Donald Trump and remote diagnosis
By 
Below I’m publishing an op-ed I co-authored with John Gartner about ten days ago, and that hasn’t found a publisher in the legacy media. We sent it around to five different editors that I’ve had good working relationships with in the past. Three didn’t respond at all, one declined politely but vaguely, and a fifth gave the most interesting response, which is that he has an ironclad rule against publishing anything that involves “remote diagnosis.”
This is a very common reaction to anything like this piece, and what’s interesting to me about it is that all investigative journalism always begins and usually ends as an exercise in remote diagnosis. What’s being diagnosed from a distance is the official story, which there is some good reason or reasons to doubt. Yet in the realm of medicine, the response that the official story needs to be accepted at face value, essentially because of an argument from authority, seems to have unusual force with the media powers that be. (It’s unnecessary to add that this is one of those journalistic principles that tends to be applied with shall we say extreme flexibility, as anyone who bothers to compare the treatment of Donald Trump’s and Joe Biden’s health situations will recognize.
For reasons that are too obvious to belabor, the official story from the White House about Donald Trump’s current health status has no evidentiary value whatsoever, except for perhaps the negative value that comes from the overwhelmingly likely assumption that the administration is simply lying about this subject, perhaps radically so.
It seems to us a completely appropriate and indeed ordinary function of the profession of journalism to try to figure out exactly what those lies encompass, to the extent it becomes possible to determine that, in part by continuing to ask inconvenient questions in the face of official mendacity.
Another safe assumption is that one day the something like the real story will come out, and it will be both more absurd and disturbing than even the most hardened of cynical observers now assumes it to be.
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Over the course of the first year of Donald Trump’s second presidency, numerous medical and legal experts have been raising questions about both the president’s mental state, and the political and legal mechanisms that are available to deal with serious cognitive deterioration in the nation’s chief executive.
These questions have taken on special urgency as Mr. Trump has, with increasing frequency, displayed symptoms that are consistent with some form of early-stage dementia. Such symptoms include the sorts of deterioration in language, memory, behavior, and psycho-motor functioning characteristic of the condition.
The president’s language use increasingly includes elements of confusion, confabulation, phonemic paraphasia, and tangential, illogical, and often incomprehensible speech. While Trump once spoke in polished paragraphs and used an advanced vocabulary, he now has trouble completing a sentence, a thought, and sometimes even a word. He fails to recognize people he knows well, such as Hakeem Jeffries. His impulse control seems grossly diminished. And his deteriorating locomotion shows unmistakable signs of a “wide-based gait,” where he swings his right leg like a dead weight, which can be a symptom of frontotemporal dementia.
Expert observers have also raised questions about the bruising that appears at regular intervals – and is often covered up by bandages and makeup – on Mr. Trump’s right hand. Some have pointed out that such bruising is consistent with the administration of intravenous drugs, and are wondering whether the president is receiving one of the pharmaceutical treatments that have become available recently for patients in the early stages of Alzheimer’s disease, and which slow the disease’s progression.
The White House denies all this, but American history is replete with examples of presidential administrations engaging in at best disingenuous behavior when it comes to disclosing the actual health of presidents to the public.
Such questions are particularly troubling, because the American legal system makes it extraordinarily difficult to remove a president who has deteriorated cognitively to the point where such removal becomes imperative.
Impeachment and conviction are, under the Constitution, supposed to be reserved only for the commission of serious legal offenses. 60 years ago, the 25th amendment was ratified to create a constitutional escape hatch for just this sort of situation, but it remains an at best clumsy mechanism.
The amendment currently requires the vice president to get a majority of the cabinet to accede to the president’s removal, and then further requires a subsequent ratification of such removal by two thirds of each house of Congress. Given that the president is free to fire any cabinet officer for any reason at any time, and given the extreme polarization of the current Congress, only the most compelling evidence of mental unfitness seems likely to have any chance of allowing this mechanism to remove even a severely cognitively diminished president.
All this makes it even more imperative that health experts in particular feel free to speak out about concerns they have regarding the possibility that we are seeing Mr. Trump move along an increasingly steep slope toward such diminishment.
Given the present circumstances, it’s especially important that we revisit the so-called “Goldwater rule.”
In the wake of a controversial incident during Barry Goldwater’s 1964 presidential campaign, the American Psychiatric Association adopted a principle that psychiatrists should not diagnose a public figure unless they personally examined the individual.
In 2018, the APA expanded this principle even further, barring not just diagnosis, but the expression of “any professional opinion whatsoever.”
Two problems plague the Goldwater rule, especially in its current extreme form. First, the framers of the original rule intended it to be, according to Allen Dyer, the surviving member of the committee that drafted it, a principle that was supposed to guide professionals, rather than an iron-clad rule, “to be followed slavishly in all circumstances.” In Dyer’s view, that principle has since ossified into a piece of “rule-based legalistic thinking,” that is interfering unduly with something that should be “a matter of professional judgment.”
Second, the rule in its present form fails to reflect advances in psychiatric knowledge. In particular, the profession has moved away from psychoanalytic theory, toward diagnostic criteria that are behaviorally observable, and do not rely either on a clinician’s theoretical outlook, or inferences about internal psychiatric processes.
In Mr. Trump’s case, mental health professionals have literally thousands of hours of publicly observable behavior available to them, as they form their professional opinions about both the extent and the possible causes of the president’s evident mental deterioration.
Indeed a profound irony besets the Goldwater rule. Contemporary psychiatry has come to understand that, far from being some sort of magical source of insight, the personal interview of a patient can often be the least useful element of the diagnostic process. Researchers have discovered that personal examinations are notoriously flawed, because of conscious and unconscious distortions that affect that process.
Furthermore, patients with severe personality disorders such as malignant narcissism are especially adept at fooling and manipulating others, and therapists enjoy no immunity from this source of potential diagnostic error. In sum, observing a subject’s public behavior, especially when combined with the testimony of informants who have interacting with the subject regularly, is likely to prove a more reliable basis for diagnosis than evidence gleaned from what the Goldwater rule treats as an indispensable personal interview.
The evidence of our senses reveals that the president’s mental condition is deteriorating. A rule that attempts to prohibit the people who are most expert regarding such a process from commenting on it is a perversion of professional ethics, and a barrier to giving the legal system the kind of information it needs to deal adequately with a severe political emergency.
Paul Campos is a professor of law at the University of Colorado. He has published extensively on the history and interpretation of the 25th amendment.
John Gartner is a psychologist who for 28 years taught at Johns Hopkins University Medical School. He is the founder of Duty to Warn, an organization of mental health professionals and laypersons who consider it their duty to warn patients, clients, and the community-at-large, when aware of potential danger.