fact simply found a particularly lurid way to do it.
The names and technologies have changed since 1964.
The temptation has not.
That is why the story still feels uncomfortably current.
Chapter 4: Goldwater Strikes Back
Barry Goldwater did not shrug the whole thing off as campaign nastiness.
He sued.
That decision changed the meaning of the controversy. The question was no longer whether Fact had behaved indecently. The question was whether it had committed libel.
That mattered because American law gives wide breathing room to criticism of public figures. Goldwater could not win merely by showing that the statements were harsh, false, or unfair. Under the constitutional standard shaped by New York Times v. Sullivan, he had to show actual malice. In other words, he had to prove something worse than bias.
He had to prove a particularly culpable form of irresponsibility.
The court’s reasoning is worth reading carefully because it gets lost in the myth of the case. The judges did not say that the mental stability of presidential candidates is off-limits. Quite the opposite. They said it is “crucial” to informed voting in an age of terrifying weapons. The court was therefore not defending Barry Goldwater from psychological scrutiny as such. It was rejecting the method by which that scrutiny had been manufactured. Fact had not carried out a clinical inquiry. It had staged one. That distinction is the hinge of the whole history.
The public’s concern about the mental fitness of leaders was treated as legitimate.
What was treated as illegitimate was the reckless use of psychiatric authority without psychiatric procedure.
The record was ugly. The court concluded that the magazine had used “slipshod and sketchy investigative techniques.” It found evidence that favorable statements had been omitted, letters had been edited or merged, and the presentation of the issue had created a misleading impression of consensus and clinical seriousness. The public was invited to believe that a medical specialty had applied its expertise to Barry Goldwater and found him wanting. What it had actually been shown was a partisan collage, held together by sensational editing and the prestige of the white coat.
One can attack a candidate lawfully. One cannot do so by manufacturing the appearance of medical judgment and then claiming the ordinary privileges of political opinion. The court would not let Fact have it both ways.
Goldwater won. The jury awarded nominal compensatory damages of one dollar and punitive damages totaling $75,000. The dollar was almost theatrical in its symbolism. It suggested that the deepest injury here was not a conventional measurable loss but a violation of reputation so entangled with public falsehood that money could only gesture at it.
For psychiatry, the lawsuit solved only part of the problem. Law can punish misuse after the fact. It cannot by itself tell a profession how to behave before the fact. Goldwater’s victory made one thing very clear: psychiatrists could not safely offer remote clinical judgments about public figures and expect the law to treat those judgments as harmless opinion. But the profession’s deeper problem remained unresolved.
What, exactly, should a psychiatrist do when a public figure’s behavior seems relevant to public safety, public trust, or the exercise of catastrophic power?
The law had said what not to do in one egregious case. It had not said how the profession should think about its civic role going forward.
The APA responded first with outrage and then with structure. Barton’s warning to Fact had emphasized that a physician renders an opinion on psychological fitness within a doctor-patient relationship grounded in “a thorough clinical examination.” Blain’s public statement was even harsher, condemning the survey as personal political opinion disguised as professional assessment and insisting the replies had “no scientific or medical validity whatsoever.” By 1973, the Association had translated that indignation into formal ethics language. Section 7.3 of the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry stated that psychiatrists may share expertise about psychiatric issues in general, but it is unethical to offer a professional opinion about a person in the public eye unless the psychiatrist has conducted an examination and obtained proper authorization for the statement.
Examination and consent: those were the two pillars.
Yet the ethics code is more interesting than the simplified slogan that later grew out of it. Section 7 does not begin in retreat. It begins with civic duty. It says physicians have a responsibility to contribute to community improvement and public health. It encourages psychiatrists to advise the executive, legislative, and judiciary branches and to share expertise on psychosocial issues with the public, while also warning them not to wrap every statement in institutional authority.
The Goldwater Rule therefore sits inside a broader framework that assumes psychiatrists do have public responsibilities.
This is why the modern debate is so hard.
The code itself contains a tension. It calls psychiatrists into public life and then sharply limits one of the most consequential ways they might participate in it.
