What do you do when the leader can’t lead? Then and now

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By Dr. Jock Murray

Special to The Advocate

It is not surprising that national leaders sometimes get incapacitated while in office. Many are older and subject to all the ills we all encounter. Some also have personality characteristics that make them prone to other stresses.

It is a rich field of study. Intelligence agencies in various countries assess the physical and mental health of the leaders of all 195 countries. They will tell you that in an average year, six leaders have assassination attempts and one is successful, two leaders have heart attacks, two are diagnosed with cancer, and one suffers a stroke. They also keep tabs on those whose mental state and erratic behaviour seems to affect their leadership. When a leader is incapacitated you can count on the following — they and their staff will try to cover it up, lie about it, and they will not give up power. They know that if the leader goes, so do they. For example, in our lifetime, 13 national leaders had strokes and stayed in power.

The public thinks they have a right to know about a leader’s health, but they don’t. The national leader has the right to the same privacy as you and me. Politicians also know they will lose votes if it is known that they have a history of physical or mental illness.

Most countries, particularly those with a parliamentary system, think they can manage a situation when the leader is incapacitated but there are lots of examples where their system failed. Only the USA showed concern, and they should, as 20 presidents have had periods of incapacitation, from brief episodes during surgery to years of disability. The most famous was President Woodrow Wilson who spent most of the last 17 months of his presidency in his bedroom at the White House after a series of strokes. The political system didn’t know how to deal with this.

The 25th Amendment

President Eisenhower recognized that three times during the Cold War, when he was incapacitated with strokes and heart attacks, he was really not able to make the kind of decisions required. In 1968 he formed a committee under Senator Birch Bayh, and they recommended the 25th Amendment to the Constitution with two important sections. It said that the president could indicate a period of disability, and pass power to an acting president. The president says when the period of disability is over. If the president is so disabled that he cannot decide, then power passes to an acting president. That would seem to cover the problem, except it was never used. It wasn’t clear what an acting president was, or who makes the decision that the president cannot serve due to disability. The 25th Amendment was never used.

The Working Group

on Disability in

US Presidents

In the 1990s a Working Group on Disability in US Presidents began to assess ways to make the 25th Amendment workable. It was a very interesting group — all the president’s physicians for the last seven presidents, the presidential historians, historians who wrote about illness in leaders, and at each meeting a different president attended. I was the only Canadian in the group.

The recommendation was that the 25th Amendment be maintained but that it be used on every occasion, so it becomes a normal process. It suggested that the chain of those who make the decisions be clearly defined and each of them informed of the rules and responsibilities before inauguration.

Another important recommendation was about the roles of the physicians and the politicians. Previously some felt the physicians should determine if the president is incapacitated, but no one is going to give the physicians that kind of power. The politicians, on the other hand, know their political heads will roll if they decide to remove the leader. The Working Group recommended separating the responsibilities. The physicians determine the degree and form of incapacity and inform the political decision makers. The political chain of command is then responsible for the decisions they make with this information. It was also suggested the president’s physician may speak publicly about the president’s health, with the president’s permission, but the physician should not lie.

A weakness is that the president’s physician may feel they are to protect the president and they become part of the political process that hides and lies about any presidential incapacity. There was a minority report to the Working Group by a group led by Birch Byah, who was also on this second committee, who wanted an independent panel of physicians to regularly examine the president. Others felt this was a confrontational arrangement and the president and the president’s physician would hide things and be uncooperative.

So how is it working?

It has become a normal process. Many TV shows depicting a president will have an aide with a red valise containing the documents about the 25th Amendment. President George W. Bush was the first to use the voluntary pass of power while undergoing an anesthetic. This will help make the process a normal one.

A lingering concern is that the process works well for a physical disability, such as a stroke, heart attack, cancer, or surgery. But it doesn’t deal well with those who seem to be mentally unstable. It also doesn’t deal with the leader displaying hubris. Lord David Owen, a physician, said that hubris has been a feature of many modern leaders. These leaders have an exaggerated self-confidence, develop a sense that they have all the answers, almost a divine mission to lead, and so they stop listening to advice, even when told their actions will hurt and undermine them. He also notes they often use crises to wield excesses of power and to break accepted rules. Historian Barbara Tuchman wrote in A March of Folly, that hubris can be seen in leaders through history, and it usually leads to their failure.

I know what you’re thinking. There has been a lot of speculation in the press and social media about President Trump. A publication, “The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President”, is a collection of essays from some of the most prominent psychiatrists and psychologists in the USA. They outline the evidence for personality problems, grandiosity, and narcissism. They believe they can diagnose his mental state as a pathological and dangerous mental disorder, deserving of impeachment. They later added that much of what they predicted in the book has come to pass, and he has weakened the institutions that might have contained him.

The problem for these psychiatrists is the Goldwater rule. The rule of the American Psychiatric Association is that it is unethical to diagnose mental illness in a public figure if you have not personally examined the person. So, no one is going to act on their recommendations. The question is — is anyone going to act? This is probably an example of how the 25th Amendment falls short.

One of the strengths of the Canadian political scene is that it is often boring. One of the weaknesses of the American political scene is that it is never boring.

Dr. T. Jock Murray grew up in Pictou and attended Pictou Academy. He is a neurologist and medical historian, former Dean of Medicine at Dalhousie Medical School and founder of the Dalhousie MS Research Unit.