American Democracy is at Best A Semi-Rational Process

 

Why A Psychiatric Diagnosis Is Not Necessary….

 

In the closing month of the federal election for President, I think it is useful to consider my previous comments on the Goldwater Rule.  The rule was promulgated by the American Psychiatric Association to prevent casual comments about psychiatric diagnoses of candidates when they had not been examined and given permission for those diagnostic evaluations.

I have always been in favor of this rule largely because it is outside the scope of psychiatric practice and like many forensic settings there can be a prominent conflict of interest based on political affiliations.  It also turns the diagnostic process on its head in that it is no longer used for the benefit of the patient, but the benefit or lack of benefit falls to third parties.  And finally, whenever psychiatric diagnosis is used in the press or other forms of common usage they lose their real meaning. They are no longer useful observations but, in many cases, become ad hominem attacks.

I have not counted the number of comments about narcissistic personality disorder, but it has grown significantly since the 2020 Presidential election and several commentaries that Trump had that disorder.  Antisocial personality disorder and psychopathy (a trait rather than a formal disorder) have also been used to describe him.  Since the terms became more visible, they have been widely applied.  You Tube and TikTok videos suggest how to make the diagnosis yourself or at least recognize it.  They describe typical speech patterns and how you should respond.  Many describe the red flags.  After watching this material none of it seems useful to a psychiatrist who makes the diagnosis and provides treatment. 

There seems to be a significant overlap with people who are difficult to get along with – often in asymmetrical roles like employer-employee.  Do the conflicts that typically happen in these situations rise to the level of a psychiatric diagnosis?  Do conflicts and misunderstanding that occur in other interpersonal relationships rise to that level? Probably not.  But there is a whole lot of videos encouraging people to make that diagnosis.   

The original arguments for making a psychiatric diagnosis on former President Trump were basically threefold.  First, that it was a professional obligation.  Psychiatrists were obliged to warn the American people about the dangers of any diagnosis basically as a public service.  There are several problems with that approach – the most significant being that diagnoses are associated with a wide range of behavior of varying severity and not predictive of anything specific.  It is unlikely that any diagnosis would have predicted the wide variety of significant problems that Trump exhibited following the election. The other problem of course is that it removes the Constitutional threshold for action by the Cabinet and replaces it with a much lower threshold – the psychiatric diagnosis.  It is basically the reason why people do not undergo civil commitment or guardianship proceedings based on a diagnosis.  The law requires obvious behavior that can be observed by any lay person. The 25^th Amendment standard is “ a written declaration that the President is unable to discharge the powers and duties of his office” from either the President himself or a “majority of either the principal officers of the executive department or of such other body as Congress…”  The determination is strictly based on lay observation and not medical or psychiatric evaluations.  Second that it provided additional information for voters that they could use in making their decision.  And finally, the somewhat grandiose assumption that it may be a superior method than the judgment of officials mentioned in the 25^th Amendment. All of those assumptions have failed at multiple levels.

Rather than be concerned about Trump’s diagnosis this may be a question of voter capacity or competence.  In other words, is the voter using available information to make a rational choice?  And can the available information be analyzed rationally?  That requires more than just stating a preference.  It requires a rationale for casting the vote. This is also a difficult measure because there is a value system baked in to some of these decisions.  For example, some votes are based on single issues or traditions like always voting for members of a certain party. Some votes are based on issues like abortion, guns, and censorship even when it is clear the results have been worsening medical care for women, gun extremism, and book banning that includes shutting down some school libraries. The value system can also include extremism like guns, racism and antisemitism.  Even though most reasonable people would agree those values have no place in modern society – they do not disqualify people who value those ideas and vote on that basis.  All of this illustrates why voting is a semi-rational process. On that basis you can also ignore all the negatives that members of the same party or Cabinet say about a candidate’s intellect and character.