The rule was necessary, but it was also incomplete. It prevented one very real abuse: the partisan misuse of psychiatric authority. It did not settle the harder question of what happens when public danger seems visible, the stakes are national, and the only people formally prevented from speaking in expert terms are the people most trained to assess judgment, impulse, dangerousness, and the limits of self-control.
In 1973, that problem still lay mostly in the future. The rule was written in the long shadow of one scandal.
It would have to survive later tests it had not been designed to imagine.
Chapter 5: Hidden Bodies, Hidden Minds
Americans have always liked to imagine that presidents are made of sturdier material than ordinary humans. The civic religion prefers leaders who look sound, stand straight, and radiate composure under the lights. History is less pious. Beneath the public iconography lies a long archive of concealed illness, private impairment, rumor, improvisation, and institutional denial.
The Goldwater Rule did not create that history and did not end it. What it did, over time, was remove psychiatrists from public discussion while leaving the underlying reality intact. The republic did not become mentally simpler because the profession chose restraint. It merely became more dependent on secrecy, whisper networks, memoirs, and hindsight.
Woodrow Wilson offers the classic early case. In 1919, after exhausting himself on a national tour to sell the Treaty of Versailles, he suffered a stroke and nearly died. The White House Historical Association notes that his wife Edith kept away most visitors and made a number of key decisions herself. One need not indulge melodrama to see the constitutional significance. A major presidential incapacity was effectively managed through household gatekeeping rather than transparent public procedure. The presidency did not stop functioning. It was nonetheless shielded. That is often how American leadership crises have been handled: not by sober collective acknowledgment, but by concealment until concealment itself becomes part of the governing arrangement.
John F. Kennedy’s case was different in tone but similar in structure. Kennedy projected youth, energy, elegance, and wit. He also lived with severe back pain, Addison’s disease, digestive problems, and a substantial medication regimen that remained carefully hidden from the public. A 2020 History essay, drawing on historians and medical records, describes a president who cultivated a robust image while managing chronic illness and numerous medications in private. An earlier CBS report, based on documents later studied by historian Robert Dallek, summarized the record more bluntly: Kennedy took painkillers, anti-anxiety drugs, stimulants, sleeping pills, and hormones that kept him alive. This is not evidence that he was unfit; in fact, historians note he performed effectively during the Cuban Missile Crisis. It is evidence of something else: the enormous gap between public image and bodily reality in the American presidency.
Richard Nixon brings the question closer to temperament and judgment. One need not turn Nixon into a clinical exhibit to acknowledge that the final phase of his presidency produced acute internal concern. In a Nixon Library oral history, former Defense Secretary James Schlesinger recalled telling General George Brown that if there were any messages from the White House, he should be informed immediately, because he wanted to protect the integrity of the chain of command and guard against “hotheaded free-lancers in the White House.” Schlesinger did not say the president had gone mad. He did not need to. The point is historical, not diagnostic: when officials worry about the steadiness of a commander in chief, they often act quietly and administratively rather than publicly and analytically. The public learns the story later, if at all.
The country has also handled mental health in politics with a mixture of stigma and cowardice. Thomas Eagleton, George McGovern’s running mate in 1972, was forced off the Democratic ticket after it became public that he had received electroshock treatment for depression. He lasted eighteen days. The episode now looks less like prudent vetting than a national panic over psychiatric history. Eagleton later returned to the Senate and won reelection, which tells its own story about how badly the moment misjudged him. In 1988, Michael Dukakis released a detailed medical history in response to weeks of rumors about his mental health. The Los Angeles Times described the episode as a lesson in how campaign rumors and insinuations could take on a life of their own. So much for the theory that silence prevents speculation. It often does the opposite.
