No Need to Break the Goldwater Rule. Here’s What Docs Propose Instead.

Psychiatrists have long held that it is unethical for them to diagnose a public figure with a mental disorder without a clinical exam. It’s called the Goldwater Rule.

But after President Donald Trump launched an expletive-laden Easter Sunday post on social media over the Iran war, and 2 days later threatened that “a whole civilization will die tonight,” some clinicians say it may be time to take a different approach.

Writing in an opinion piece for The BMJ, two experts suggested that while doctors should not have free rein to proclaim their own perceived medical diagnoses of the president or other public figures, physicians can still sound an alarm by calling for clinical assessment.

“Urgent clinical assessment is needed — now more than ever,” wrote David Nicholl, MD, a neurologist with Sandwell Health Campus, and Trish Greenhalgh, MD, of the University of Oxford, both in England.

The issue of whether doctors should diagnose a president or candidate from afar prompted a heated discussion during the American Psychiatric Association’s annual meeting in 2016, ahead of Trump’s first presidential election.

And later that year, three academic psychiatrists wrote a letter to then-President Barack Obama raising concerns about Trump’s fitness for office, saying that while professional standards prevent them from offering a diagnosis, features of his personality — such as an “apparent inability to distinguish fantasy from reality” — suggested that an impartial medical assessment was an urgent priority.

Nicholl and Greenhalgh said they “fully concur” with those doctors’ hesitation to comment clinically, but also with their advice to perform an assessment.

The opportunity for such outside assessment was potentially missed during former President Joe Biden’s term, when he was mostly kept out of the spotlight until a disastrous debate performance began to raise questions about his capacity to run for a second term.

Biden was ultimately convinced to drop out of the race, but his cognitive capacity while in office was the subject of a 2025 House Republican investigation that concluded his mental decline was known to staffers in the West Wing but kept quiet from the public.

Trump, 79, last year became the oldest U.S. president at the time of an inauguration. His physician as recently as October said he was in “exceptional health,” which followed a diagnosis of chronic venous insufficiency and questions about a persistent bruise on the back of his hand set.

But recent concerns on Trump have focused on his alleged cognitive decline, Nicholl and Greenhalgh noted.

Their commentary referenced a recent Daily Beast interview following the president’s social media posts on Iran with clinical psychologist and psychotherapist John Gartner, PhD, who with media clips and quotes argued that Trump has been “showing signs” of frontotemporal dementia (FTD), poor judgment, and aggressive behaviors.

MS NOW senior medical analyst Vin Gupta, MD, also weighed in, saying the president is “exhibiting all the signs of dementia.”

But Nicholl and Greenhalgh explained that the diagnosis of any neurodegenerative disorder, and especially the behavioural variant of FTD (bvFTD), “is difficult, even in expert hands.”

“Criteria such as ‘loss of manners’ or ‘diminished personal warmth’ are highly subjective and culturally variable,” they wrote. “In our view, making a diagnosis of probable bvFTD would be impossible without full clinical assessment and appropriate imaging. Although Trump stated in December 2025 that he had ‘aced his third cognitive assessment,’ the tests he reportedly had performed would not meet the requirement of ‘a full neuropsychological profile.'”

Allen Frances, MD, chairman emeritus of psychiatry at Duke University in North Carolina and former chair of the American Psychiatric Association’s DSM-IV Task Force, disagreed with the dementia diagnosis and also cautioned doctors against diagnosing someone they haven’t examined.

“To say he’s demented is a stretch,” Frances told MedPage Today. “It just cheapens the argument by going overboard.”

That said, Frances does believe that some of the president’s behaviors are “abominable” and that the Goldwater Rule isn’t necessarily “relevant at a time when Trump can destroy the world.”

Trump and his doctors have often been opaque about his medical record: reports indicate that the White House downplayed the severity of Trump’s COVID hospitalization in 2020 and a full medical report was never released ahead of the 2024 election.

And the health issues of past presidents have often been kept secret, as was the case for Franklin D. Roosevelt, whose high blood pressure was never disclosed. Not long into his fourth presidential term, Roosevelt dropped dead from a brain hemorrhage.

Bandy X. Lee, MD, a forensic psychiatrist and editor of the 2017 book, The Dangerous Case of Donald Trump, told MedPage Today that the Goldwater Rule seems to ignore that mental health clinicians have a duty not just to their own patients, but to society as a whole.

“I believe in the original Goldwater Rule. I do not believe one should diagnose, as if one were going to treat, a public figure,” she said. “But I do believe it is our legally and ethically bound obligation to speak when there are signs of danger.”

Nicholl and Greenhalgh may be able to get behind that statement.

“We caution strongly against making the diagnosis of a defined cognitive condition on the basis of media clips, and we offer no clinical comments on statements made by doctors who have attempted to do so,” they wrote. “But we think it is time to distinguish more clearly between ‘clinical commentary’ and ‘clinically informed concerns.'”