Correspondence
Presidential Health
N Engl J Med 1996; 334:467-469February 15, 1996
- Article
To the Editor:
Professor Annas's article “The Health of the President and Presidential Candidates — The Public's Right to Know” (Oct. 5 issue)1 reaches back in time to the illnesses and disabilities of President Eisenhower. Unfortunately, references to the 1960 presidential campaigns of Vice-President Richard M. Nixon and Senator John F. Kennedy are omitted. In a 1984 article,2 I described the acute illness that began at the onset of Nixon's campaign and seriously interfered with his effectiveness as a campaigner.
Although Professor Annas deals only with presidential candidates, it is my contention that disclosure of information about health should be expanded to include Supreme Court justices, those at the pinnacle of our nation's judicial system. The illnesses of Justices Charles E. Whittaker, William O. Douglas, John Harlan, Thurgood Marshall, and others have all been well documented. In a previous editorial,3 I proposed the appointment of a federal commission to study the issues relating to the health of members of the judiciary. This is, of course, similar to the independent commission advocated by some to evaluate presidential health.
I agree that there are important issues of privacy. However, the legacy of illness and disability in presidents, presidential candidates, and Supreme Court justices cries out for the establishment of such a commission. The public must be assured that their elected representatives are truly governing and that the decisions of justices of the highest court of the land are their own.
3 ReferencesRaymond Scalettar, M.D.
730 24th St., NW, Washington, DC 200371
Annas GJ . The health of the President and presidential candidates -- the public's right to know. N Engl J Med 1995;333:945-949
Full Text | Web of Science | Medline2
Scalettar R . Presidential candidate disability. JAMA 1984;251:2811-2811
CrossRef | Web of Science | Medline3
Scalettar R. Health disclosure for judicial appointees. Washington Times. April 8, 1994.
To the Editor:
Professor Annas says, “U.S. Presidents have always been more likely to be killed or disabled by assassins than by diseases.” He seems to have miscounted. The assassinated presidents were Lincoln, Kennedy, Garfield, and McKinley. Those who died of diseases in office were F.D. Roosevelt, W.H. Harrison, Taylor, and Harding — an exact tie. Disablement is a bit harder to judge, but the “disease” list includes at least Eisenhower, Wilson, Reagan, and perhaps L.B. Johnson and is longer than the list of unsuccessful assassination attempts, which resulted in serious injury only in the case of Reagan. The “disease” list could be augmented further if you included Bush's treatment for Graves' disease, Kennedy's Addison's disease, and so forth.
Virginia Trimble, Ph.D.
, Tucson, AZ 85726To the Editor:
Professor Annas distinguishes between the public's knowledge of a president's health and its knowledge of a presidential candidate's health. He supports the decision of presidential candidates McCarthy and Clinton to protect their medical privacy as “the proper one” and concludes that the 1996 election provides “an opportunity . . . to curb our tabloid-press–fed curiosity about the private medical information of presidential candidates.”
There are three reasons that the medical histories of presidential candidates should be made public. First, all presidential candidates are by definition public figures. As such, their educational records, financial records, and health records become matters of intense public interest. It is no more realistic for presidential candidates to shield their medical histories from public scrutiny than it would be to shield their financial histories.
Second, lack of disclosure invites the innuendo and misrepresentation of the facts that are common to political campaigns. In 1959, Governor “Pat” Brown of California said to John F. Kennedy at their first meeting, “I understand you've got Addison's disease.”1 In 1960, Mrs. India Edwards and John Connolly, two of Lyndon Johnson's supporters, made an issue of the rumor of Kennedy's Addison's disease to counteract public concern about Johnson's cardiac history.2
Finally, when the public votes for a presidential candidate, they have the right to a reasonable expectation that he or she is healthy enough to serve out his or her term. The case of Paul Tsongas illustrates this point well. Tsongas did not release a complete account of his previous battle with cancer during the 1992 presidential campaign but then withdrew from the race for nonmedical reasons. Nonetheless, news of the recurrence of his cancer was announced on November 25, 1992,3 just weeks after the presidential election. One can only speculate about the ramifications of a president-elect's contracting a potentially serious illness.