Ronald Reagan added yet another chapter. After his first debate against Walter Mondale in 1984, serious public questions arose about his age and acuity. The Smithsonian has noted that the performance prompted concerns among the press, the public, and some in Reagan’s circle. During the Iran-Contra period a few years later, a memo even raised the possibility of the Twenty-Fifth Amendment, though the idea went nowhere. Historians disagree sharply over what these episodes meant, and that disagreement is itself instructive. Democracies do not handle questions of leader fitness elegantly. They oscillate between denial, gossip, euphemism, and posthumous reconstruction. What they rarely achieve is a disciplined public language for discussing risk while events are still unfolding.
This history should change how we think about the Goldwater Rule. The issue is not that Americans never worried about the minds and bodies of leaders before Donald Trump’s fitness was brought into question. They worried repeatedly. They worried about Wilson, whispered about Kennedy, maneuvered around Nixon, stigmatized Eagleton, baited Dukakis, and rationalized Reagan.
The deeper problem is that the country has never developed a stable, honest way to discuss leadership impairment or dangerousness without either sliding into cruelty or retreating into euphemism.
The Goldwater Rule did not create that problem. But by taking psychiatrists almost entirely out of the public conversation, it helped ensure that the vacuum would be filled by campaign operatives, gossip merchants, and television personalities whose principal qualification was political spin.
Chapter 6: The Screen, the Stage, and the Mask
The media environment that produced Barry Goldwater was already changing fast, but by later standards it still looks almost quaint.
Television had begun to transform politics in the 1950s. The Miller Center notes that sales of television sets in the United States exploded from 172,000 in 1949 to more than 52 million by 1953, forcing politicians to learn how to present themselves not merely as office-seekers but as images. The 1952 election marked the first time presidential candidates turned decisively to television to communicate with voters. From that point forward, presidents would not simply govern. They would perform governance. Media advisors, advertisers, and showmen would become central to political success. The modern candidate-centered campaign was born in the studio as much as in the party hall.
That change had consequences beyond campaign technique. Television rewarded ease, posture, rhythm, and face. It favored confidence over caveat. It pulled politics toward personality. By the 1960 Kennedy-Nixon debates, the country had already entered what one historian called the era of “showbiz politics.” By the 1990s, as the Library of Congress observes, the old line between news and entertainment had blurred badly. The rise of cable television, celebrity pundits, and performative political coverage pushed public life further into the realm of spectacle. News had always contained drama; now it acquired pacing, branding, recurring characters, and a commercial incentive to make conflict feel continuous.
Politics did not become fake. It became televisual.
That is not the same thing, but it can be just as distorting.
Ronald Reagan understood this transformation better than most of his contemporaries because he had spent years inside the machinery of entertainment. The Miller Center notes that he worked in radio, then in film, appeared in more than fifty movies, and learned “the art of staging a scene effectively,” a skill he used repeatedly in political life. Reagan himself joked that he had been “the Errol Flynn of the B’s,” which was a modest way of acknowledging a serious talent. He knew where the camera was. He knew what mood looked like before it became words. He knew that presence is not frivolous in democratic politics; it is part of the instrument. The republic, one might say, had always loved actors. It simply took a while to admit how useful acting could be in a president.
Donald Trump represented the next step, not because he was identical to Reagan but because he emerged from a still more accelerated media culture. Before politics, Trump had spent decades as a brand, a tabloid figure, a licensing machine, a beauty-pageant owner, and most famously the star of The Apprentice. The Miller Center notes that the show projected him as a blunt, successful, charismatic straight-talker and carried him into homes far beyond the usual range of New York real-estate notoriety. Trump’s political significance is not exhausted by his television history, but it cannot be understood without it. By the time he entered the White House, the country had already spent years learning to consume him as performance. Reality television had trained a public to read dominance, spontaneity, and humiliation as leadership cues. That was not psychiatry. It was theater.
Psychiatry changed during the same broad period. The discipline that confronted Goldwater in 1964 was not identical to the one that later confronted Trump. The American Psychiatric Association’s own history of the DSM notes that psychiatry long struggled with competing classification systems and relatively loose diagnostic boundaries. DSM-III, published in 1980 after work that began in 1974, introduced explicit diagnostic criteria and a more structured, empirically oriented approach. That shift is important because it complicates the usual defense of the Goldwater Rule as if the profession were identical across decades. The rule was born in 1973, just before the discipline’s major turn toward explicit criteria and a more standardized diagnostic method. In one sense that timing strengthens the case for restraint. In another, it highlights how much psychiatry itself has evolved while the public rule has stayed remarkably static.
