“We all breathe the same air.

We all cherish our children’s future.

And we are all mortal.”

(President John F. Kennedy).Footnote 1

The recent unannounced visit by President Trump to Walter Reed Medical Center,1 coupled with German Chancellor Angela Merkel’s unexplained tremors while on camera,2 has once again raised the question of what medical information political figures should be required to disclose. These two events have coincided with the 60th anniversary of the presidential campaign of Senator John F. Kennedy (who received last rites five times in his life and was arguably the sickest person ever elected to the White House),3 and the 100th anniversary of President Wilson’s disabling stroke, which removed him from political life and thus began “the most serious case of presidential disability and White House cover-up” in American history.4 In all these instances, the public knew very little, thanks to the complicity of personal physicians, failure of the press, and a lack of clear legislation. Hence, the need to revisit the issue.

Two glaring examples of leaders’ illnesses that changed history were the neurological ordeals of Presidents Wilson and Roosevelt. Neither was known to the American public, and both required substantial cover-up. Woodrow Wilson had a long history of hypertension complicated by a first stroke at age 40, and a second one in 1906 that left him blind in the central portion of the left eye.5 He had more neurovascular symptoms in 1907 and 1910, followed by a third stroke in 1913 that caused left arm weakness. In July 1919, he experienced transient amnesia.6, 7 Then, three months after signing the Versailles Peace Treaty, the president suffered a massive stroke. This catastrophe consigned the country to the care of his wife, who went to great lengths to hide the extent of her husband’s disability. The president’s physician helped her cover up by describing Wilson’s condition as “a nervous breakdown, indigestion and a depleted system.”8 With Wilson incapacitated, Congress rejected the peace treaty, refused to join the League of Nations, and eventually distanced the USA from European matters—thus creating the vacuum that contributed to the rise of Mussolini, Hitler, and Franco and ultimately the breakout of World War II.6

Just before that war ended in 1945, Roosevelt, Churchill, and Stalin met at Yalta for a conference that shaped the remainder of the twentieth century. Yet, Roosevelt was in terrible health, with blood pressure readings of 260/150 mmHg that often caused him to become dazed. Some historians suggest vascular dementia.6 William Harriman, the American special envoy to Europe, noted, “At Yalta, I believe, [Roosevelt] didn’t have the strength to be quite as stubborn as he liked to be. I suppose that if FDR had been in better health, he might have held out longer and got his way on a number of detailed points.”9 Roosevelt died two months later of a hypertensive crisis (300/190 mmHg) complicated by massive cerebral hemorrhage.10 He left behind a divided Europe, a long Cold War, and a geopolitical division from which we are still suffering.

Medical secrecy is not the exclusive domain of American presidents. When Anthony Eden became British Prime Minister in 1955, he was still suffering from the sequelae of a 1953 cholecystectomy that had gone terribly wrong: the bile duct was “inadvertently” tied (causing postoperative jaundice), the ligature of the cystic duct quickly broke down, and the surgeon suffered a nervous breakdown that caused the operation to be put on hold while he composed his nerves.11 Then, during the follow-up surgery, the biliary duct was cut (“the knife slipped”), while the right branch of the hepatic artery was “inadvertently” ligated, eventually causing atrophy of the right hepatic lobe.12 Eden came close to death, but slowly recovered, and in June 1953, traveled to Boston to undergo repair surgery. Despite this, in 1954 and 1955, he experienced four episodes of shaking chills, fever, and abdominal pain, and in October 1956, he developed one more episode of pain and rigor, with fevers to 106 °F. He was eventually diagnosed with ascending cholangitis and given sulfur drugs, together with barbiturates for sleep and amphetamines during daytime. It was in these conditions that he dealt with the Suez Canal Crisis,12 whose mishandling created not only mistrust with the USA but also a Middle East chaos that ultimately benefited the Soviet Union. Once again, the British public was unaware.

Three years after Eden stepped down, John F. Kennedy boasted of being “the healthiest candidate for president.”8 In reality, he was the one on the largest pharmacopeia.13, 14 This included corticosteroids for Addison’s disease and liothyronine for hypothyroidism (he probably had Schmidt syndrome),15 plus local anesthetics, barbiturates, narcotics, stimulants, tranquilizers, sleeping pills, testosterone, and the infamous Dr. Feelgood’s Elixir, a steroid-laced methamphetamine mix concocted by Dr. Max Jacobson, a New York physician who eventually lost his license.16,17,18 Kennedy’s ailments might have even influenced the 1961 Vienna summit, a tense meeting where JFK was strong-armed by the Soviet Premier Nikita Khrushchev.19 Later, Kennedy commented, “he beat hell out of me.”20 In fact, the strange passivity of the young American president convinced Khrushchev that Kennedy was an inexperienced lightweight who could be easily pushed around.20 Within two months, the Berlin Wall went up, and the following year, Khrushchev placed nuclear missiles in Cuba. Would have this happened if Kennedy in Vienna had not been dazed by all the drugs Dr. Jacobson was giving him for a back strain suffered two weeks before during a tree-planting ceremony?17

A more recent but instructive example of medical misinformation involved Massachusetts Senator Paul Tsongas. While running for the 1992 Democratic presidential nomination against Arkansas Governor Bill Clinton, Tsongas maintained that he was cured of the non-Hodgkin’s lymphoma that had afflicted him years before. Two of his physicians at the Dana Farber Cancer Institute of Harvard repeatedly confirmed that claim and denied any relapse. “In terms of sheer physical strength,” said Tsongas during the campaign, “there are very few people my age who are in as good shape as I am.”21 Unbeknownst to Americans (but well known to his physicians)22, he had already suffered a cancer relapse five years prior to his presidential bid, and was soon to suffer a second one just two weeks after the November election. Tsongas eventually died in 1997 of complications from his disease, just two days short of what would have been a full term. Had he been elected, he would have probably been forced to resign, and health issues would have undoubtedly jeopardized his mandate.

