What is the public entitled to know about a president’s mental health?

Hardly a week goes by when a journalist doesn’t call, asking me to comment on President Trump’s mental health. I have consistently resisted, invoking the Goldwater rule — the informal name given to Section 7.3 of the American Psychiatric Association’s code of ethics, which states that it’s unethical for psychiatrists to make public statements about a public figure they have not evaluated.

During the 1964 presidential campaign, the now-defunct Fact magazine published an article, “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater,” which polled psychiatrists about whether the Republican candidate was fit for the presidency.

{mosads}The majority concluded that Goldwater was psychologically unfit to be president, with comments ranging from calling him a dangerous lunatic and paranoid to others accusing him of having an impulsive quality and being emotionally unstable with a godlike self-image. After losing the election, Goldwater sued the magazine’s editor for libel — and won.

Gail Sheehy, the well-known author and journalist, has reached out to me from the primary campaigns through the inauguration, imploring me to endorse her diagnosis of bipolar disorder, saying Trump meets every single diagnostic criterion. I have steadfastly avoided pinning a psychiatric diagnosis on someone whose behavior and policies are found by some to be objectionable, particularly someone I have not personally examined. It only lets them off the moral hook, and demeans those who do suffer from those disorders.

Recently, some of my colleagues have deviated from this ethical precept and publicly opined about the president’s mental state. While I cannot countenance such actions, I can certainly understand why there is so much interest in this topic. President Trump’s freewheeling behavior is unconventional, to say the least.

This raises two questions that I believe are appropriate to discuss: What is the public entitled to know about the health, including mental health, of presidential candidates? And, on what grounds does a president become unfit to serve for reasons of mental health? This is not to impugn our current president or imply that he is unfit for office, but the frequency of inquiries raised about his behavior makes it timely, if not imperative, to address these questions.

Presidential campaigns essentially serve to vet candidates on issues relevant to governing the country. In this context, past performance, behavior and other aspects of their lives become relevant. To address their financial history, for instance, candidates release tax returns (although this one hasn’t).

However, when it comes to the question of their health, there is no standard benchmark. The convention has been to provide a doctor’s letter attesting to the candidate’s’ health. However, this is like a financial statement that has not been audited or certified — it has no proven validity.

The health of candidates is clearly consequential. Former Sen. Paul Tsongas’s (D-Mass.) cancer was an issue in the 1992 campaign, and vice presidential candidate Thomas Eagleton was forced to withdraw from the Democratic ticket in 1972 when his history of depression and treatment with electroconvulsive therapy became known.

Information that could be damaging is often withheld from the public. When Woodrow Wilson suffered a stroke, his wife and physician covered up his condition rather than installing a designee to assume the powers of the office. FDR’s disability from polio was masked; questions still linger over whether Ronald Reagan’s Alzheimer’s disease had begun to affect him in his second term.

It would seem that the public’s right to know would outweigh the right to privacy of the candidates, which begs us to wonder if there should be a standard procedure to determine and reveal the medical history and status of presidential candidates, including their mental health.

The same logic applies to determining when a sitting president is unfit to serve. The 25th Amendment of the Constitution provides for succession if “the President dies, resigns or is unfit to discharge her/his duties.” However, there are no specific criteria to define the latter, an issue that is further compounded when it concerns mental disability.

The 25th Amendment has been invoked six times since its ratification, from reasons ranging to the scandals of the Nixon administration to presidents who underwent medical procedures requiring general anesthesia. No one would argue with the possibility of a disabling presidential infirmity for reasons of mental disorder. Psychosis, dementia, depression and addiction could be severe enough to impair a president’s ability to discharge his or her duties. However, we lack a process and criteria to apply this constitutional mechanism for reasons related to mental function.

I believe the closest we have come to this is the aftermath of the Reagan assassination attempt in 1981. Howard Baker, the incoming White House chief of staff, was advised by his predecessor to be prepared for a possible invocation of the 25th Amendment due to Reagan’s incapacity.

Reagan’s behavior in meetings somehow signaled his staff to believe that he was “losing his grip.”

During a meeting with Baker’s staff, Reagan biographer Edmund Morris writes, “Reagan who was, of course, completely unaware that they were launching a death watch on him, came in stimulated by the audience of his new staff and performed splendidly. At the end of the meeting, they breathed a sigh of relief realizing he was in full command of himself.”

It is time to establish a standard for vetting the physical and mental health of candidates. If we must undergo medical examinations for life insurance policies, various jobs of importance, professional sports and entry into the military, why shouldn’t this be the case for those aspiring to hold the most powerful position in the world?

Jeffrey Lieberman, M.D., is chair of Psychiatry at Columbia University Columbia University Medical Center and psychiatrist in chief of the New York Presbyterian Hospital, as well as past president of the APA. He is author of “Shrinks: The Untold Story of Psychiatry.”

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