The great irony is that the Goldwater Rule now operates in a world of abundance rather than scarcity. In 1964, a psychiatrist looking from afar saw a limited public record filtered through a small number of speeches, interviews, and campaign events. Today the record can include years of video, transcripts, public statements, social media posts, unscripted exchanges, rally performances, interviews, and reactions under stress. None of that is a substitute for an examination. But it is not nothing.
The modern media system is a mask factory, but it is also an archive. Public figures perform constantly, and over time patterns emerge from performance itself. The APA has insisted that even abundant public information remains insufficient for professional opinion. That is a principled position. It is also, increasingly, a very rigid one.
Meanwhile the void is never empty. When professionals retreat, pundits advance. Cable hosts, partisan strategists, amateur body-language analysts, internet clairvoyants, and social-media diagnosticians rush in to narrate the mind of power without training and without shame. Television panels are built for argument, not assessment. Their business model is heat.
Yet because psychiatry has constrained itself so tightly, public understanding of leader behavior is often shaped more by the loudest generalists than by the most careful specialists.
The profession’s old fear, that psychiatrists might look partisan, has been replaced by a new and equally awkward reality: the public asks psychiatric questions every day, but often gets its answers from people whose expertise runs mainly to lighting and timing.
Chapter 7: Duty to Warn, Free Speech, and the Return of the Debate
The Goldwater debate becomes much sharper once another doctrine enters the frame: Tarasoff.
In 1976, three years after the Goldwater Rule was formalized, the California Supreme Court held in Tarasoff v. Regents of the University of California that when a therapist determines, or should determine, that a patient poses a serious danger of violence to another, the therapist has an obligation to use reasonable care to protect the intended victim. The case is famous for its governing sentence: “The protective privilege ends where the public peril begins.”
No one should pretend that Tarasoff maps neatly onto presidents and candidates. It does not. The doctrine grew out of treatment, confidentiality, and a specific threat. But its moral force has always been larger than its formal boundaries. It stands for the proposition that professional silence is not absolute. Under some conditions, danger outruns discretion.
The APA has resisted applying that logic to public figures. In its ethics opinions, the Association argues that Tarasoff is about the limited disclosure of confidential information learned in treatment or evaluation. A president who is not one’s patient does not fit that model. Nor does the general public resemble a specifically identified victim in the classic Tarasoff sense. Those are fair objections. The legal doctrines are not interchangeable. But the modern dispute is not really about whether Tarasoff directly governs campaign speech. It is about whether psychiatry’s ethical imagination has become too narrow.
A profession that remembers only Goldwater learns caution.
A profession that remembers Goldwater and Tarasoff learns that caution is not the only virtue.
Donald Trump forced that question back into open professional life. Trump did not create media spectacle, celebrity politics, or public concern about leadership temperament. But he made those things impossible to bracket. In March 2017 the APA publicly reaffirmed its support for the Goldwater Rule, stating that psychiatrists should not give professional opinions about the mental state of someone they have not personally evaluated. The Association’s subsequent ethics guidance went further, clarifying that a psychiatrist need not make a formal diagnosis for the statement to count as a prohibited professional opinion. Commentary about a public figure’s behavior, affect, speech, or presentation could also violate the rule if it drew on psychiatric expertise.
In other words, the modern rule is broader than “no diagnosis from afar.”
It is closer to “no meaningful psychiatric commentary from afar.”
The 2025 APA ethics opinions make this broad interpretation unmistakable. They state that even in the digital age, where public information may be abundant, such material remains insufficient for a professional opinion about a public figure. They also state that psychiatrists may speak as citizens, but may not assume a professional role in doing so.