The issue is not whether a presidential candidate's medical history should be made public, but rather the manner in which it is done. It would seem reasonable to establish an expert panel to evaluate a president's health status and that of presidential candidates as well. Such a panel would permit the personal physicians of the candidates to maintain the integrity of the doctor–patient relationship and would take decisions about the distribution of such important information away from the editors of tabloid newspapers and put them into the hands of a responsible panel of medical experts.
3 ReferencesKevin R. Loughlin, M.D.
Brigham and Women's Hospital, Boston, MA 02115To the Editor:
Your readers and others may be interested in knowing how the American Bar Association handled the problem discussed by Annas of the public's right to know.
Many years ago, the president of the American Bar Association chose me to determine, on the basis of all the medical data submitted to me, whether the health of candidates for positions on the federal bench was such that they would most likely be able to fulfill a judge's duties for at least five years. I never knew or met any of the candidates. The public was never told of my activities and decisions.
One candidate from a midwestern state had had a heart attack. Nonetheless, I thought it most likely that he would be able to serve satisfactorily for at least five years. And he did.
For a short time I was asked to do the same thing by the Philadelphia Bar Association. Two of the candidates had high blood pressure. I could find absolutely no evidence of end-organ disease. For this reason I felt certain that the two candidates would also be able to serve for at least five years. And they did. At no time did the public know this practice existed.
A similar procedure could be used by presidential candidates. Their physicians would simply state that the health of their patients was such that they would most likely be able to serve the four-year term of office.
Candidates, of course, have a legal right to prohibit their physicians from giving any information whatsoever to the public. . . .
Louis A. Soloff, M.D.
Temple University, Philadelphia, PA 19140To the Editor:
Does Professor Annas truly wish to propose that the president's appointees are the surest arbiters of his sanity, “since the President's closest advisors and senior cabinet members will certainly be aware of his or her ability to function mentally”? It is precisely “the President's closest advisors and senior cabinet members” who hold the strongest interest in maintaining an impaired figurehead on the throne, while they exercise their own powers unchecked.
Surely we would not trust the guardians to guard the guardians.
Alan Lipschitz, M.D.
395 South End Ave., New York, NY 10280To the Editor:
When elected president of France, in May 1981, François Mitterrand told voters that he would ask his physician to release a medical statement twice a year. Mitterrand said he wanted to avert what happened in 1973 and 1974, when President Georges Pompidou had multiple myeloma and was undergoing treatment with high doses of cortisone. Everyone could witness the side effects of the drug on the president's body, but officially it was described as a “bad flu.” Pompidou died in April 1974.
From June 1981, when the first bulletin was released, to June 1992, all the medical statements about Mitterrand attested that his health was good, though there were old rumors, dating back to 1981, that the president had cancer. In September 1992, Mitterrand was admitted to a Paris teaching hospital for a prostatectomy. Two days later, his physician declared that cancerous cells had been found in the removed tissues, but he also said that the cancer was at an early stage and that all other test results were normal. Instead of cooling things down this statement fed more rumors. One urologist, though not aware of the medical records, gave a long interview to the French news agency Agence France-Presse. I was contacted personally by a urologist who said he had attended the procedure and was ready to provide details. Day after day, journalists, usually without any medical background, wrote articles on the spread of the cancer and the prognosis. France was entering a period of general elections. Political editors, suddenly transformed into urologists, were speculating on the number of weeks or months Mitterrand still had to live. Questions were raised about his ability, under treatment, to be the commander-in-chief of our nuclear arsenal.
The next medical statement, although generally reassuring, acknowledged that the level of prostate-specific antigen (PSA) was above normal. Journalists then started to ask for the results of the PSA test. At a new Year's party, Mitterrand yielded to the press and announced his most recent PSA level. The peak of the furor was reached on September 10, 1994. The daily Le Monde wrote that Mitterrand's cancer was totally out of control. From tips said to come from the closest medical advisors of the president, a full description of the progression of the disease was offered to readers, with explanations of cancer stages. The article implied that the president would probably not be able to complete his term, which extended to May 1995.
