Book Review

When Illness Strikes the Leader: The Dilemma of the Captive King

N Engl J Med 1993; 329:1431November 4, 1993

Article

When Illness Strikes the Leader: The Dilemma of the Captive King
By Jerrold M. Post and Robert S. Robins. 243 pp. New Haven, Conn., Yale University Press, 1993. $25. ISBN: 0-300-05683-4

The relation between political leaders' states of health and the institutions of state that they govern are necessarily complex. The authors of this book describe these relations as though a leader, whether a monarch or a democratically elected president, presides over a group of courtiers and possesses all the instruments of a palace. The description is not inappropriate. Staffs of latter-day presidents and prime ministers behave in many ways as did courtiers of old. The political surroundings of democratic leaders retain much of the coloring of intrigue and the rewards usually associated with older regimes.

This book is a highly useful account of what is special about illness and incapacity in political leaders. It concerns their state of physical and mental health and the integrity of their governments and political systems.

Physical illness, especially when its onset is acute -- a stroke, a myocardial infarction, acute abdominal distress, or physical trauma -- can be devastating to the individual leader. Depending on the personal character of his or her leadership, the leader's relation to the governed, or the state of the institutions of governance, the fact of illness and incapacitation may greatly affect stock markets, rival political groups, military adversaries, and the orderliness of government business. The polity desires leaders who are strong, wise, and powerful and is made very uncomfortable even by hints of illness or incapacitation. As the authors point out, those reaching positions of political leadership are frequently senior in age and hence particularly vulnerable to physical and mental incapacitation.

Because of these very circumstances, which make a king's illness more special than that of his subjects, it tends to be treated differently. The fact of illness is downplayed or not disclosed. Members of the court, sometimes even in a loose conspiracy with the press, conceal information or minimize the degree of incapacity (as in the case of Franklin Roosevelt's poliomyelitis or Pompidou's multiple myeloma). The authors describe elements of deception in the cases of three American presidents -- Wilson, Cleveland, and Franklin Roosevelt.

All of this highlights interesting challenges facing physicians who attend leaders. These, too, are special relationships because of special circumstances. Although the relationship between leaders and physicians is particularly intimate, it is unlike any other. The judgments of treating physicians inevitably have profound political consequences as well as medical ones. Clinical decisions inevitably become commingled with or even subordinated to political judgments of others surrounding the leader (“others in the court”). In the worst circumstance, conflict can arise between what is medically desirable and what is politically desirable.

It is in the realm of mental ill health among political leaders that this book becomes most interesting (not unexpectedly, since one of the authors is a psychiatrist). The illustrations are particularly rich. The intellectual challenge is especially profound. The analyses are more fully drawn. As the authors point out, narcissistic traits are common among leaders and even help them to achieve power. A narcissist appears self-sufficient, independent, confident, and authoritative. Yet, underlying feelings of inadequacy or paranoia may lead to even further exaggeration of self-confidence or arrogance. The dividing line between the two is not always easy to discern. In addition, the further arrogation of power because of mental instability may have profound or devastating political consequences for the state of the governed.

For the authors, all of this is, in a sense, preamble to a discussion of orderly succession on the occasion of mental or physical incapacity. They illustrate their points by citing cases from the Ottoman Empire to the Reagan administration. Succession is smoother the better it is thought out and institutionalized. Older political systems tend to be better institutionalized than newer ones. Parliamentary systems have an easier time of it than do presidential ones. In every case, political considerations will be prominent. A certain degree of flexibility and statutory imprecision is desirable.

When Illness Strikes the Leader is a substantial contribution on a complex and fascinating subject. The authors, combining medicine and political science, have the right combination of talents.

Edward J. Burger, Jr., M.D., Sc.D.
Institute for Health Policy Analysis, Silver Spring, MD 20910