POTUS, Politics, & Neuropsychiatric Assessment: What Do We Need to Know and When Do We Need to Know It?

潔 丹野/AdobeStock

COMMENTARY

Long before the 1984 Presidential debate in which Ronald Reagan introduced the issue of age into presidential politics with his wry comment, “I am not going to exploit, for political purposes, my opponent’s (Walter Mondale) youth and inexperience,” age and health had played critical roles in the presidency.¹

Woodrow Wilson was severely incapacitated from a stroke for his last 2 years in office (a fact not publicly disclosed and discretely managed by his wife and doctor). Franklin Roosevelt was plagued by ill health in his fourth term and died in office. Eisenhower’s near-fatal heart attack limited his capacity during his second term.² Aides to President Ronald Reagan were on the verge of declaring Ronald Reagan unfit following his assassination attempt.³ (We now know “the Gipper” was almost certainly in the early stages of Alzheimer disease in his second term.)

Perhaps because of this history, the health, fitness, and age of recent presidential candidates have been subject to intense scrutiny. Former President Trump provoked endless speculation on which neuropsychiatric condition may be responsible for his erratic and unconventional behavior. President Biden had a history of rhetorical gaffes and memory slips which evoked affectionate references to “Uncle Joe.” However, when serious questions of his competence intensified following his addled debate performance, President Biden felt that discretion is the better part of valor,⁴ and that it was best for him to endorse his Vice President, Kamala Harris, as his party’s Presidential candidate. In doing so he would spare himself the rigors of the campaign and focus on the job of governing for the remainder of his term of office.

However, armchair observations are hardly a sufficient basis for a medical opinion even by medical and mental health professionals. As chair of Psychiatry at Columbia University for over 17 years and past president of the American Psychiatric Association, I feel strongly that psychiatrists, as well as psychologists or other mental health professionals, should not comment of the clinical status or attempt to diagnose a President based on their observed behavior, in the media and information in the public domain. This is codified in the Goldwater Rule – Section 7.3 of the American Psychiatric Association’s Code of Ethics, which makes it improper for psychiatrists to make public statements about a public figure that they have not personally evaluated.⁵

The rule derives from the 1964 presidential campaign, during which the now-defunct Fact magazine published a survey of psychiatrists that concluded that Goldwater was "psychologically unfit" to be President, with comments calling him a “dangerous lunatic” and “emotionally unstable.” After losing the election, Goldwater sued the magazine's editor for libel—and won.

The reality is that we have had neither definitive nor complete evidence of the extent of either candidate’s mental impairment because none is required. In addition, there is no clear constitutional standard by which to conclude that they had a medical condition let alone mental disorder rendering them unfit to serve. Moreover, the fact that the POTUS may suffer from a serious illness is not grounds for removal, their viability depends on their ability to function and which treatment, regardless of the gravity of their illness, may enable them to do.

The most relevant constitutional mechanism is the 25th Amendment.⁶ Ratified in 1967 following JFK’s assassination, its fourth clause states, “Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.”

However, the 25th amendment’s fourth clause has never been utilized for several reasons. The lack of specific criteria on the severity of the impairment, whether it is transient or progressive, or amenable to treatment, proves problematic. There is also the political obstacle of those with the authority to invoke it; the vice president and cabinet officers are usually members of the president’s own party who will understandably be disinclined towards removing a member of their own part. No matter how you spin it, invocation of the 25th Amendment involves an awesomely difficult question: when does love of constitutional democracy supersede political and party loyalty at the highest levels of government?

Nixon is the only sitting POTUS to voluntarily (albeit under threat of impeachment) vacate the Presidency in the modern era.⁷ Biden’s decision to seek reelection follows Lyndon Johnson’s similar resolution but for different reasons. Biden stood aside and supported his VP Kamala Harris to be the party’s candidate while Johnson’s motivation was his angst over the Vietnam War. In neither case was their departure from office based on a constitutionally mandated process that found the President unable to discharge the powers and duties of his office. Given that our population is aging, and people are living longer along with the way our political system works with no term limits and the advantages of incumbency, we can expect that our government will increasingly be populated with older individuals. Clearly, we need a better way to deal with the twin issues of age and fitness for office.

This problem has been hiding in plain sight, reflected in the demographics of our current congress.⁸ There are 12 octogenarians in the US House of Representatives and the Senate is the eldest in history with Charles Grassley of Iowa the oldest at 91. This is after the recent departure of 4 senior Senators Diane Feinstein (90) of California, Richard Shelby (88) of Alabama, Jim Inhofe (88) of Oklahoma and Patrick Leahy (82) of Vermont.

Former presidential candidate Nikki Haley called for mandatory competence tests for politicians over 75. However, such an arbitrary age criterion is absurd, as not all septuagenarians are alike, some being older and others younger than their chronologic age. We do not want policies that are age discriminatory and deprive us of the experience and wisdom of older segments of our population. At the same time, we cannot ignore the inexorability of senescence in the maturational cycle and the associated diseases of aging. Therefore, we do need a means of ensuring their health and capabilities.

