With medical letters and the general health of the U.S. Presidential candidates being the big topic of discussion last week, we were all treated to analyses of issues like blood clots and BMI and other topics. Pundits on both sides suggested some concern about the medical fitness of the opposing candidate.
But, where did this interest in medical fitness come from? What's fit or unfit in 2016? Basically, what would cause you, or the leadership of a major party, to declare a candidate not medically qualified to be President and not worthy of a vote?
This answer is different for a physician.
Fitness is not as obvious as you might think. Doctors, me included, will automatically defer to the primary physician of a candidate as the final arbiter of medical health, because that is who personally examined the patient and has access to the actual, complete medical record. However, doctors are not just chosen because they are great doctors, they are also chosen because they make a candidate comfortable. Candidates decide what is revealed so really all we have to go on is that a doctor is not going to lie about the information they disclose. Or, they risk loss of license to practice and potential medical Board sanctions. It says little about what is not included.
According to Dr. Connie Mariano, who was the White House physician for George W. Bush and Bill Clinton, “It’s a very touchy subject. Having been at the White House for nine years, my opinion is only as it impacts their ability to perform their job in office, which is to make decisions and communicate.” (1)
By this standard, would that negate the possibility of someone with impaired speech, damaged vocal cord or resected head and neck from a cured cancer? An individual with a tracheotomy? Someone with hearing loss able to sign?
Is there a special form a physician completes to attest to fitness or lack there of? Certain vaccines necessary and vital signs? Shockingly, given the endless forms doctors complete from schools, single afternoon field trips, adventure expeditions, the circus, military clearance, camps, high and low risk occupations, professional and collegiate sports, safaris and more it is actually astounding that I cannot uncover one for the most powerful position in our country. Inane requirements are obligatory in task completion for the most minor of excursions but not for the person who controls nuclear launch codes.
There is no defined or stated criteria for clearance, so here is an example from the February 28, 2010 letter by Captain Jeffrey Kuhlman, Physician to the President, who described the purpose of President Barack Obama’s first routine periodic physical examination:
"to provide the President every opportunity to enjoy the benefits of good health, now and for years to come, and to provide the public with a candid medical assessment of the President’s ability to carry out the duties of his office, now and for the duration of his tenure."
We all know that one physical can't speak to anyone's ability to assure fitness for a President's entire tenure, many things can happen in four years with or without risk factors, and that letter was written. And how do you get that job? This Navy Captain received his medical degree in 1987 from Loma Linda University, School of Medicine and entered into an apparent military medical career.
What constitutes a job description for determining the medical fitness of the President? For that I referenced the actual Constitution. Article II, Sections 2 & 3 mention the scope of the job:
The President shall be Commander in Chief of the Army and Navy of the United States, and of the Militia of the several States, when called into the actual Service of the United States; he may require the Opinion, in writing, of the principal Officer in each of the executive Departments, upon any Subject relating to the Duties of their respective Offices, and he shall have Power to Grant Reprieves and Pardons for Offences against the United States, except in Cases of Impeachment. He shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two thirds of the Senators present concur; and he shall nominate, and by and with the Advice and Consent of the Senate, shall appoint Ambassadors, other public Ministers and Consuls, Judges of the supreme Court, and all other Officers of the United States, whose Appointments are not herein otherwise provided for, and which shall be established by Law: but the Congress may by Law vest the Appointment of such inferior Officers, as they think proper, in the President alone, in the Courts of Law, or in the Heads of Departments.
He shall from time to time give to the Congress Information on the State of the Union, and recommend to their Consideration such Measures as he shall judge necessary and expedient; he may, on extraordinary Occasions, convene both Houses, or either of them, and in Case of Disagreement between them, with Respect to the Time of Adjournment, he may adjourn them to such Time as he shall think proper; he shall receive Ambassadors and other public Ministers; he shall take Care that the Laws be faithfully executed, and shall Commission all the Officers of the United States.
So a physician is signing off on medical fitness for the job of President, which is two-fold: Chief Executive of the federal government and Commander-in-Chief of the Armed Forces. As we know from civics class, the former involves signing or vetoing laws passed by Congress, developing policies, preparing a national budget, and appointing federal officials. Those are not physically demanding tasks but they do involve frequent travel, meeting dignitaries, giving speeches, throwing out a first pitch at a baseball game, etc. The latter involves approval for sending troops to combat or rescue missions and even engaging nuclear weapons, but not actually going. No physical requirement there either, but, it's important to have intact recall with the ability to employ keen insight and executive judgment when faced with difficult decisions while under chronic high stress and likely simultaneous sleep deprivation.
Some of that is personality more than what is easily physically qualified, so being "bombastic", as Donald Trump has been called, is not a medical issue, nor is there a medical way to know if someone will be successful. Being outwardly “measured” or with “perfect temperament” is also not a guarantee for success or a definitive indicator of superior mental health and fortitude. Ever heard the expression “still waters run deep?” But they are factors in higher executive mental functioning.
