The Professional Ethical Challenge Of Publicly Discussing A President Who Appears Cognitively Compromised

04/25/2017 01:07 pm ET Updated May 03, 2017
AP

In the past few weeks, the 45th president of the United States has displayed public behaviors that have led many to believe he is suffering from some form of brain illness and that this is a root cause of his recent bizarre acts and statements. Just recently, on Friday April 21, 2017, the president sat down with AP White House correspondent Julie Pace and gave an interview that raised alarm for many in the media and general public.

In this interview, the president was described as “unintelligible” at least 16 times and his thoughts appeared to wander at points. In addition, he appeared to become confused as to what he said not seconds earlier in the interview.

An excerpt from an interview with the president and AP White House Correspondent Julie Pace. Many have interpreted this excha
AP
An excerpt from an interview with the president and AP White House Correspondent Julie Pace. Many have interpreted this exchange as a sign of cognitive decline (whether psychological or neurological or both) in the sitting Commander-in-Chief.

The alarm raised this week has rekindled a debate that has been ongoing since last year’s primary season regarding the role of mental health experts and the determination of fitness for duty of a potential (and now sitting) president. At face value, the American Psychiatric Association’s (APA) rules of ethics appear to bar its member psychiatrists from publicly diagnosing an individual without having evaluated him or her personally and without the person’s permission. This is known as the Goldwater Rule and refers to ethical codes enacted following the very public negative assessment of presidential candidate Barry Goldwater in 1964 (For current APA stance click here).

However, mental health professionals also have a “duty to warn” any individuals who may be at harm based on information gathered during clinical interactions. This statute arose from a 1976 court case, Tarasoff vs. The Regents of the University of California, designed to warn third parties of a patient’s harmful threats.

Right now, one debate in public and professional circles is whether the current behavior of the sitting president and its potential for harm to the American people falls under the Goldwater Rule or “duty to warn.” In fact, 35 psychiatrists met at Yale University last week to defend their breaking of the Goldwater Rule in favor of “duty to warn” against the dangers of the president’s current mental health status and his abnormal behavior (per their opinion).

By many accounts, this president is cognitively compromised and has shown recent signs of impaired decision making, whether limited to single moments or as part of a pattern of confused behavior. This has been evident in:

― His departure from an Executive Order signing ceremony prior to signing the Order on March 31st of this year

The President leaves an Executive Order signing ceremony without having signed the Order on March 31, 2017.
GETTY IMAGES
The President leaves an Executive Order signing ceremony without having signed the Order on March 31, 2017.

― His statement during an interview with Fox Business Network, while recalling the decision to send 59 Tomahawk missiles into Syria, that “We have just launched 59 missiles, heading to Iraq”

― Apparently forgetting to place his hand over his heart during the national anthem at last Monday’s White House Easter Egg Roll

The President places his hand over his heart during playing of the national anthem, after an apparent reminder to do so from
GETTY IMAGES
The President places his hand over his heart during playing of the national anthem, after an apparent reminder to do so from First Lady Melania Trump, at the White House Easter Egg Roll.

Tossing a young man’s hat into a crowd of people immediately after signing it at the boy’s request at the latter White House Easter event

The President signs a young man’s hat before inexplicably tossing it into the onlooking crowd at White House Easter Egg Roll
REUTERS
The President signs a young man’s hat before inexplicably tossing it into the onlooking crowd at White House Easter Egg Roll on April 17, 2017.

― Appearing to refer to Speaker of the House Paul Ryan as “Ron” twice during an event in Wisconsin on Tuesday, April 18, 2017.

Conflating the two most recent leaders of North Korea (father and son, the late Kim Jong-il and the currently presiding Kim Jong-un) in an interview with Fox News on Tuesday, April 18, 2017.

― His aforementioned AP interview in which he appeared confused, distracted, and “unintelligible” on Friday, April 21, 2017.

The clinical question being debated by psychiatrists, psychologists, neurologists, neuroscientists, and licensed clinical social workers, to name a few professions, is:

Are we seeing the behaviors of a 70-year-old sitting president with mental illness, neurologically-based (or age-associated) dementia, or some complex clinical presentation of both?

If you examine the recent AP interview, you will see signs that could be indicators of psychiatric or neurological impairment. The truth is it is difficult to determine the causal factors for his strange, confused, and often bizarre behavior. This interview included signature “Trumpisms” including:

clear narcissistic behaviors, with a distorted sense of reality in which facts and fiction were routinely interwoven and his first inclination was self-congratulatory (e.g., “more success in eight weeks than Obama had in eight years”) and bordered on delusional (e.g., “[Congressman Elijah Cummings] said [I] will be the greatest president in the history of this country”) – severe narcissists can display a delusional state (separation from reality) that rivals psychotic disorders

repeated lies in the face of conflicting evidence, including the maintenance of long-standing deceptions (e.g., his Electoral College landslide victory; “great chemistry” with many world leaders including German Chancellor Merkel; saving hundreds of millions on the F-35 military aircraft project; securing revised healthcare, tax reform, and his coveted border wall in the span of a week). This is going to take a toll on his mental capacities. There is an increased need for mental resources when he must navigate the border between what is fact and what he is saying is true.

At any moment, there lies the possibility for a crack or complete collapse of the lie. In other words, a 70-year-old man, who would be expected to have age-associated mental lapses, has to simultaneously monitor what he is saying, what his body language is showing, and what the interviewer might ask next.

At this point, it is impossible for outside clinical experts to pinpoint a specific diagnosis or to single out a main root cause for the president’s mental lapses but one thing remains clear (and has for years), his ability to govern the American people safely and effectively is compromised.

This was the case when many suggested that the Electoral College step in and do their Constitutionally allowable duty and vote against his presidency, when congressional leadership and Vice President Pence were/are asked to invoke the 25th Amendment, when hundreds of thousands marched against him in January and again this past weekend, and that remains the case today as we approach the 100-day mark of his first year in office.

The reality is that whether or not this president is showing signs of psychiatric or neurological impairments (or both) can be left for debate among qualified experts. For example, a cognitive function specialist has suggested that the president is suffering from dysfunction in the frontotemporal regions of his brain while psychiatrists have suggested that the Commander-in-Chief has a dangerous mental illness in the form or malignant narcissism (although there have also been dissenting opinions). I tend to believe that we are seeing a confluence of co-morbid neuropsychiatric clinical presentations. Outside of a comprehensive evaluation, there is no way to further nail this down clinically.

What can no longer be debated is the lack of fitness for duty of this president (setting aside apparent Russian collusion and/or treason as well as continued violations of the Emoluments Clause of U.S. Constitution), and the urgent need for action on behalf of concerned citizens here and worldwide.

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