There are, in fact, two types of illness that the public should know about: those that can threaten the life of the leader and those that can cloud judgment. Illnesses that do neither should remain confidential. Yet, separating them is difficult and often rife with ambiguity. For instance, should physicians disclose a pneumonia that might resolve? Should they breach confidentiality if a leader’s illness will not compromise discharge of duties? Who decides that? How do you separate public curiosity from public interest? Should Congress require proof of health from all candidates to office? Who would establish that?

An obvious medical concern is mental illness. Leaving aside the homicidal psychopathology of extreme cases like Adolf Hitler (also democratically elected), dementia is a worry. Some cases are relatively straightforward, such as that of Finnish Prime Minister Urho Kekkonen, who in the late 1970s developed “arteriosclerosis universalis” (most likely what we would now term Alzheimer’s disease) and then tried in vain to cover it up.23 Others are more insidious, such as the dementia of German President Paul Von Hindenburg (who appointed Hitler to the Chancellorship), 24 British Prime Minister and Labour Leader Harold Wilson, 25 and American President Ronald Reagan. In 1980, Reagan told The New York Times medical correspondent Lawrence Altman that he would resign if White House doctors found him mentally unfit.26 White House physicians never detected any changes in the President’s mental abilities while in office, yet years before Alzheimer’s was diagnosed in 1994, Reagan did present subtle changes in speaking patterns that might have indicated early dementia.27 Hence, recognizing mental impairment is not easy, especially when it comes to psychiatric disorders.

Ultimately, illnesses of heads of state can destabilize a country. The clouding of the leader’s judgment and the lies required to keep the illness secret can each sow disorder and confusion and thus compromise national policy and security. The difficulties of removing an ailing leader from office can also become an impediment to the rule of government. How can we recognize incapacitation and intervene?

After apologizing for having misled the American people, Tsongas urged President Clinton to appoint a national commission to decide what health information a presidential candidate should disclose.28 Clinton, however, never did so. President Carter also suggested the creation of a bipartisan panel of physicians, but one that could have full access to the health records of sitting presidents and periodically evaluate their fitness. He did so by publishing an opinion piece in JAMA immediately after news of President Reagan’s dementia became public.29 Carter argued that the determination of presidential disability called for by the Twenty-fifth Amendment to the Constitution should not be left to often-questionable reports by personal physicians or leaders themselves. The most peculiar example of that was the 2015 letter signed by Donald Trump’s personal physician that failed to disclose any medical data and simply stated that Mr. Trump was going to be “the healthiest individual ever elected to the presidency”. Later, it became known that the letter had been dictated by Trump himself, who then had his doctor sign it.30 As an aside, the physician’s unethical behavior was never censured by the New York Medical Board.31

Leaders’ illnesses certainly pose an ethical dilemma for physicians. Should they remain loyal to their patients or instead take into account the political health of their country? Do the interests of the many trump the privacy concerns of one? Should patients’ secrets always go to the grave with them, as the British physician Lord Cohen of Birkenhead used to quip?12

This conundrum is not even solved by the Hippocratic Oath. While the classical version urges physicians to protect patient’s privacy, a 1964 version (and the one mostly used by medical schools), also reminds them that they remain “members of society, with special obligations to all fellow human beings”32.

In 1957, the American Medical Association’s “Code of Medical Ethics” stated that patient-physician confidentiality ought to be rescinded if human lives are threatened by a patient.33 Situations that justify disclosure for the sake of the common good include the reporting of cases of tuberculosis or child abuse, and the reporting of medical conditions afflicting airline pilots and military personnel. This proviso was maintained in the latest version of the code.34 Yet, in the USA, the only system in place to report the psycho-physical ailments of the most powerful leader in the world is the Twenty-fifth Amendment to the Constitution, which has flaws. Hence, we need a better system. In fact, given the overwhelming evidence that concealed illnesses can change history and that heads of state are reluctant to disclose them, it is hard to understand why clear legislation has not yet been written to address this issue. What are the barriers?

A danger of full disclosure is that it might provide political enemies with arguments against leaders who are otherwise effective. This is particularly important in our times of distrust and polarization. Examples of illnesses that did not necessarily imply incapacitation were President Roosevelt’s crippling polio and Lincoln’s depression.35 In fact, one could even argue that experiencing illness might increase compassion and wisdom, and thus make the leader even more effective. Yet, would Americans have elected Lincoln and Roosevelt if they had known about their disabilities? And if Lincoln and Roosevelt had been prevented from entering the White House would not we have lost two great and compassionate leaders? In the end, John F. Kennedy might have said it best: “the only valid test of leadership is the ability to lead, and lead vigorously.”36

Nevertheless, we need a national conversation that can finally enact legislation to protect voters’ right to informed decisions, and remove presidents that have become medically or mentally “unable to discharge the powers and duties of the office.”37 This will be a difficult task, and thus require the joint effort of ethicists, physicians, lawyers, and policymakers. Yet, it has to be done. The alternative is for the public to remain in the dark, which historically has had serious repercussions.