There is also another factor to be considered which, while being a genuine scientific advance with transformative potential for health care and the aging process, adds to the complexity of adapting legislation or policies on qualifications for government leadership to the demographic and political trends. This is the advent of longevity science spawned in the context of the genetics revolution when a family of 7 genes embedded in the genome was discovered.⁹ The Sirtuin genes (short for Silent Information Regulator Proteins) serve a variety of critical cell biological functions and determine the average lifespan of each species. Their discovery opened the path for researchers to develop pharmaceuticals that can slow or even reverse the aging process.¹⁰

When these drugs come to fruition the combination of a healthy lifestyle and anti-aging medications herald the prospect of increasing longevity by slowing the rate of aging. In other words, your biologic age can be less than your chronologic age.¹¹ Chronologic age is determined by subtracting the current date by your birthdate while biologic age is determined by genetic, molecular, and cellular mechanisms that can be measured.¹² However, until such possibilities are realized we should consider the chorus of concerns expressed as a wake up to establish a policy and protocol that will assure the public of the health and viability of candidates in a way that is medically reliable, but respects as much as possible the person’s privacy. Such medical and mental evaluations are routinely done in other professions such as airline pilots and ship captains, CEOs of corporations, and in writing large life insurance policies.

Figure. We Can Now Measure and Modify the Biology of Aging

Toward that end, candidates for the most powerful position on earth should be vetted on their health and mental status in a more rigorous and reliable way than simply producing a note from their doctor and requiring elected government leaders to undergo independent annual medical evaluations including assessments of neuropsychologic function, mental status, and brain MRI at a minimum.¹³

The information provided by such tests would avoid the need to speculate about whether the commander in chief was not firing on all cylinders and prevent adverse consequences. The only question then becomes, “Where do we draw the line on level of impairment?” An All-Star pitcher who has lost his fast ball can still be a 20-game winner. This would require an independent objective evaluative process that had consensually agreed upon criteria for competence. At the same time, safeguards are required to prevent the evaluation process from being exploited for political purposes as has occurred in the past—for example, in Nazi Germany and the Soviet Union.¹⁴

To withhold information that would inform us about our commander in chief’s health and competence in deference to their personal privacy and political obfuscation in a 2-party system makes no sense and imperils the safety and well-being of our nation. If we limit the age of POTUS aspirants, we deprive ourselves of the wisdom that age confers to the elders of our society who wish to serve in positions of government leadership, especially with the benefits of longevity science on the horizon. These considerations must inform the development of a policy that ensures the American people of the capability and well-being of their government leaders and the person in the most powerful position on earth.

Dr Lieberman is the president of ARETE Health, Well-Being and Human Potential, Inc, and holds the Constance and Stephen Lieber Chair in Psychiatry at Columbia University Vagelos College of Physicians and Surgeons. In addition to over 800 scientific publications, he is the author of SHRINKS: The Untold Story of Psychiatry (Little Brown, 2015) and MALADY OF THE MIND: Schizophrenia and the Path to Prevention (Scribner-Simon and Schuster, 2023).

References

1. Debate Between The President And Former Vice President Walter F. Mondale In Kansas City, Missouri. Reagan Foundation. Accessed September 13, 2024. https://www.reaganfoundation.org/ronald-reagan/reagan-quotes-speeches/debate-between-the-president-and-former-vice-president-walter-f-mondale-in-kansas-city-missouri/

2. Mattimore R. 5 presidents who hid their health issues. History. October 10, 2023. Accessed September 13, 2024. https://www.history.com/news/5-presidents-who-hid-their-health-issues

3. The 25th Amendment: Section 4 and March 30, 1981. The Regan Library Education Blog. Accessed September 13, 2024. https://reagan.blogs.archives.gov/2017/07/26/the-25th-amendment-section-4-and-march-30-1981/

4. Shakespeare W. Henry IV Part 1. Act V Scene 4.

5. Goldwater Rule. Psychology Today. Accessed September 13, 2024. https://www.psychologytoday.com/us/basics/goldwater-rule

6. Presidential disability and succession. National Constitution Center. Accessed September 13, 2024. https://constitutioncenter.org/the-constitution/amendments/amendment-xxv

7. Kilpatrick C. Nixon resigns. Washington Post. August 9, 1974. Accessed September 13, 2024. https://www.washingtonpost.com/wp-srv/national/longterm/watergate/articles/080974-3.htm

8. Mean age of Members of Congress in the United States from 2009 to 2023. Statista. Accessed September 13, 2024. https://www.statista.com/statistics/1357207/congress-members-average-age-us/

9. Michan S, Sinclair D. Sirtuins in mammals: insights into their biological function. Biochem J. 2007;404(1):1-13.

10. Martin GM, Bergman A, Barzilai N. Genetic determinants of human health span and life span: progress and new opportunities. PLoS Genet. 2007;3(7):e125.

11. Chen PT, Yeong KY. New sirtuin modulators: their uncovering, pharmacophore, and implications in drug discovery. Med Chem Res. 2024;33:1064-1078.

12. Salih A, Nichols T, Szabo L, et al. Conceptual overview of biological age estimation. Aging Dis. 2023;14(3):583-588.

13. Neuropsychological testing and assessment. Cleveland Clinic. Accessed September 13, 2024. https://my.clevelandclinic.org/health/diagnostics/4893-neuropsychological-testing-and-assessment

14. van Voren R, Keukens R. Political abuse of psychiatry. In: Sadler JZ, Fulford KWM, van Staden CW, eds. The Oxford Handbook of Psychiatric Ethics, Vol. 2. Oxford Academic; 2014.