Being a narcissist or having characteristics of the personality disorder do not preclude one from effectively governing. A certain amount of vanity and hubris is vital to succeeding enough to get in reach of the position in the first place. We could argue that most candidates and presidents possess so much hubris and vanity that they are a lot more like each other than they are the general public.
So what about physical fitness? Do you even need to be ambulatory for the job? Franklin D. Roosevelt guided us to victory in World War II from a wheelchair.
Really, the only medical disqualification I could find was Thomas Eagleton, who was briefly the Vice-Presidential nominee under George McGovern for Democrats in 1972. In his lifetime, he battled depression requiring a few hospital stays, but when that, along with his receipt of electroconvulsive therapy (ECT), was revealed, Eagleton acted on McGovern's request and withdrew from the race. Were Democrats unwilling to vote for him? He returned to the Senate in 1974 with a significant percent of the popular vote and a TIME magazine poll found that 77% of respondents felt his medical record would not impact their vote. McGovern lost to Nixon in a landslide, a margin of 23.2% in the popular vote. Eagleton was obviously not the big problem. (2)
But, there was belief it would be. There is extensive history of U.S. candidates and presidents hiding health conditions, committing outright deception. For example, Woodrow Wilson’s stroke and Grover Cleveland’s secret operation for an oral cancer.
What makes a candidate medically unfit?
So, what would I deem unfit? Conditions that impaired normal mentation and brain function. This would include situations where there was significant damage to the brain, in particular, the frontal lobe by trauma, ischemic or hemorrhagic stroke, for instance, and other etiologies. This area of the brain makes you you. It is responsible for higher executive function. Significant insult in other areas of the brain could also prompt elimination. Dementia is also an exclusionary illness — Alzheimer’s is a major cause of it. Obviously to medically reject someone for these types of disorders would involve extensive assessments first. (3)
Intractable seizure disorders could make the list. There are varying degrees of issues with epilepsy as it is very patient dependent. Mild forms and partial ones would likely not impair an individual like more severe types that cannot sufficiently be controlled by medications and have high frequency of occurring. With the latter, post-ictal states (aka post-seizure) bring about protracted periods of confusion or being ‘out-of-it’ till fully recovered. Longstanding care by the same physician who understands that person’s disease would best be informed to make that decision.
Neurological and neurodegenerative diseases would be highly variable in their dismissal of a candidate. Multiple Sclerosis has a vast spectrum of disease. Some are profoundly disabled, while others have very livable, manageable disease.
Psychiatric disorders like schizophrenia would be a significant challenge to fitness and a recent history of homicidal or suicidal ideation would dismiss candidacy. Every individual does not take comprehensive psychological and psychiatric assessments. Abnormal behavior and certainly psychotic events would preclude a contender. Recent mania, which is not defined by being hyper or overly excited. Mood disorders, in general, would involve the input of a treating psychiatrist to determine suitability for a nominee.
Addiction, specifically in acute disease, would be considered an impairment for office. There are reports of JFK having issues with painkillers while in office but that was not a well-examined problem at the time.
How about chronic disease? Those with diabetes, heart disease, amputation, wheel-chair necessity, Crohn’s and so on would be qualified. The stress of office might exacerbate certain conditions, but wouldn’t negate or prohibit the opportunity to serve.
The shades of grey enter the arena with those needing dialysis a few times a week (which can be done in some instances with portable machines) or take medications that could influence mentation. For example, plenty of people work effectively in high stress and serious roles while receiving chemotherapy as the degrees of toxicity are variable. This would be a patient-specific decision involving the oncologist as well.
The take home message is that chronic illness and a person’s medical story has a life of its own, and it is unique to that person. Yes or no can be too subjective. Also, conditions from before ascending to the position does not mean the issues are still present or will continue during office. Before modern media, many were elected who would stand no chance today. Not because doctors would disqualify them, but because the public might not elect them.
That's likely why most candidates don’t reveal their entire medical record. John McCain did but he was an outlier. Instead, the history of presidents shows a shocking lack of transparency about their personal well-being. Since privacy laws handicap the physician, what is released is at the complete discretion of the patient.
Based on the limited medical information available, the public casts the ultimate vote.
(2) How would Eagleton do today? Many suffer from depression and lead influential and impactful lives. ECT as a therapy is still used today. Typically, if the disease is so extreme that medicines alone cannot stabilize the person, then it is employed. ECT can contribute to memory loss (in particular, retrograde amnesia) which in most cases improves months later. While receiving therapy, a person can be nauseated and have headaches which can be medicated and, rarely, if have underlying heart issues then it can be a more risky procedure. In this situation, if a person were actively receiving ECT it is unlikely they would be able to perform the duties of the Presidency. If it were years later without recurrence and the patient had innumerable favorable cognitive studies, then this conclusion might be different.
(3) To reject someone for fitness for these types of disorders would involve extensive physical examinations, assessments by neurologists, possibly neurosurgeons, and tests of cognitive ability along with neuropsychiatric testing well beyond just imaging the brain itself.
(1) LaMotte, Sandee. Do voters have the right to know presidential candidates health histories? CNN.com. Tuesday, December 15, 2005.