Mental health of political figures - Ethics of commentary and psychiatric assessment related to the death of Vladimir Bekhterev (1857-1927)

Amidst ongoing conflicts and the COVID-19 pandemic, public speculation about the mental health of political figures has become increasingly prevalent across popular discourse and the media. Within various jurisdictions and constitutions, democratically elected politicians can be legally removed from their position if deemed medically incapable of exercising their duties. In recent years, there have been discussions about the wellbeing of leaders in North America and Eastern Europe and whether they should be removed from office on conjectural grounds of mental illness. In some cases, such discourse can undermine legitimate concerns about rational abuses of political power and may lead to increased stigmatisation around psychiatric disorders.[1]

Worldwide, ethical guidelines and professional organisations forbid psychiatrists from presumptive, public diagnoses without appropriate consent. For example, the American Psychiatric Association’s (APA) “Goldwater Rule” states:

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 […] a psychiatrist may share with the public [their] 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.[2]

Other influential national bodies, including the Royal College of Psychiatrists in the United Kingdom, advise similarly;[3] to the authors’ knowledge, no such rubric is stipulated by the Indian Psychiatric Society,[4] but researchers have advocated for its creation.[5] Recently, in the United States, several experts defied the APA’s guidelines, offering prospective opinions about President Donald Trump and questioning his capacity to hold office, both in the press and within academic publications. This raised major concerns about the ethics of public debate. Proportions are of course unknown, but some supported the actions of these psychiatrists in defence of free speech and commended their perceived bravery, whilst others condemned apparent ethical transgressions.[6,7]

Interestingly, an epoch from psychiatric history may provide a test-case for these arguments; namely the final days of the Russian psychiatrist and neurologist, Vladimir Bekhterev (1857-1927) [Figure 1]. Throughout a long and varied career, Bekhterev researched neuroanatomy, mental processes, psychophysiology, and described symptoms of ankylosing spondylitis, which was subsequently named after him. In 1927, Bekhterev visited the Kremlin for a medical assessment of Joseph Stalin (1878-1953). The Soviet leader had requested an examination of a left-hand atrophy that troubled him throughout his life. Exact details of this meeting are unknown; however, Bekhterev supposedly declared to colleagues afterwards: “I have just examined a paranoiac, with a short dry hand” (in reference to Stalin).[8] The next day, Bekhterev died in mysterious circumstances, having reportedly encountered shadowy figures and Russian Secret Service physicians.[8] Eschewing common practices, no autopsy was conducted before cremation and Bekhterev’s brain was removed prior to this, in spite of his family’s wishes.[9] This further heightened conspiratorial suspicions. Deemed an inconclusive death (at least “officially”), many believe Bekhterev was deliberately poisoned, precipitated by his open pronouncement on Stalin’s supposed psychopathology.[8,9]

Figure 1.

“Portrait of Vladimir Bekhterev” by Ilya Repin, 1913. Public domain

Although seemingly in extremis, this incident prefigures modern disputes concerning the ethics of public psychiatric opinions about politicians without their consent, as discussed in recent medical publications.[6,7] More importantly, it also illustrates the potentially life-threatening consequences for those who do speak out, particularly within autocratic environments. Would Bekhterev’s actions contravene today’s professional standards? Are the hermeneutics of contemporaneous ethical rubrics determined by our own ideological or political frameworks? Intended to uphold apolitical ideals and standards in psychiatric practice, such guidelines can often provoke adverse controversies.[10]

Throughout history, societal shifts from liberal to suppressive conditions are unpredictable. Amidst these settings, medical experts may openly offer an opinion at a certain time and be latterly punished for doing so. How would psychiatric associations position themselves towards those who have violated ethical regulations, but are subsequently threatened by despotic caprices? For instance, would organisations intervene if licenses to practice were at risk for political reasons? In the authors’ view, this is a timely concern that is missing from the debates about the applicability and relevance of the Goldwater Rule and other guidelines. Conflicts exist between a medical expert’s “duty to warn” and a psychiatric association’s institutional “duty of care” to those it represents. Alarmingly, in Bekhterev’s case, even his family were future targets for Stalin’s regime.

It could be argued that Bekhterev’s scientific legacy was undermined by state-sponsored neglect, characteristic of the Stalinist era; his academic importance only became recognised again towards the end of the Soviet Union when his works began to be re-disseminated.[9] Yet, the nature of his death (apparently through his public comments on Stalin) invokes pertinent questions about how openly voiced psychiatric opinions may be perceived by some to be professionally justifiable and morally appropriate, depending on wider political frameworks. Alongside Bekhterev’s substantial scholarly contributions, his plight foreshadows what some perceive to be intrinsic inconsistencies between ethically grounded psychiatric guidelines applicable in democratic contexts and the medical “duty to warn”. These issues can become increasingly composite when principles of individual liberty and freedom of speech are threatened by autocratic regimes. Bekhterev’s demise may reflect the times in which he lived and worked, but as the suspicious circumstances of his death indicate, sharing professional expertise at a public or even private level can prove injurious, especially in authoritarian settings.