Diagnosis at a distance

Karsten Hytten About the author

Should doctors discuss the health of individuals in the media?

The Norwegian Code of Ethics for Doctors, Chapter I, paragraph 11 states the following: «A doctor should according to his or her ability contribute to objective information to the public and the authorities on medical matters» (1). If we take as our basis the biopsychosocial model of understanding of disorder and disease, many factors could be perceived as medical matters. However, when public discussion concerns the health of an individual, the invitation to make public statements may conflict with other paragraphs in the Code of Ethics.

One obvious consideration is the duty of confidentiality (Chapter I, paragraph 4): «A doctor shall maintain confidentiality and exercise discretion in respect of information he or she obtains in his or her medical capacity …». Another consideration is the relationship with colleagues: «A doctor should take care not to criticise colleagues and collaborators when speaking to patients and their relatives, but must always keep the patient’s interests in view» (Chapter II, paragraph 4). An especially important consideration is that of the integrity and privacy of the person under discussion (Chapter I, paragraph 1): «A doctor shall base his practice on respect for fundamental human rights, and on truth and justice in relations with patients and to society.»

These considerations have been central to several of the cases discussed by the Council for Medical Ethics in the Norwegian Medical Association in recent years.

In one case, the Council was critical of a doctor who, in a newspaper interview, criticised the use of sickness benefit for an individual who was dismissed from his position after a drink driving offence. The Council’s opinion was that the doctor’s inadequate knowledge of the man’s health gave him no basis for assessing the specific case, and he could have instead raised the sickness benefit scheme as a general topic for debate (2).

Diagnosis of the 22 July terrorist at a distance

A widely debated case is the involvement of doctors in the assessment and diagnosis of the 22 July terrorist in Norway. Numerous doctors made statements regarding the first forensic psychiatric report before the trial in 2012, and believed that they had better knowledge of the nature of the terrorist’s psychiatric diagnosis than the expert witnesses.

These cases were never submitted to the Council for processing as complaints, but it nevertheless made the following statement in a newspaper chronicle (3): «It is, however, the Council’s opinion that a number of professionals went too far in their statements. This is particularly related to making alternative diagnoses without having personally examined the perpetrator. There is a difference between adopting a critical stance with regard to a diagnosis based on use of methodology, and putting forward an alternative diagnosis. The requirement for objectivity is especially important in a case where those being subjected to criticism have no opportunity to take part in the discussion.» And further: «There is little doubt that a number of violations of the duty of confidentiality were committed on the part of several actors.»

In spring 2016, a trial was held concerning the 22 July terrorist’s prison conditions. Once again, «diagnosis at a distance» was the order of the day. In his article Is it worthy of a cultural nation? Ulrik Malt, professor of psychiatry at the University of Oslo, wrote the following (4): «By mocking and ridiculing Behring Breivik we demonstrate a lack of will, and for some perhaps also an inability, to attempt to understand mentally ill persons.» While stopping short of making a psychiatric diagnosis, Malt went a long way in his psychiatric assessments.

Malt’s newspaper article caused the philosopher Einar Øverenget to react (5). Øverenget is of the opinion that when a psychiatrist makes a diagnosis, he is subject to the Health Personnel Act and the Patients’ Rights Act, and he claims that making a diagnosis without a person’s consent constitutes an offence. «He thus undermines the psychiatrist’s professionalism. He does this by showing contempt for the basic principles of the philosophy and ethics of science,» wrote the philosopher, challenging the psychiatric profession to clean up its act with regard to the unprofessionalism in its own ranks (5). In her response to this criticism, Anne Kristine Bergem, president of the Norwegian Psychiatric Association, emphasised freedom of speech and in addition referred to the supervisory bodies for possible sanctions (6).

The case in question has not been discussed by the Medical Ethics Council, but in principle it is extremely problematic to «diagnose at a distance» (cf. Chapter I, paragraph 1 of the Code of Ethics, which includes the respect for fundamental human rights). However, our Code of Ethics contains no explicit formulation in this regard.

On the other hand, the code of ethics of the American Psychiatric Association does contain such a formulation. The so-called Goldwater rule states that psychiatrists should not provide a psychiatric assessment without having examined a person: «… A psychiatrist may share with the public his or her 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 for such a statement» (7).

