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Political Landscape Poses Ethical Questions for Mental Health Professionals

October 15, 2019

By H. Steven Moffic, MD
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

In terms of politics, the mental health field indirectly has some of the same separation considerations of church and state as does religion.  Because local and federal government funds public care and regulates insurance companies in the United States, those in power have enormous influence over mental healthcare resources. One of the most striking examples of this was when President Ronald Reagan in 1980 turned the federal funding for Community Mental Health Centers established by President John F. Kennedy into state block grants that could be – and were – used for other services instead of mental healthcare.

Other countries have used psychiatry for political purposes. These examples include:

  • The support and acquiescence of Nazi psychiatrists in the killings of the mentally ill, the first group targeted for extermination
  • The use of psychiatrists to improperly diagnose “sluggish” schizophrenia in political dissidents in the former Soviet Union, justifying their hospitalization in the 1970s
  • Psychologists, but not psychiatrists, who enabled torture of prisoners in the War on Terrorism in Iraq

It should be clear, then, that speaking out about political leadership can be costly for mental healthcare professionals. Yet, in this time of escalating political conflict and speculation about President Donald Trump’s mental health and its repercussions (more on this later), mental health professionals and organizations do have the ethical challenge of what, if anything, to say and do about our current political situation.

In my field of psychiatry and medicine, we do have ethical principles that apply. Other disciplines have related ethical principles. In our Principles of Medical Ethics with Annotations Especially Applicable to Psychiatrists (2013), we have:

  • Section 7: “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health”
  • In Annotation 2 of this section, psychiatrists are told that they can share and interpret their expertise with the public, but to be mindful of the different roles of being a dedicated citizen and professional expert. Following that, in Annotation 3 of this section, we have the so-called “Goldwater Rule”, which is unique to psychiatrists. We are told that it is unethical to provide a professional opinion about public figures we have not examined in person and also not received a consent to comment publicly by our patient.

As clear as these principles may be, they beg the question of whether a higher ethical concern, such as the perceived risk to public mental health and safety, should take priority over them. That is something like the Tarasoff legal ruling that a clinician should work toward hospitalization or police intervention for any patient who is deemed too risky for the lives of other people, despite the other ethical need to protect confidentiality and autonomy. This political question leaves us with many ethical considerations, including:

The increase in mental problems in society. Over recent years, there has been a rise in suicides, diagnosable mental disorders, burnout and xenophobia in our country. Does our political situation contribute to that rise? If so, how should we respond?

Models of societal leadership. Does it matter that political leaders (as it currently is more than one, and more than one party) spew profanity and call others by derogatory names? Does that get modeled by citizens and thereby reduce human dignity? How do we make human dignity as exciting and inspiring as expressions of human indignity?

The resolution of political conflict. Is there anything that the mental health professions can do to reduce the extent of partisan and conflictual politics? Would our involvement in conflict resolution, or even group therapy, help?

Safe psychological spaces for discussion. What can we recommend to families and communities as to discussion about political issues, knowing that important relationships have ended due to strong differences of political opinions? Do we recommend silence or the establishment of safe psychological spaces for discussion? If the latter, should we be leading community town hall meetings to discuss such volatile issues?

The benefits and harms of mental disorders in political leaders. When is a certain type of mental disorder helpful for societal leadership, and when not? For instance, the recurrent depressions of President Abraham Lincoln seemed to help him be empathetic to the plight of black Americans. On the other hand, did the early stages of Alzheimer’s disease impair the leadership of Reagan? (Note: In a memoir published in 2011, Reagan’s son Ron said he noticed his father began exhibiting symptoms of Alzheimer’s during his first term.) We need to educate the public and what kind of mental status helps or hinders political leadership at any given societal time.

A group of mental healthcare professionals, including the authors of the book “The Dangerous Case of Donald Trump” (a collection of 37 essays written by psychiatrists and mental health professionals on the observed behaviors of the president), as well as members of the World Mental Health Coalition, have been operating informally as watch dogs of our country’s current politics, and decided that the current political risks to society necessitate speaking out in new ways that do not focus on the concerns of the Goldwater Rule. In a letter provided to members of Congress earlier this week, right before the Democratic presidential debate, two recommendations were deemed urgent:

“The impeachment hearings must proceed with all deliberate speed, and if possible, Congress should reinforce existing laws that limit a president’s ability single-handedly to make war or launch military actions.”

Changes of law are also an ethical principle for psychiatrists, which makes it ethical for us to try to join Congress in that deliberation. Note Section 3:

“A physician shall respect the law and also recognize a responsibility to seek changes in those requirements . . .”

Such ethical principles and current societal situation leave all of us with a decision of whether to speak out or stay silent. If we speak out, what do we say and why? When we do speak, how do we clarify if we are speaking professionally and/or as a citizen? Are we willing to risk retribution in terms of job loss or being expelled from professional organizations? Silence is indirectly a support for the status quo. Therefore, what, if anything, have you and your colleagues been doing or saying, and what will you do in the future about these ethical challenges? Whatever it is, the goal should be to enhance mental health, should it not?

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