Choosing a President

By Jacob M. Appel, M.D.

Two candidates are running for president. The older of the two is the Democratic incumbent who survived an attempted coup at the outset of his administration and whose campaign is centered upon having returned the nation to stability. Yet his years in office have taken their toll and appear to many observers to have exhausted him. His advisers scrupulously manage his public appearances to conceal his mobility difficulties.

In contrast, the Republican challenger, slightly younger, when not in court or at his country club, travels the country, hosting large rallies and showcasing his supposed vigor. He is overweight but otherwise appears to be in good physical health. At a time of vocal dissent at home and unprecedented challenges abroad, voters wonder which candidate, if either, is most physically and psychologically fit to lead the nation.

This scenario is far from hypothetical. The American voter would have faced precisely such a dilemma in 1940—the year Franklin Delano Roosevelt defeated Wendell Willkie for a third term in the White House.

For those keeping a medical scorecard, Roosevelt soon led the country through the Second World War and secured a fourth term in 1944. That same year, the younger and supposedly much healthier Willkie suffered a series of major heart attacks and died before the expiration of what would have been his first term in office. Rather than an anomaly, such medical “surprises” are as much the rule as the exception in presidential politics.

In the current presidential election cycle, voters have consistently expressed concerns about the physical and psychological health of both candidates. Whether such concerns are likely to change voters’ preferences is much less clear. Nevertheless, medical and mental health practitioners are often asked to weigh in on the candidates’ well-being.

Yet, since 1973, the Goldwater Rule has prohibited members of the American Psychiatric Association (APA) from offering commentary on the psychiatric conditions of public figures whom they have not personally examined. This rule does not apply to clinical psychologists or to general medical doctors—although sound judgment might discourage such commentary based upon limited information. That the limits apply only to psychiatrists, and not to others, has proven a source of controversy.

However, the Goldwater Rule does not prevent psychiatrists from offering some general thoughts on how voters should consider medical information about presidential candidates. The following three principles may prove useful in helping voters grapple with such information—much of which is often hard to decipher, even for medical professionals.

Available information is usually incomplete and highly unreliable

Neither the president, his challenger, nor their physicians have any legal obligation to be forthright with the American people regarding the medical or mental health of candidates. In fact, outright deception in this area has long been the norm.

Starting with James Madison in 1813, a range of presidents including Grover Cleveland, Woodrow Wilson, Franklin Roosevelt, John F. Kennedy, and Lyndon Johnson—to name only those long deceased—have gone to great lengths to mislead the voters about their medical care. In 1992, candidate Paul Tsongas and his doctors are widely believed to have led the public to conclude that he was “cancer-free,” when he was not. Tsongas, like Willkie, died before what would have been the end of his first term, of recurrent lymphoma.

The public often learns the full truth many years later, if at all. Further, even a physician who wishes to share such medical secrets in the public interest is prohibited from doing so by medical confidentiality and could face criminal charges for violating federal law.

Of course, good reasons may exist to keep such information from the American public. For instance, any information available to U. S. voters also becomes known to our nation’s adversaries abroad, who would likely use it to their advantage. Does our nation really want the Chinese military or the Russian Federal Security Service to know the most private details of our leaders’ lives?

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The presidency requires a unique skill set

Serving as president of the United States is truly a job like none other. Jefferson famously described the post as a “splendid misery”; Truman compared it to “riding a tiger”; Lyndon Johnson colorfully observed that “being president is like being a jackass in a hailstorm. There’s nothing to do but to stand there and take it.”

While the job is certainly taxing, the specific challenges may prove fundamentally distinct from those of any other occupation. Sound judgment and perspective are likely essential. With an army of assistants and advisors, a memory for detail is arguably far less so. Since only six living voters have actually occupied the Oval Office, the rest of the electorate lacks the experience to comprehend fully to what extent any particular skill is necessary or sufficient for the job.

Predicting health outcomes for presidents is highly challenging

Actuarial tables are often helpful in estimating the morbidity and mortality of ordinary people. Recent history has shown they are far less useful when attempting to predict the future of presidents and presidential candidates.

Of the most recently deceased presidents, Gerald Ford and Ronald Reagan both lived to 93, and George H. W. Bush lived to 94. As of this writing, Jimmy Carter remains alive at 99. Challengers George McGovern (90), Walter Mondale (93), and Robert Dole (98) also vastly exceeded their statistical life expectancies—as did John McCain, despite his death at the widely perceived to be premature age of 81.

The vast medical resources available to the president render conditions that might go undetected or prove fatal in others manageable for the occupants of the White House. Similarly, the vast social capital required to become a major party contender ensures access to medical care beyond the imagination of the average citizen. Far more members of the public would likely live into their 90s or beyond if they had a personal physician following them around at all times—which is, in essence, one of the perks of the presidency.

In short, what the electorate does know about the health of presidential candidates is unlikely to prove particularly useful to them inside a polling station. Even if a candidate did disclose his entire medical record and his doctors swore that he had done so, the public would have no way to confirm the claim.

Yet, the media may believe the medical travails of presidents and their challengers are newsworthy, as were Jimmy Carter’s hemorrhoids in 1978. However, in choosing our leaders, this information is about as helpful as knowing that Rutherford B. Hayes once suffered from poison ivy.

Voters are free to vote their consciences. Or their pocketbooks. Ideally, they should vote for candidates who share their values and their policy preferences. They should not vote based on the publicly known medical histories of the candidates. If they do, they might as well choose a random name inside the voting booths.

Jacob M. Appel, M.D., is a professor of psychiatry and medical education at the Icahn School of Medicine at Mount Sinai and a member of the Committee on Psychiatry & The Law at the Group for the Advancement of Psychiatry.