Mitterrand did complete his term. He died on January 8, 1996. A few days later, Dr. Claude Gubler, his personal physician from 1981 to 1994, revealed in the weekly Paris-Match that Mitterrand's cancer was not diagnosed in September 1992, as officially reported. Instead, he declared that the diagnosis was actually made in November 1981. Though the president had pledged during the election campaign to tell the whole truth regarding his health, all medical statements from 1981 to September 1992 omitted mention of any medical problem. Mitterrand ran successfully in 1988 for a second term. The family of the former president has sued Dr. Gubler for violation of his patient's confidentiality.
This story underscores some interesting points. First, Mitterrand pledged to tell the truth, but it appears, retrospectively, that medical statements published before his cancer diagnosis were falsely reassuring. Second, the more you give, the more the media ask for. Was it essential to know the PSA level? Surprisingly, the more the media provided pessimistic details of the president's disease, the more the public seemed to feel they constituted an unwarranted attack on a sick man. The public's right to know is not always in tune with the media's thirst to know.
J. Daniel Flaysakier, M.D.
France 2 Télévision, 75008 Paris, FranceAuthor/Editor Response
Professor Annas replies:
To the Editor: These letters raise a variety of issues that were mostly dealt with tangentially in my article, which argued that there are certain types of medical information that both presidential candidates and presidents should be able to keep confidential (“sensitive information that is inherently embarrassing or invites irrational prejudice,” such as that involving mental health care, abortion, the human immunodeficiency virus, and presymptomatic genetic-screening tests). Only Dr. Loughlin seems to take issue with this, but he does not directly address these four specific examples, none of which would shed any useful light on the question of whether or not the candidate was healthy enough to serve out his or her term. Like Dr. Scalettar, he would like to see an expert panel set up to review medical histories — but even if one thought this was a good idea (which I do not), we would still have to decide who should be on this commission, what information they should have, what questions they should address, and to whom and in what form they should report their findings. As Dr. Soloff properly notes, even with such a commission candidates would retain the legal right to prohibit their physicians from cooperating with the commission or giving any medical information to the public. Another problem with a medical commission is that its existence would make the decision of who should lead the country seem like a medical rather than a political one. This could be detrimental to the country, since even very serious medical problems may not detract from a person's ability to be a great president, as the examples of George Washington, Andrew Jackson, and Abraham Lincoln all illustrate.
Dr. Trimble suggests that I may have miscounted when I asserted that presidents have always been more at risk from assassins than diseases, and she counts a tie between presidents killed in office and those dying of diseases. But the point is not how presidents die but whether their deaths in office could have been predicted before election because of some preexisting medical condition. Thus, for example, William Henry Harrison died, one month after assuming office, of pneumonia that he is said to have contracted by giving his inaugural address in a cold drizzle without a hat or coat. Zachary Taylor likewise died in office of an unpredictable illness, as did Warren Harding. The only U.S. president who actually died of a preexisting condition that made his death in office likely was Franklin Roosevelt.
Dr. Trimble is quite correct, however, in noting that disability is much more difficult to judge. Campaigns have a tendency to weed out sick candidates, and Dr. Scalettar suggests that Nixon may have learned this in his unsuccessful campaign against Kennedy. Once in office, the much more difficult question is, Who should make the determination of presidential incapacity? In this regard, Dr. Lipschitz argues that I am wrong to conclude that this decision properly belongs in “the political arena,” where the 25th Amendment places it, and suggests that we should “not trust the guardians to guard the guardians.” The short answer is that we don't really trust anyone, and the press has the job of keeping the guardians honest. But the press can be the problem as well as the solution. As Dr. Flaysakier astutely notes, the more medical information a leader discloses, the more the press wants to know.
George J. Annas, J.D., M.P.H.
Boston University Schools of Medicine and Public Health, Boston, MA 02118- Citing Articles (1)
Citing Articles
1
(2005) Illness and Secrecy on the Supreme Court. New England Journal of Medicine 352:13, 1387-1388
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