The only inconsistency in the law that occurs is that capacity to vote is considered in guardianship and conservatorship decisions by the court.  In my experience I have seen the county forms, but in the hundreds of assessments that I have done – capacity or competency to vote was never a dimension that I commented on.  Associated capacities for entering marriage and contracts were also typically listed but not commented on.  In practice it may be that people who are under guardianship or conservatorship are not offered a trip to the polls or a contract but I cannot say for sure.

The polls themselves handle the issue like everything else in the law and politics as a contentious issue.  For example, these are direct quotes from Minnesota Statutes regarding election procedures:

“Mental capacity is a question of fact for judges of election.” Op. 82, Atty. Gen. Rep. 1942, October 22, 1942.  

and

“The criminal penalties in the election-eligibility statute (section 201.014) and the unlawful-voting statute (section 204C.14) do not apply to the caucus eligibility statute (section 202A.16). Minn. Democratic-Farmer-Labor Party by Martin v. Simon, 970 N.W.2d 689 (Minn. Ct. App. 2022).  p. 26

and

“Provision of Minnesota Constitution prohibiting a person under guardianship from voting at any election in the state did not violate the Equal Protection

Clauses of the U.S. and Minnesota Constitutions, since pursuant to Minnesota statute, persons under guardianship were presumed to retain the right to vote, and the constitutional prohibition against voting based on guardianship status applied only when there had been an individualized judicial finding of incapacity to vote. Minnesota Voters Alliance v. Ritchie, 890 F. Supp.2d 1106 (D. Minn. 2012).”  p. 43

The county auditor shall mail a notice indicating the person's name, address, precinct, and polling place to any registered voter whose civil rights have been restored after a felony conviction; who has been removed from under a guardianship of the person under which the person did not retain the right to vote; or who has been restored to capacity by the court after being ineligible to vote. The notice must require that it be returned if not deliverable”.  P. 386

I have never heard of a single situation where an election judge challenged a voter based on their mental capacity and do not understand how that would happen unless they were exhibiting signs of severe mental illness and were disruptive.

All these considerations point to the fact that voting and politics in the United States and elsewhere is a semi-rational process.  It was designed that way by the founders.  There are minimal qualifications to run for office - basically age, citizenship, and in some cases residency requirements. It is interesting that you cannot vote in many states if you are convicted of a felony but that does not disqualify you from running for President.  The top issues for most voters are not rational decisions.  I wrote a recent post on the fact that the President has little to do with the economy and an academic analysis showing Democrats were much better for the economy could not be explained rationally. That type of analysis can be applied to any of the top issues that voters are considering. There is one candidate who has been severely criticized for intellectual and character defects that include ignoring an attempt to overthrow the US government, lying for 4 years about an election outcome, lying more recently about disaster relief, and being convicted of multiple felonies. A significant number of voters and politicians in his own party elect to ignore these facts.  On the other hand members of his own party have endorsed the opposition candidate and actively campaigned for her. Forty of 44 cabinet and staff members of his own administration have said he should never be in the White House again.

This election exposes all the ugliness of American democracy that was previously not discussed.  All it took was a candidate who was more focused on himself and a few people at the highest income levels, disingenuous antiestablishment rhetoric, a lot of name calling, and some active obstructionism to real solutions.

My guess is the Founders of the Republic – did not see that coming.   

 

George Dawson, MD, DFAPA

 

References:

1:  2024 MINNESOTA ELECTION LAWS Office of the Minnesota Secretary of State, Elections Division. Annotations provided by Minnesota Attorney General.  Accessed on October 11, 2024.  https://www.sos.state.mn.us/media/5067/minnesota-election-laws-statutes-and-rules.pdf

 

Graphics Credit:

1:  Trump Photo:  Gage Skidmore from Surprise, AZ, United States of America, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Donald_Trump_(52250930172)_(cropped).jpg

2:  Harris Photo:  Lawrence Jackson, Kamala Harris Vice Presidential Portrait.  Public domain, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Kamala_Harris_Vice_Presidential_Portrait.jpg