Ethics and disinformation on the campaign trail: psychiatry, the Goldwater Rule, and the 2024 United States presidential election

Less than nine months until the 2024 US presidential election and another divisive contest between incumbent president, Joe Biden, and former president, Donald Trump, looks likely. Although disclosed medical records show no evidence of psychiatric symptoms, there has been widespread psychopathological supposition about these candidates, influenced by their age profiles and polarised political trends.1, 2, 3 Continuing into 2024 and the Republican primaries, this discourse could be heightened by growing disinformation generated by digital technologies and artificial intelligence (AI).⁴

Amidst this complex and sensitive landscape, psychiatrists may face significant challenges, reigniting contentious debates about commentary on public figures and impinging upon the American Psychiatric Association's (APA) Goldwater Rule⁵; this regulation prohibits APA member-psychiatrists from discussing the mental health of individuals without assessment or consent. Accordingly, interventions involving relevant stakeholders, including the APA, international psychiatric bodies, the media, and technology organisations, may help safeguard the reputation of psychiatry and elevate sociopolitical exchanges around mental health.

The mental health of American presidential candidates has continually attracted scrutiny.⁶ During the 2016 contest, such discussions became increasingly animated when psychiatrists provoked ethical controversies through public views on Mr. Trump.^1,5,7 Later, in the 2020 campaign, speculation abounded about Mr. Biden, as exemplified when Mr. Trump publicised his own results from the Montreal Cognitive Assessment (a screening tool for cognitive decline and dementia).³

These narratives have intensified throughout Mr. Biden's presidency and may be resonating with diverse constituencies; only 32% of participants in a 2023 survey indicated that Mr. Biden had the “mental sharpness” for high office.³ To a different extent, Mr. Trump faces ongoing psychopathological conjecture, reflecting persistent arguments since 2016.^2,5 Separately, recent incidents involving US Senators have amplified concerns about age and psychopathology in American politics.⁸

As a contemporary development, digital expansions in AI are complexifying these debates, exacerbating the potential for distorted and politicised content.^3,4 Hypothetically, alongside other misapplications, this could include falsified medical records, neuroimaging scans, or even doctored representations of expert psychiatric commentary. Akin to fake news in past elections, these could shape post-truth messaging and voter sentiment; notably, deepfakes of Mr. Biden exhibiting signs of cognitive decline have already captured news headlines.^3,4

Thus, in the 2024 cycle, psychiatrists will need to balance ethical obligations alongside public demands for scientific insights, likely renewing tensions over the APA's Goldwater Rule. Intended to uphold professional standards and attenuate stigmatising paradigms, this could be particularly pertinent with the tribalism surrounding the forthcoming election, where psychiatric opinions risk being exploited for political capital.³

Nevertheless, critics contend that the Goldwater Rule restricts free expression, enabling experts from allied fields (e.g., psychologists or neurologists), non-US psychiatrists, or laypeople to disproportionately sway public agendas.⁷ Others highlight a lack of enforcement mechanisms and the anachronisms of the Goldwater Rule for modern online platforms. Both may require nuanced consideration given the ethical implications of digitally-generated disinformation.

With another pivotal US presidential race approaching, the psychiatric discipline may need to proactively respond to these scenarios through the APA or international entities, such as the World Psychiatric Association (WPA), of which the APA is an organisational member.

Repudiating conjectural diagnoses and instead encouraging general evidence-based commentary, especially around symptomatology and stigma, could advance sociopolitical exchanges and mitigate sensationalism. Therefore, as in 2016, a pre-emptive APA statement may be warranted, reaffirming ethically-grounded practices.⁹ APA-endorsed advocacy programmes could support this, distinguishing between responsible dialogues and the dangers of unethical psychiatric opinions.

However, the latter could still conceivably be fabricated through deepfake or AI technologies. Likewise, per previous contests, it is probable that some APA member-psychiatrists may transgress the Goldwater Rule by speculating on the psychopathology of the 2024 candidates. Since the consequences of rule violations remain ambiguous, particularly with the rise of digital disinformation, clarifications may be necessary ahead of the forthcoming campaign, emphasising verification protocols, regulatory applications, and professional obligations.

Additionally, by strengthening prior projects, dedicated APA or WPA committees should provide leadership on how psychiatrists can ethically counter mental health disinformation about public figures.¹⁰ As speculative diagnoses about politicians are becoming an increasingly international issue, these initiatives could assume global relevance,⁷ with other prominent elections scheduled for 2024, like in India and across Latin America and the European Union.

Equally, given the sizeable disinformation threat, direct engagement between psychiatric associations, media outlets, social media companies, and the technology sector may yield broader sociopolitical benefits. Here, the APA and the WPA could leverage their position to shape responsible reporting policies and protocols for flagging digital content that politicises or misrepresents psychiatric perspectives.

In the authors’ opinion, collective and multidisciplinary actions are critical for creating a more well-informed and sensitised landscape around mental health in US presidential politics and wider settings. We urge relevant stakeholders to contribute to these goals, in turn preserving psychiatric probity, protecting individual dignity, and upholding the integrity of democratic procedures.

Contributors

A.S, M.L: Writing–original draft.

A.S, D.B, M.S.C, M.A.O, A.V, M.L: Writing–review & editing.

Declaration of interests

Dinesh Bhugra is a past president of the World Psychiatric Association, the Royal College of Psychiatrists, and the British Medical Association. Maria A. Oquendo is a past president of the American Psychiatric Association and is a member of the International Advisory Board for The Lancet Regional Health—Americas. All other authors declare no competing interests.