This is the point at which many critics part company with the Association. The distinction between citizen and professional is tidy in theory and somewhat fictional in practice. The public does not forget who a psychiatrist is when that psychiatrist enters public debate. Expertise follows the person into the square. The question is therefore not whether psychiatrists may speak at all. It is whether they may speak in an honestly expert way while also acknowledging limits.
The present APA answer is, largely, no.
Critics have been arguing for years that this is too much silence. The First Amendment Encyclopedia notes that opponents of the rule believe it removes the people best qualified to interpret troubling mental states from public discourse and leaves the field open to untrained observers. Leonard Glass argued in 2018 that the APA had effectively expanded the rule into a “gag rule,” and he proposed a different approach: allow psychiatrists to speak, provided they clearly state that they have not examined the public figure and are not offering a definitive diagnosis. That is the obvious middle ground between irresponsible certainty and professional muteness. The trouble is that the APA has shown little appetite for occupying that middle ground.
The First Amendment issue is similarly more complicated than it first appears. The Goldwater Rule is not a federal law. No government agent will arrest a psychiatrist for talking about a candidate. In that narrow legal sense, this is not state censorship. But professional organizations can still impose penalties, shape norms, and narrow public debate in ways that matter. That is why the rule keeps reappearing in free-speech discussions. It is an instance not of governmental suppression but of professional self-regulation so stringent that it may undermine the very public purpose the broader ethics code elsewhere invokes.
Chapter 8: Is This Just American?
The Goldwater Rule is often treated as if it were a universal principle of psychiatric ethics. It is not. It is an American professional rule born of an American scandal. That does not make it parochial or foolish. It does, however, make it historically contingent.
Recent research in European Psychiatry found no single Europe-wide or homogeneous guideline forbidding psychiatrists from commenting publicly on people they have not treated. Some European organizations support something very much like Goldwater. The Royal College of Psychiatrists in the United Kingdom explicitly supports it, and the Finnish Psychiatric Association has a comparable stance. Other countries rely more on general confidentiality or dignity rules, and many have no specific formal protocol at all. Europe, in other words, is a patchwork rather than a cathedral.
That same study is revealing for another reason. It notes that the World Psychiatric Association’s 2020 Code of Ethics includes a principle stating that psychiatrists should offer accurate information to the media in order to educate the public about psychiatric disorders and dispel misconceptions. That is not the same as endorsing remote diagnosis of politicians. But it does suggest a more outward-facing model of professional responsibility than the rigid American version often permits in practice. The European authors also observe that the Goldwater Rule may be especially resonant in the United States because of the country’s polarization and sensational media culture. That seems right. American politics has a particular talent for turning every ethical boundary into both a weapon and a grievance. But the core dilemma is not purely American. Public figures, media speculation, and professional restraint exist elsewhere too.
At the same time, the international record offers a powerful caution against naïveté. There is a nightmare inverse to the Goldwater problem, and it is not hypothetical. The twentieth century saw systematic political abuse of psychiatry in the Soviet Union and elsewhere. A historical overview in Schizophrenia Bulletin notes that roughly one-third of Soviet political prisoners were confined in psychiatric hospitals and that the scandal forced a major rupture within the World Psychiatric Association, from which Soviet psychiatry withdrew in 1983 before returning conditionally later. A University of Virginia law summary of the same history describes the incarceration of political and religious dissidents in maximum-security psychiatric hospitals without medical justification. This is what happens when psychiatry is not too silent but too obedient. The profession becomes an arm of the state and disorder becomes whatever power says it is.
That international warning matters because it keeps the argument honest. Anyone calling for a revision of the Goldwater Rule must also insist on barriers against the weaponization of diagnosis. History has already shown what politicized psychiatry can look like at its ugliest. The answer to one abuse cannot be an invitation to another. This is why the best case against the present rule is not abolition but reform. A profession that wants a public voice must earn it through explicit method, transparency about uncertainty, and a very strong refusal to let political dislike masquerade as clinical certainty. Goldwater taught that lesson in one direction. Soviet abuse taught it in another. The ethical task is to avoid both forms of corruption at once.
