US President Donald Trump speaks to members of the media as he departs the White House en route to Kansas, in Washington, DC, US, October 19, 2026.
When President Lyndon Johnson ran for president in 1964 against Sen. Barry Goldwater (R-AZ), a group of pro-Johnson psychiatrists falsely accused Goldwater of being literally insane and therefore unfit for office. Even though there is no evidence Goldwater lost because of that article, it certainly didn't help, and a federal court in Goldwater v. Ginzburg sided with Goldwater when he sued over the matter. The so-called Goldwater Rule has existed ever since. Per the American Psychiatric Association, its members from diagnosing public figures unless they have personally evaluated them.
Flash forward to the age of President Donald Trump.
If you ask his defenders, they will say that Trump's seeming acts of insanity are either harmless eccentricities or a "madman" act, something along the lines of Presidents Dwight Eisenhower and Richard Nixon feigning oddness and/or insanity to keep their foes on their feet. Talk to his critics, and you'll hear feedback like that of Dr. Henry Abraham, an esteemed psychiatrist formerly of Tufts University who led a letter of three dozen top health professionals expressing alarm over Trump's public displays of decline; he told AlterNet that Trump is a "maniac." Or you'll listen to Dr. Ed Gresser, an economist who specializes in trade for the Progressive Policy Institute, there will be discussion of Trump being "weird" in picking a trade war with Canada, one of America's longtime economic and political allies.
To better assess this question, I turned to Jacob M. Appel, a bioethicist and expert on the health of American presidents. He was the subject of the 2019 documentary film Jacob by Jon Stahl, which covered how Appel has succeeded as a doctor, lawyer, novelist, playwright, poet, college professor and licensed New York City tour guide.
The following interview has been lightly edited for clarity, context and length.
The Goldwater Rule and presidential history.
Matthew Rozsa: Does the Goldwater Rule still make sense today, when the public can watch hours of a president’s unscripted speech nearly every week?
Jacob Appel: Absolutely not. I’ve been a longstanding critic of the Goldwater Rule. One of the problems with the Goldwater Rule is that it was designed in an era when the public had much less access to public figures, and therefore they were relying on secondhand information. Now, as you said, they can watch the president. But also, the public has no sense of the difference between psychologists and psychiatrists, and for that matter, between psychiatrists and other medical doctors. And the Goldwater Rule applies not just to psychiatrists, but only to psychiatrists who are part of the American Psychiatric Association. Psychiatrists who are not part of the association, psychologists and neurologists go on television all the time and make diagnoses about public figures. So the rule is deeply antiquated and restricts the public from gaining useful information.
Rozsa: Without diagnosing him, what observable changes in Trump’s speech, movement or behavior do you think are fair for the public to notice and discuss?
Appel: What I always tell people is that we know nothing about what’s really going on in the president’s body or the president’s health. History has shown us that it will often be decades, sometimes even many decades, before we learn what’s really going on. That was certainly true with Kennedy and Nixon. We are starting to learn about the extent of Ronald Reagan’s Alzheimer’s impairment through analysis of his press conferences and other public speaking. In 20 to 30 years, we will hopefully learn what was going on medically with both President Biden and President Trump. So the public should look at the president like they look at any other individual they know. They shouldn’t try to diagnose him or figure out if there’s a medical issue. They should ask themselves: Do they think this person is capable of being president?
That’s a very different question. I like to emphasize that some of our most physically or psychologically impaired leaders are often ranked by many people as among our best presidents. Frankly, Roosevelt was extremely ill during much of World War II, and many people viewed him as a hero. In contrast, many of our healthiest presidents — Gerald Ford and Rutherford Hayes come to mind — are generally not viewed as among our best presidents. So health is really not a great guide to who you want running the country.
Rozsa: Which past presidents hid serious mental health problems from the public? I’m referring specifically to diagnosable pathologies that are psychological in nature. The two that come to mind for me are Woodrow Wilson, who was cognitively impaired somewhat by his 1919 stroke, and Richard Nixon, who began to go insane in 1973 as the Watergate scandal heated up.
