Charles G. Kels
San Antonio, Texas, United States
|Grover Cleveland, 22nd (1885-1889) and 24th President (1893-1897) of the United States, with trademark mustache intact. He is the only US president to serve non-consecutive terms. National Archives, Washington, D.C., USA. Public domain.|
Politicians have long endeavored to keep their health concerns secret. In US presidential politics, the efforts of both incumbents and candidates to project vitality and minimize frailty have at times bordered on the surreal.
In 1893, President Grover Cleveland underwent surgery for oral cancer on a private yacht to avoid public detection, with his medical team under strict orders not to alter the president’s trademark mustache.1 President Woodrow Wilson’s debilitating stroke was largely concealed from the public, as was the extent of President Franklin D. Roosevelt’s paralysis.2
While campaigning in 1960, then-Senator John F. Kennedy proclaimed that “no one who has the real Addison’s disease should run for the presidency, but I do not have it.”2 This self-assessment did not prevent Kennedy from receiving frequent corticosteroid injections for adrenal insufficiency as president, along with a host of other prescriptions (including narcotics and amphetamines) for various disorders.3 As late as 1977, the 1968 presidential runner-up Senator Hubert Humphrey characterized his rehospitalization for aggressive bladder cancer as a “checkup”; he died from the disease, which may have been present as far back as his vice-presidency, the following year.4,5
Psychiatric conditions can be especially politically charged. In 1972, Senator Thomas Eagleton was forced to withdraw as Senator George McGovern’s running mate after only eighteen days on the Democratic presidential ticket when it was revealed he had thrice been hospitalized for depression and underwent electroconvulsive therapy.6 McGovern later wrote that Eagleton had been less than forthcoming about his medical history, even disguising a 1966 inpatient stay for severe depression as a case of “gastric disturbance.”7
Given this track record, it is understandable that many Americans respond skeptically to politicians’ claims of robust health. In late 2019, President Donald Trump’s unscheduled visit to Walter Reed National Military Medical Center touched off fevered speculation about his health status. The White House’s explanation that Trump was completing his annual physical exam in stages did little to tamp down rumors of a cardiac or neurological event, necessitating a memo from the president’s physician to offer validation.8
Some of the speculation that the White House physician sought to rebut came from the medical community itself. President Barack Obama’s former personal physician told CNN that Trump “has some neurological issues.” He posited that the president is “having small strokes” and that as an emergency rather than primary care doctor, the president’s current military physician may have felt ill-equipped to monitor the condition without the unannounced trip to Walter Reed.9 Trump’s mental and neurological health have been the subject of breathless reports since the 2016 campaign,10 generating a flurry of books11 and articles12 on the topic.
The president’s fellow septuagenarian and political rival, former Vice President Joe Biden, has not escaped the medical rumor mill. After Biden released a medical summary characterizing him as “healthy, vigorous [and] fit,”13 Obama’s former doctor again weighed in with the media, declaring the 2020 candidate “not a healthy guy.”14
Discussion of the health of political leaders often pits the public’s “right” or “need” to know against the physician’s duty of confidentiality. While the legal and ethical precepts underlying medical privacy do not change when the patient is a public figure, it is generally agreed that when authorized to disclose health information, treating physicians should endeavor to paint an accurate overall picture.15 This may not have occurred in the case of Humphrey, whose 1976 cancer surgery was portrayed as “curative,”15 and that of Senator Paul Tsongas, an erstwhile presidential frontrunner in 1992 who was pronounced “cancer-free” despite an ultimately fatal recurrence of his lymphoma.3
Discussion of public figures by non-treating physicians centers on issues of professionalism as opposed to privacy. In 2017 the American Medical Association (AMA) adopted ethical guidance exhorting physicians interacting with the media to “refrain from making clinical diagnoses” about individuals in the public eye unless they have personally examined them.16 The AMA guidance closely mirrored the American Psychiatric Association’s (APA’s) much-discussed “Goldwater Rule,” which cautions psychiatrists against rendering a professional opinion about an individual without conducting an examination and obtaining authorization.17 The APA’s rule came on the heels of a scandalous magazine poll in which nearly 1,200 US psychiatrists had opined (some with colorful language) that the Republicans’ 1964 presidential candidate, Senator Barry Goldwater, was psychologically unfit to occupy the White House.18
Importantly, Goldwater retired decades later as a respected elder statesman, and testified to the personal toll of psychiatrists’ public commentary on his masculinity and sexuality.19 Doubts raised by a group of doctors in 2008 over Senator John McCain’s prognosis for melanoma proved similarly unsubstantiated, as McCain died from an unrelated glioblastoma a decade afterward.20
|Senators Thomas Eagleton (left) of Missouri and George McGovern (right) of South Dakota during their short-lived political partnership in 1972. Associated Press, New York, N.Y., USA. Source|
Both the AMA and APA ethics rules are intended to distinguish physicians’ educational activities in sharing their medical expertise from diagnostic and prognostic pronouncements neither solicited by the individual nor supported by clinical evaluation. Physicians in media play a valuable role in explaining medical processes and concepts, but specific armchair assessments are apt to be as counterproductive as the perceived misinformation they are designed to correct.21
Whether a health condition impacts a politician’s fitness for office is ultimately a political, not a medical, question. The vortex of the campaign trail is the public’s window into a candidate’s endurance and resilience.15 The much-debated, and as often misinterpreted, 25th Amendment to the US Constitution reaffirms this idea,22 creating purely political procedures for both voluntary and involuntary devolution of presidential powers in cases of temporary inability.23 Under the 25th Amendment’s thus far never-utilized involuntary mechanism, the vice president serves as the “indispensable actor” to invoke its provisions.24 Indeed, the 1967 Amendment was explicitly based on a “disability agreement” formalized between President Dwight D. Eisenhower and his Vice President Richard Nixon, which was replicated by their successors President Kennedy and Vice President Lyndon B. Johnson.24
It bears keeping in mind that many of the sickest US presidents, including those suffering from mental illness, are now ranked by historians as among the best.3 If history is any guide, public skepticism of leaders’ health claims is justified, but medical sensationalism is not. The answer to political prevarications on health matters is public accountability for politicians, not medical speculation by doctors.