The European study also raises a point especially relevant to the future. Its authors note that the Goldwater Rule was created in a democratic society and that its applicability under oppressive political conditions remains uncertain. They even suggest that there have been cases in which psychiatrists speaking about people they had not examined helped expose abuses and contributed to liberation from detention-based settings. One need not universalize that claim to see its force. An ethics of absolute silence is easiest to defend in a reasonably healthy democracy, where institutions, press freedom, and elections still do much of the corrective work. It is harder to defend where power is increasingly personalized, media ecosystems are manipulated, and public truth is unstable. In such conditions, professional restraint can become indistinguishable from quietism.
This is where the American discussion becomes too self-enclosed. The question is not simply whether the rule protected psychiatry from another Fact-style embarrassment. It did. The question is whether the rule, as currently interpreted, equips the profession for the world now emerging—one marked by democratic strain, informational excess, performative politics, and leaders whose public behavior is often both more visible and more erratic than in earlier decades.
On that question, the international comparison is sobering. There is no global consensus that the American solution is the final or best one. There is instead a field of competing values: dignity, confidentiality, anti-stigma, public education, civic warning, and resistance to political misuse. The United States chose one balance in 1973. It is not obvious that it must choose the same balance forever.
So, no: this is not just an American issue. But America has dramatized it in a particularly intense form. The country that invented mass political television, perfected celebrity politics, and turned punditry into an industry now asks whether its most psychologically sophisticated medical specialty should remain almost entirely silent about the men and women who run its government. Other nations have answered that question differently, or not answered it at all. That alone should loosen the aura of inevitability surrounding the current American rule. It is a choice, not a law of nature.
And history, which is less sentimental than professional ethics statements, has a way of reminding institutions that choices made in one era can become liabilities in another.
Chapter 9: When Silence Becomes Complicity
The easiest way to misunderstand this argument is to imagine it as a plea for less rigor. A revised Goldwater Rule would not permit psychiatrists to wander onto talk shows and pronounce diagnoses over the opening music. It would not turn partisan fear into clinical vocabulary. It would not reward the clever doctor who says, in effect, “I cannot diagnose Senator X, but people who behave like Senator X generally have such-and-such disorder,” which is merely diagnosis wearing a fake mustache. The profession is right to reject that sort of disingenuous performance. Goldwater was wronged in 1964, and the rule’s original instinct, to prevent the reckless use of psychiatric prestige in electoral politics, remains sound.
But a sound instinct can become an unsound absolute.
The modern Goldwater Rule now reaches well beyond what the original scandal strictly requires. As the APA’s own ethics opinions make clear, it treats comments about behavior, speech, affect, or presentation as professional opinions even when no diagnosis is offered. That effectively bars psychiatrists from saying many things that other experts say routinely in their own fields: that certain patterns suggest declining capacity, severe impulsivity, dangerous disinhibition, impaired judgment, or the need for urgent formal evaluation. To forbid definitive diagnosis without examination is one thing. To forbid almost all expert interpretation of repeated, consequential, public behavior is another. The first protects method. The second can suffocate usefulness.
A better standard would begin with a distinction the profession already half recognizes. In its 2025 ethics opinions, the APA permits scholarly psychological profiling of historical figures under careful conditions so long as it does not amount to diagnosis and is clear about limitations. That concession shows the profession already knows how to draw a line between rigorous interpretive work and clinical overclaiming. The problem is that it largely refuses to extend that distinction into present time, precisely where democratic stakes may be highest. Dead leaders may be analyzed. Living leaders, no matter how dangerous their observable conduct may appear, trigger a near-total ban.
It is an ethical choice, and one that now deserves open challenge.
What would revision look like?
First, keep the prohibition on remote diagnosis. Keep it firmly.
Second, allow psychiatrists, under a defined public-interest standard, to comment on observable patterns of behavior, functional capacity, dangerousness, coercive rhetoric, cognitive slippage, or impaired judgment, provided they explicitly disclose that they have not examined the person and are not offering a formal diagnosis.