Appel: There are a number of presidents who have had significant psychiatric illness. Franklin Pierce, who served from 1852 to 1856, was on a train between his inauguration and his election, and his son was thrown from the train and decapitated. He found his son’s head, and he was deeply depressed for most of his term. His alcoholism was exacerbated, and he eventually drank himself to death. Calvin Coolidge, who was widely perceived as a very laconic, taciturn New Englander, was actually much more talkative before his son died while he was in the White House, and then by all accounts suffered a severe clinical depression. There is substantial evidence that John Kennedy took too much amphetamine treatment one night while he was president, ran naked through the Carlyle Hotel and had to be sedated.
So there are numerous examples of this in our history.
Rozsa: The question remains: To what extent should the public know about it?
Appel: In an ideal world, the public would have this information. Unfortunately, and I’ve written about this a fair amount, there is no practical, operationalizable way to release this information, because people will claim it’s politicized, and people will politicize it. If you want to have the president independently evaluated, there will never be agreement on who those doctors should be. I also remind people that if you release information to the public, you’re also releasing it to the Russians and to the Chinese, and people can do significant damage knowing the vulnerabilities of our leaders.
The Constitution and Canada.
Rozsa: In that case, shouldn’t we invoke the 25th Amendment?
Appel: I will first point out that practically, it’s virtually impossible to invoke the 25th Amendment. Under its current structure, unless Congress were to create an independent body, all the president needs to do is fire any Cabinet member he suspects will invoke it, until there’s no longer a mechanism for doing so. It’s a flaw in the amendment. That being said, it’s not clear that any of these individuals reached that threshold. We only know the image the president presents to us. We have reason to believe, for example, that Dwight Eisenhower wanted the Russians to think he was less psychiatrically stable than he was, because he wanted them to think he might use nuclear weapons during massive retaliation. We have no idea to what degree President Trump’s behavior is biologically or psychiatrically driven, and to what degree it is a crafted impression he wants to make on the public that then absolves him of responsibility for decisions. I could speculate, but I never know for sure.
Rozsa: Then are there any mechanisms at all that people can rely on to be protected from a potentially deranged president?
Appel: In the current system, unfortunately, there aren’t. I’m actually working on a book on this. There are measures we could establish. The most logical one would be creating independent panels, before people are elected, that presidential candidates could voluntarily agree to sit for to get a full, neutral evaluation. If they didn’t agree to sit for one, they could still run for president and people could still vote for them, but there would be a suspicion or a cloud over that choice. Right now, we have not set up that mechanism. Once someone is president, the level of impairment you would need to remove them in a partisan system is simply too high to operationalize. We have had presidents who were truly psychotic for moments in office, who were intoxicated for weeks on end, and at the time, even with the 25th Amendment available, nobody was able to do anything.
So this is not a problem unique to the current moment. It’s been a problem for at least 60 years.
Rozsa: Let me use one example. Trump seems to be picking a fight with Canada that is based entirely on his own inner impulses. This isn’t like when he gives money to big oil and to his political consultants and cronies, which can be viewed as transactional ideology or simply corruption. His beef with Canada seems to exist in the quirks of his personality rather than originating in any logical, albeit perhaps immoral, external factor. So hundreds of millions of people are suffering economically because a potentially mentally unwell president is being belligerent toward one of our longest-standing allies and causing an unnecessary trade war. And there is nothing we can do to discuss the diagnostic factors at play.
Appel: Under the system currently set up, unfortunately, no. And I will add: Just because people are petty or selfish or ignorant or belligerent doesn’t mean they are mentally ill. It means they are people I would not want to vote for or spend Christmas dinner with. Being mentally ill is a very different threshold. Part of the problem is that there’s no consensus on exactly what the threshold is for an impaired president. There have been numerous efforts to define it, and they have all failed, because nobody can agree on terms for their leader versus a different leader. And even if you agree on a rubric, when somebody actually becomes president, agreeing that they meet that rubric is an even harder battle. You might say we should invoke the 25th Amendment or remove the president. But doing so will always cause a major crisis, because a certain percentage of the population will simply view that as illegitimate.It’s one of the unfortunate shortcomings of our democracy, and it was pointed out as early as the Constitutional Convention by John Dickinson, who basically said that defining disability was virtually impossible.
Rozsa: I appreciate you being so thorough, even if the results are dispiriting. Is there anything else you’d like to say?
Appel: I always say that just because you don’t get a psychiatric diagnosis doesn’t mean you can’t be angry or upset at something your leaders do. And just by looking at them, you can make informed choices that are probably going to be as informed as anything a doctor can tell you.