Despite this rule, it is easy to find examples of psychiatrists and psychologists in the USA who have made professional assessments of public figures without having examined them personally. The Russian President, Vladimir Putin, has been assessed as having an autism spectrum disorder, and Donald Trump as having narcissistic traits (8, 9).

The motive for such pronouncements may vary. One motive might be to provide a psychological perspective to enable a better understanding of a politician, possibly to predict a politician’s behaviour or to warn against the person concerned. A considerable problem with this type of practice is the use of professional power to influence public opinion indirectly instead of participating in a discussion offering explicit political viewpoints.

Political psychology

Political psychology is a multidisciplinary academic field that attempts to understand politics, politicians and political behaviour through the application of psychological theories (10). Norway offers one example from the field of political psychology, in which the importance of «diagnosis at a distance» was acknowledged in the struggle for peace and freedom. This concerns the many articles by the psychiatrist Johan Scharffenberg on Adolf Hitler’s psychopathology (11) – long before the abovementioned rules were formulated.

Like other people, politicians may have serious mental disorders, which can have serious consequences for many. Adolf Hitler is the most prominent example from more recent times. Johan Scharffenberg was one of those who made a public diagnosis of Hitler at a very early stage. Between 24 July and 30 October 1933, he published a series of 16 perspective articles in the Arbeiderbladet daily newspaper under the main title Saviour or fool (11). He concluded that Hitler «may well conform to a known syndrome, that of the paranoid psychopath, specifically the prophet bordering on insanity». He also emphasised the danger of such persons were they to obtain power, potentially leading to war and chaos in Europe.

His diagnosis created a considerable headache for the authorities, which had to uphold freedom of speech as well as enforcing defamation law (12). Scharffenberg was later recognised for his early warnings against Hitler (12, 13).

Conclusion

It is essential that doctors use their freedom of speech and participate in social debate, in part because the doctor’s role provides a unique insight into people’s social conditions. However, public discussion regarding the health of individuals requires that doctors have a high degree of ethical awareness. It is all too easy to move from describing a person’s personality traits to making an explicit clinical diagnosis, and in public discussions doctors have reasonably robust sources on which to base such assessments.

As a main principle, doctors shall not diagnose other people for whom they are not acting as the treating physician, or appointed as experts mandated to make a diagnosis. Medical codes of ethics offer clear guidelines for how doctors should behave in public discussions on the health of individual persons. At the same time, the Scharffenberg case illustrates that codes of ethics should be used with discretion and encourage active reflection rather than being used as absolute guidelines.

2

Hytten K. Legeetikk og ytringsfrihet. Tidsskr Nor Legeforen 2016; 136: 628 – 9. [PubMed]

3

Hytten K, Markestad T. Legeetikkens dilemmaer. Dagbladet 12.9.2012.

4

Malt, UF. Er det en kulturnasjon verdig? Aftenposten 30.3.2016.

5

Øverenget E. Psykiatriens uprofesjonalitet. Aftenposten 5.4.2016.

6

Bergem AK. «Psykiatriens uprofesjonalitet?» Aftenposten 11.4.2016.

7

American psychiatric association. https://www.psychiatry.org/psychiatrists/practice/ethics (24.1.2017).

8

Joshi P. Russian president Vladimir Putin may have Asperger’s syndrome, Pentagon claims. International Business Times 5.2.2015. www.ibtimes.co.uk/russian-president-vladimir-putin-may-have-aspergers-syndrome-pentagon-claims-1486835 (24.1.2017).

9

Verhaagen D. Understanding Donald Trump’s narcissism. Shrink tank 2016. www.shrinktank.com/understanding-donald-trumps-narcissism/ (24.1.2017).

10

Lavik NJ. Politisk psykologi. Oslo: Pax forlag, 1990.

11

Scharffenberg J. Frelser eller narr. Arbeiderbladet, 1933.

12

Lavik NJ. Makt og galskap: en psykiater i konfrontasjon med nazismen. Oslo: Pax forlag, 1990.

13

Søbye E. En mann fra forgangne århundrer. Overlege Johan Scharffenbergs liv og virke 1869 – 1965. En arkivstudie. Oslo, Pax forlag, 2010.

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