Third, encourage collective or institutional statements over lone celebrity interventions whenever possible. A panel of carefully chosen experts is less likely to drift into ego, performance, or ideological exhibitionism than a single media-hungry doctor.
Fourth, require methodological transparency: what public materials were reviewed, what can and cannot be concluded, and where uncertainty remains. That would not make the discussion perfect. It would make it adult.
Such a rule would also better align psychiatry with the ethical world it already inhabits. Section 7 of the APA code says psychiatrists should contribute to the community, advise government, and share expertise with the public. Tarasoff reminds the profession that under some conditions danger changes the moral balance. The World Psychiatric Association emphasizes accurate media information and public education. Even critics of the current American rule usually do not seek license for unbounded speculation; they seek a structured way to warn without diagnosing. In other words, the raw materials for a more balanced framework are already on the table. What has been missing is not an ethical vocabulary but the will to reorganize it.
There is also a democratic point here that should not be evaded. When people ask, “If not psychiatrists, then who?” they are not asking for an oracle. They are noticing a vacuum. Political leaders create policy, precedent, war, bureaucracy, legal climate, and national mood. Their judgments can alter millions of lives. Yet the people most trained to assess patterns of dangerousness, distortion, grandiosity, coercive charisma, and functional decline are told that their most ethically secure public role is to speak only in abstractions.
At some point, silence stops being prudence and begins to look like complicity—not complicity in any one party’s agenda, but complicity in a civic arrangement that leaves the public to interpret dangerous leadership without disciplined help.
History gives that worry weight. Americans concealed Wilson, mythologized Kennedy, privately managed Nixon, stigmatized Eagleton, rumor-chased Dukakis, and euphemized Reagan. The Trump years then exposed how badly the old etiquette fits a hyper-mediated, high-risk, low-restraint political culture.
The historical pattern is not reassuring. The safer inference is not that future leaders will become calmer and easier to judge. It is that public life will continue rewarding performance, grievance, and spectacle, and that some future figures may be both more polished and more dangerous than the ones who have already alarmed us. That is an inference, not a prophecy, but history leans that way.
The Goldwater Rule was born from one scandal and one humiliation.
It served a purpose.
It reminded psychiatry that authority without method is theater.
But the rule, as presently interpreted, now risks another mistake: confusing moral cleanliness with civic responsibility. A democracy does not need psychiatrists to become propagandists. It does need them to stop pretending that the only alternatives are irresponsible diagnosis and perfect silence.
There is a middle ground, and the future of the rule depends on finding it. Barry Goldwater could not be responsibly diagnosed from afar. That remains true. The question now is whether the public must therefore be left with no disciplined psychiatric warning at all when power itself begins to look dangerous.
I do not believe it must.
And I do not believe history supports the comfort of that silence any longer.
Epilogue: The Silence After the Warning
There is a particular American habit, old as the republic and stubborn as mildew, of pretending that power is healthier than it is. We dress it up. We powder it for television. We hand it a flag, a podium, a teleprompter, a campaign bus, a spouse with a fixed smile, and a soundtrack fit for a war movie. Then we stand back and admire the packaging, as if the packaging were the person. We tell ourselves that history is made by statesmen, not by bundles of appetite, vanity, grievance, fear, impulse, compulsion, and performance stitched into a suit and handed the launch codes.
We prefer the ceremony to the anatomy. It is tidier that way.
But history is not tidy, and power is not therapy. Power does not heal pathology; it often feeds it. It does not calm the grandiose; it furnishes them. It does not discipline the impulsive; it tempts them hourly. It does not humble the resentful; it gives resentment a motorcade. The presidency, like every high office, attracts admirable people and serious people and disciplined people. It also attracts performers, narcissists, obsessives, charm merchants, grievance addicts, control freaks, sadists in silk ties, and human weather systems who leave behind wreckage and call it leadership.
This is not cynicism.
It is a historical observation.
The surprise is not that troubled people seek power. The surprise is that the rest of us are forever surprised.
