Several weeks after former President Ronald Reagan announced his Alzheimer disease diagnosis in 1994, his predecessor, Jimmy Carter, appealed to the medical community. But Carter, the 39th president of the United States, didn’t urge physicians to take up a fight against this neurodegenerative disease. Instead, Carter attempted to tackle presidential disability and the 25th Amendment of the US Constitution.
In a published commentary, Carter contended that Section 4 of the amendment—a mechanism that allows the vice president and a majority of Cabinet members to pronounce a president “unable to discharge the powers and duties of his office”—is inadequate. They would need accurate, unbiased medical advice from qualified physicians, Carter wrote. It would require those physicians to delicately balance patient confidentiality, personal interest, and the country’s well-being.
“We must find a better way,” he stated.
His suggestion: create a nonpartisan group of medical experts not directly involved in the president’s care to determine presidential disability. Twenty-three years later, Carter’s proposal hasn’t come to fruition. But it’s no longer lying dormant.
Rep Jamie Raskin (D, Maryland) introduced a House bill in April to create an 11-member “presidential capacity” commission composed of psychiatrists, other physicians, and retired government officials selected by leaders in Congress. “Now is the time to do it,” Raskin said in a statement.
In a recent bestselling book, 2 practicing psychiatrists offered an alternative proposal, recommending that a 7-member expert panel be established to evaluate presidential fitness.
During an interview with JAMA, a leading medical journal, one of these psychiatrists discussed the issue of presidents’—past and present—fitness to serve. An edited version of that conversation follows.
Question: Why did you decide to wade into the territory of presidential fitness?
Answer: President Trump’s mental status engendered controversy among our colleagues because of the Goldwater rule. During Barry Goldwater’s run for president in 1964, a magazine polled about 1100 psychiatrists who rendered opinions about his mental fitness without seeing him for an evaluation. Afterward, Goldwater sued the magazine for libel and won. As a result, the American Psychiatric Association instituted the Goldwater Rule, which prohibits psychiatrists from diagnosing an individual without a face-to-face evaluation. When mental health professionals began to raise concerns about President Trump’s mental stability, the APA added a further proscription against offering any opinion about his mental health. In April, Dr Bandy Lee (assistant clinical professor in the Law and Psychiatry Division, Yale School of Medicine) chaired a conference at Yale to discuss psychiatrists’ “duty to warn.”
Question: What is duty to warn, and could you explain how the concept came about?
Psychiatrist’s answer: This obligation is derived from the landmark [Tarasoff v Regents of the University of California] decision by the California Supreme Court in 1976. It states that if patients disclose to their therapist that they intend to injure specific individuals, the therapist has a duty to warn those individuals. The Tarasoff decision ultimately created a legal duty to protect that overrode the confidentiality of the patient-therapist relationship. This duty was subsequently adopted in other states in various forms and has become a standard of mental health practice.
Question: To what other US presidents would a presidential fitness commission have been applicable?
Answer: A review of US Presidents from 1776 to 1974 found that 49% of those 37 presidents met criteria that suggest neuropsychiatric disorders. For example, Presidents Franklin Pierce and Abraham Lincoln had symptoms of depression; Nixon and Johnson, paranoia; and Reagan, dementia. President Woodrow Wilson suffered a massive stroke in office that resulted in severe cognitive impairments. Although military personnel who are charged with relaying and executing nuclear orders from the president must undergo rigorous medical, psychological, and financial evaluations to determine their fitness for duty, no such evaluation is necessary for their commander-in-chief. We feel that this glaring omission can be remedied.
Question: What is the remedy?
Answer: The 25th Amendment to the Constitution addresses presidential disability and succession. Section Four of this amendment has never been invoked to evaluate whether a president is fit to serve. We exhort Congress to use this section of the 25th Amendment to impanel an independent, impartial group of experts to evaluate whether the current and future presidents and vice presidents are mentally fit to fulfill the duties of office.
Question: Who would serve on such a panel and how would the members be chosen?
Answer: The panel should consist of 3 psychiatrists—1 clinical, 1 academic, and 1 military; 1 clinical psychologist; 1 neurologist; and 2 internists. Panel members should be nominated by the nonpartisan, nongovernmental National Academy of Medicine. The experts should serve 6-year terms with the provision that 1 member per year be rotated off and replaced. Congress should enact legislation to authorize this panel to perform comprehensive mental health and medical evaluations of the president and vice president on an annual basis. The legislation should require the panel to evaluate all future presidential and vice presidential candidates. The panel should also be empowered to conduct emergency evaluations should there be an acute change in the mental or physical health of the president or vice president. The evaluation should be strictly confidential unless the panel determines that the mental health or medical condition of the president or vice president renders him or her incapable of fulfilling the duties of office. We feel that this process should be initiated immediately.
Question: How did you decide on the types of experts that should be on the panel?
Answer: Psychiatrists would be able to evaluate someone’s mental status and diagnose any significant mental disorders and also to evaluate for potential dangerousness. The clinical psychologist is usually a specialist in psychological testing, and a neurologist could help evaluate cognitive and brain functioning. Of course, internists would look at the general medical status of the person. We figured that would cover all the bases that we would need to be concerned about.
Question: Why did you want to have a military panel member?
Answer: We thought it would be fair to have someone who may have a better sense of the kinds of situations that a president would face in terms of handling the nuclear arsenal.
Question: Would nominations to the panel require approval by Congress or some other body?
Answer: Since this is brand new territory, I suspect that it would be incumbent upon the Congress to impanel this group of professionals. But I think it could be difficult, so in my opinion, it would be better if Congress would rely on the National Academy of Medicine to come up with these experts. You want it as nonpartisan as possible.
Question: You’ve shared your ideas with President Obama and some members of Congress. Did you consider that part of your duty to warn?
Answer: Yes. We believe that we have a higher duty to warn if we feel that the US president presents a danger to others—others being this country and the world.
From a medical perspective, I believe these suggestions are quite reasonable and should be implemented quickly. In today’s toxic political environment, however, this may be a pipe dream. But, nevertheless, it could at least serve to identify those voting against such a plan as certifiably insane and legitimate candidates for the loony house! Now which party do you suppose could comprise the lion’s share of those “no” votes?