As a psychiatrist, I’ve seen many families battle with when to take away Grandpa’s car keys, and what to tell the rest of the family about his mental decline or cancer diagnosis. In these tragic situations, I have always tried to be warm and empathic. Usually, the family found a way to address these difficulties. Other times, a car serious accident occurred.
But when the patient is a political leader, additional concerns emerge.
Recent revelations about former President Biden’s prostate cancer and cognitive state during his presidency pose many concerns. I hope his cancer treatment succeeds.
Yet his situation is not unique. As the life expectancy of the nation’s population and political leaders rises, questions about our elected officials’ health will continue to do so as well.
It is hard to address Biden’s problems since they are both personal and political, and much remains unknown. Nonetheless, large ongoing quandaries emerge for our nation as a whole. Biden’s problems are terribly sad, but nonetheless provide a teachable moment about elected officials’ health, VIP syndrome, and the nature of cognitive decline, and highlight needs for better policies.
Grover Cleveland, Woodrow Wilson, FDR, JFK, Biden, and President Trump differed in many ways, but they all could have been affected by VIP syndrome. First described as a medical phenomenon in 1964 among psychiatric patients, VIP syndrome occurs when a powerful individual’s medical or psychiatric symptoms get ignored or badly treated, with over- or under-treatment and failure to follow appropriate standards of care or consideration.
As a psychiatrist, I have seen fellow doctors bending over backwards to hide or provide too much or too little care to such patients, at times causing problems.
Grover Cleveland’s doctors secretly operated on him, removing his cancer, while they sailed up and down the Hudson River, ostensibly fishing. Woodrow Wilson and his inner circle whitewashed his severe strokes that prevented him from governing at the end of his presidency. His wife made crucial decisions for him. JFK reportedly regularly saw “Dr. Feelgood,” took large doses of amphetamines, and concealed his severe Addison’s disease and related hospitalizations. Reagan’s Alzheimer’s began during his presidency, according to one of his sons. Trump reportedly camouflaged from the public the extent of his COVID, which, his doctors later admitted, could have killed him. Members of Congress have appeared to suffer from cognitive deficits, as well. At a news conference in 2023, then-Senate Majority Leader Mitch McConnell froze mid-sentence for 19 seconds and remained so until an aide escorted him away.
The 25th Amendment passed in 1967, following President Kennedy’s assassination, stipulates that if the vice president and the majority of “either the principal officers of the executive departments or of such other body as Congress may by law provide” declares that “the president is unable to discharge the powers and duties of his office,” due to incapacitation because of serious illness or other reasons, the vice president shall take over.
President Jimmy Carter and others became concerned that this amendment depended only on the president’s personal doctor, who might have a conflict of interest, and they proposed creation of a nonpartisan group of medical experts. A Working Group on Presidential Disability provided recommendations to President Bill Clinton in 1996 that the 25th Amendment did not require revision, but that “guidelines are needed to ensure its effective implementation,” and that while “determination of presidential impairment is a medical judgement … determination of presidential inability is a political judgement.” While the president’s physician is the “best source of information” about the president’s health, the president or designees have the responsibility “to make accurate disclosures to the public.”
In 2020, Nancy Pelosi proposed legislation to establish a standing bipartisan commission requiring that presidents undergo physical examinations yearly, based on which the commission would objectively judge the president’s fitness for office.
As we get older, we gain knowledge, wisdom, and neuronal efficiency, but our ability to process information slows. Speed drops by around 20% at age 40, and 40%-60% by the time we are 80. Memory diminishes, too. By age 85, 20% of Americans will have Alzheimer’s. But though around 40% of people over 65 have occasional memory, most of us do not proceed to develop dementia. We may sometimes take a bit longer to remember particular words or names, but usually eventually recall them. Forgetting a word, in itself, is generally normal. It doesn’t disrupt our overall ability to reason and function, or necessarily indicate impending dementia.
But sometimes these problems progress and can become dangerous.
For political leaders, we need to mandate annual medical exams and periodic cognitive testing, when indicated, with full release of the results. Full disclosure and transparency are vital, and should not be partial or optional. During his first presidential election, Trump released only a paragraph dictated by a doctor who was a friend and said, without citing any evidence, that Trump was more fit for the office than anyone in the history of the country. More details are essential.
For cognitive functioning, rigid cut-offs may be hard to establish, but reputable organizations, such as the National Academies of Medicine and the American Medical Association can develop standards.
Such challenges will increasingly emerge. At some point, we will have a new president from one party or the other, and cognitive decline and Alzheimer’s cross the political aisle. We therefore need a bipartisan effort to prepare now. Many patients with cognitive loss end up causing some kind of serious accident; hopefully, they’re not also leading our nation.