COVID-19 and the problem of presidential succession

Rep. Jamie Raskin (D-Md.) has introduced legislation to create a congressional commission of doctors and former government officials to assess future presidents’ ability to execute their duties. Speaker Nancy Pelosi (D-Calif.) has acknowledged that this legislation would not as a practical matter apply to President Trump.

We support this long-overdue proposal, but the role of such a commission should not be limited to situations in which a president is obviously incapacitated, as in the case of a period of unconsciousness or coma. The much harder questions arise when a chief executive falls short of such an obvious circumstance. One hundred years ago, Woodrow Wilson became ill with influenza, then suffered a severe stroke that essentially sidelined him. 

The world was much less complicated, and a conspiracy of his wife and close advisers concealed his incapacitation from the public. By the mid-20th century, the nuclear superpower needed to come to terms with presidential disability and death episodes. Dwight D. Eisenhower suffered a stroke in 1957 and considered resigning from the office. As the former NATO commander, he appreciated the burden and responsibilities of being Commander-in-Chief. At his initiative, Congress began deliberations on and enacted the 25th Amendment in 1967.

The trigger for the third section of the 25th Amendment that specifies a written temporary handoff from the president to the vice president is clear enough. More problematic is the amendment’s fourth section, which provides that a majority of the cabinet or two-thirds of congress can temporarily transfer power. But what triggers a drastic action that displaces the highest officer produced by our system of government? As the proposed legislation recognizes, when a president is suspected to be “unable to discharge the powers and duties of his office,” that should initiate debate at the highest levels on the president’s competence. 

But what warrants such a suspicion? Despite the line of succession provided for in the 25th Amendment, the precise circumstances required to trigger each step must remain, to some degree, reliant on individual determinations. There is no substitute for thoughtful and clear procedures to act when a president’s illness can potentially weaken the capacity of executing the duties of the office. Fortunately, clinical medicine has progressed sufficiently over the past decades to enable conscientious practitioners, using sophisticated neuroimaging and testing, to assess high-performing individuals’ cognitive functioning and capabilities.

The symptoms associated with  COVID-19 and the largely experimental treatments themselves have highlighted the need for a more subtle approach than the gross conditions associated with lapsed consciousness. The more obvious medical issues associated with this disease — loss of taste and smell, congestion, shortness of breath, hypoxemia and many more — don’t capture the still more disconcerting and as yet poorly understood neuropsychological challenges. The virus directly affects the nervous system and can have a long-term impact. Many patients have reported anxiety, depression, confusion and sleep problems in the acute phase of the illness. These symptoms are subtle. Able practitioners can disagree about how much they affect any individual. Nonetheless, COVID-19 can cause impairments in thinking and altered mental state cannot be ignored. Especially in older patients like the president, these impairments can persist long after the infection’s immediate effects have faded.

Then there are the potential psychological complications associated with the treatments being provided. Consider only the steroid dexamethasone. Long experience with this drug includes documented mood changes of uncertain severity and duration, including the kind of exuberance that can lead to an ill-advised tour of fans at the hospital gates. It’s not a  COVID-19 treatment one would want to introduce in a patient with mild symptoms. Without second-guessing, the president’s physicians being viewed as a VIP can be a risk factor for aggressive treatment. Their understandable eagerness to return the president to health should not induce them to exceed the standard of care. But if the steroid is indicated in their sound judgment, this therapy can compound the neurological complications of the underlying disease.

Regardless of the temperament of the occupant of the White House, it was only a matter of time before this scenario of a president with a neuropsychologically complicated illness came to public attention. The nation requires and deserves the availability of a standing group of experts that can advise the government about succession when the situation is a complex one. Respect for expertise has taken a beating lately, but the constitution’s framers admired the arts and sciences. They would surely have expected us to take on their unfinished business.

Stephen N. Xenakis, a psychiatrist and retired Army brigadier general, serves on the executive boards of The Center for Ethics & the Rule of Law at the University of Pennsylvania and is an adjunct professor at the Uniformed Services University of Health Sciences. Follow him on Twitter @SteveXen.

Jonathan D. Moreno teaches medical ethics and health policy at the University of Pennsylvania. His most recent book is, “Everybody Wants to Go to Heaven, but Nobody Wants to Die: Bioethics and the Transformation of Health Care in America.” Follow him on Twitter @pennprof.