That is the larger weakness in the Goldwater Rule as it has come to be understood. It is not that the rule began in error. It began in embarrassment, which is different, and often more useful. The profession had been dragged into a partisan circus in 1964 and had every right to recoil. It had watched psychiatric language turned into campaign artillery, and it drew a line. Fine. Good. Necessary. But somewhere along the way a line became a shrine. A temporary corrective hardened into an ethic of retreat. The profession did not merely say, “We will not diagnose from afar.” It drifted, over time, toward saying something closer to, “We will not meaningfully help the public think about dangerous leaders at all, at least not in public, at least not while it still matters.”
That is a very different proposition, and a much weaker one.
And so we arrive at the question buried beneath all the etiquette.
What exactly are we protecting when we protect silence this fiercely?
Are we protecting patients? Sometimes, yes. Are we protecting professional rigor? Also yes. Are we protecting the public from stigma and lazy pseudo-diagnosis? We should be. But are we also protecting the profession from discomfort, from conflict, from the unpleasant burden of speaking when speaking is dangerous to one’s reputation or institutional standing? Almost certainly.
That is the part nobody likes to say aloud.
Silence can be principled.
Silence can also be convenient.
It can preserve a profession’s sense of cleanliness long after it has ceased to preserve the public good.
Psychiatry cannot save democracy. That is not its job.
But neither can it forever behave as though democracy’s most volatile human questions are somehow beneath its public concern.
It is not enough to say, “We do not diagnose from afar,” and then fold up the tent while the country argues over the judgment, impulse control, and dangerousness of its leaders with no disciplined language at all.
At some point restraint mutates into ritual helplessness.
At some point the refusal to speak becomes its own form of professional theater, a performance of purity enacted while others do the dirty work badly.
Selected References
Primary legal and ethics documents behind this draft include Goldwater v. Ginzburg, 414 F.2d 324 (2d Cir. 1969); Tarasoff v. Regents of the University of California, 17 Cal.3d 425 (1976); the American Psychiatric Association’s Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry; the APA’s 2017 public reaffirmation of the Goldwater Rule; and the APA’s 2025 Opinions of the Ethics Committee, which clarify the rule’s application to comments on public figures’ behavior, speech, and presentation. These are the core documents for the book’s legal and professional argument.
For the historical chapters on Goldwater and the 1964 campaign, the most useful sources were the U.S. Senate Historical Office’s biographical pages on Barry Goldwater, the American Presidency Project’s texts for Goldwater’s nomination speech, Johnson’s 1964 campaign remarks, and the official 1964 election statistics, together with the APA’s own historical retellings of the Fact controversy and the Library of Congress account of the “Daisy” ad. The Martin Luther King Jr. Research and Education Institute is especially useful for understanding why Goldwater frightened civil-rights leaders in the summer and fall of 1964.
For the broader presidential-history material, the White House Historical Association’s Wilson biography, the Kennedy health reporting in History and CBS, the Nixon Library oral history with James Schlesinger, the Miller Center and Missouri Historical Society material on Thomas Eagleton, the Los Angeles Times report on Michael Dukakis’s medical disclosure, and the Smithsonian and History reporting on Reagan’s age and capacity concerns were central. These sources support the book’s argument that the United States has a long history of concealing, mishandling, or stigmatizing questions of leader fitness rather than confronting them soberly.
For the modern media and international chapters, the key materials were the Miller Center’s work on television and the presidency, the Library of Congress discussion of the blurring of entertainment and news, the Miller Center biographies of Reagan and Trump, the APA’s DSM history, the European Psychiatry article on the Goldwater Rule’s relevance in Europe, the World Psychiatric Association language quoted there on media education, the University of Virginia law summary of Soviet psychiatric abuse, and the historical overview in Schizophrenia Bulletin. For the free-speech and reform debate, the First Amendment Encyclopedia, the APsaA’s 2017 statement, and the 2018 STAT pieces on Leonard Glass and the proposed rollback were especially helpful.