- Algeo M. The President is a Sick Man. Chicago: Chicago Review Press; 2011.
- Markel H, Stern AM. Presidential health and the public’s need to know. JAMA. 2008;299(21):2558-2560.
- Lerner BH. Five myths on presidential health. Washington Post. September 18, 2016:B2.
- Cohn V. We must know more about our leader’s health. Washington Post. March 26, 1978:C1.
- Hruban RH, van der Riet P, Erozan YS, Sidransky D. Molecular biology and the early detection of carcinoma of the bladder – the case of Hubert H. Humphrey. N Engl J Med. 1994;330(18):1276-1278.
- Glasser JM. The Eighteen-Day Running Mate. New Haven, CT: Yale University Press; 2012.
- McGovern GS. Grassroots. New York: Random House; 1977.
- Conley SP. Memorandum to the White House Press Secretary. November 18, 2019. https://twitter.com/PressSec/status/1196622001982623744. Accessed January 30, 2020.
- CNN. OutFront. November 19, 2019. https://www.mediaite.com/tv/former-white-house-physician-on-trumps-health-theres-a-neurological-issue-not-being-addressed/. Accessed January 30, 2020.
- Carey B. Analyzing Trump. New York Times. August 16, 2016:D1.
- Lee BX, ed. The Dangerous Case of Donald Trump. New York: St. Martin’s Press, 2017.
- Lenzer J. Do doctors have a “duty to warn” if they believe a leader is dangerously mentally ill? BMJ. 2017;356:j1087.
- O’Connor KC. Summary of Medical History. December 15, 2019. https://go.joebiden.com/page/-/CiU2iAa4Ig_%20j5EQzueoad.pdf. Accessed January 30, 2020.
- Leonard K, Simonson J. “Lot of issues”: former Obama doctor says Biden “not a healthy guy.” Washington Examiner. December 19, 2019. https://www.washingtonexaminer.com/news/lot-of-issues-former-obama-doctor-says-biden-is-not-a-healthy-guy. Accessed January 30, 2020.
- Annas GJ. The health of the president and presidential candidates. N Engl J Med. 1995;333(14):945-949.
- American Medical Association. AMA adopts guidance for ethical physician conduct in the media. November 14, 2017. https://www.ama-assn.org/ama-adopts-guidance-ethical-physician-conduct-media. Accessed January 30, 2020.
- American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry. 2013 ed. [Section 7.3] https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Ethics/principles-medical-ethics.pdf. Accessed January 30, 2020.
- Boroson W. What psychiatrists say about Goldwater. Fact. 1964;1(5):24-64.
- Martin-Joy J. Goldwater v Ginzburg. Am J Pysch. 2015;172(8):729-730.
- Brown D. Questions linger about McCain’s prognosis after skin cancer. Washington Post. October 18, 2008:A4.
- Friedman RA. Role of physicians and mental health professionals in discussions of public figures. JAMA. 2018;300(11):1348-1350.
- US Constitution. 25th Amendment (1967).
- Curran WJ. Presidential inability to function: the medicolegal issues. N Engl J Med. 1986;314(5):300-301.
- Neale TH. Presidential disability under the twenty-fifth amendment: constitutional provisions and perspectives for congress. Congressional Research Service; Report R45394. November 5, 2018.
Lt Col CHARLES G. KELS, JD, is an attorney-adviser for the U.S. Department of State’s Bureau of Medical Services and a judge advocate (JAG) in the U.S. Air Force Reserve. He practices health and disability law and researches in the areas of medical privacy, informed consent, and professional ethics. The views expressed are those of the author alone and do not reflect those of the State Department, Air Force, or Department of Defense.
Highlighted in Frontispiece Volume 12, Issue 3 – Summer 2020