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PRIVACY VERSUS THE

PUBLIC'S RIGHT TO KNOW
- PRESIDENTIAL HEALTH
AND THE WHITE HOUSE
PHYSICIAN
a
Aaron Seth Kesselheim
a
PGY-1, Department of Medicine, Brigham &
Women's Hospital, Harvard University
Published online: 10 Nov 2010.

To cite this article: Aaron Seth Kesselheim (2002) PRIVACY VERSUS

THE PUBLIC'S RIGHT TO KNOW - PRESIDENTIAL HEALTH AND THE WHITE
HOUSE PHYSICIAN, Journal of Legal Medicine, 23:4, 523-545, DOI:
10.1080/01947640290050328

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 The Journal of Legal Medicine, 23:523– 545
Copyright °C 2002 Taylor & Francis
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DOI: 10.1080/0194764029005032 8

2002 Schwartz Award

PRIVACY VERSUS THE PUBLIC’S RIGHT

TO KNOW
PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN
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Aaron Seth Kesselheim, M.D., J.D.*

INTRODUCTION
Recent events both factual and Ž ctional have brought to the forefront of dis-
cussion the medical care provided to our political leaders. Vice President Dick
Cheney’s heart troubles have been widely reported: he has had a myocardial
infarction—his fourth overall—as well as coronary artery stenting, angio-
plasty to reopen the stent, and an intracardiac deŽ brillator placement since his
and President George W. Bush’s November 2000 election. Congress contin-
ues discussions on contingency plans for bioterrorist attacks on Washington,
D.C. NBC’s “West Wing” depicted its President Josiah Bartlett as strug-
gling with progression of multiple sclerosis.1 Recent history, however, in-
dicates that such issues are not to be taken lightly. In fact, at least 14 of the
19 United States Presidents in the twentieth century suffered from signiŽ -
cant illnesses while in the White House, ranging from Woodrow Wilson’s
debilitatin g stroke to Franklin Delano Roosevelt’s congestive heart failure

* PGY-1, Department of Medicine, Brigham & Women’s Hospital, Harvard University. This article arose
out of research conducted for the College of Physicians of Philadelphia in concert with its Forum on
Disability and the Presidency of the United States. The author would like to acknowledge the support
and guidance of Professor William L. Kissick, former Executive Director of the College, Dr. Marc
S. Micozzi, and Dick Levinson. The opinions expressed in this article are the author’s alone and do
not necessarily represent the opinions of the College. Address correspondenc e to Dr. Kesselheim at
Brigham & Women’s Hospital, Department of Medicine, Division of Internal Medicine, 75 Francis
Street, Boston, Massachusetts 02115, or via e-mail at [email protected] .
1 “The West Wing’s” Ž ctional notion of a President hiding his multiple sclerosis diagnosis is apparently

not so fanciful. Minnesota senator Paul Wellstone revealed that his limp, which he had claimed for many
years was a childhood wrestling injury, was in reality “evidence of a mild form of multiple sclerosis.”
Prairie Populism v Suburban Realism, ECONOMIST, Mar. 9, 2002, at 37.

523
 524 KESSELHEIM

to Ronald Reagan’s colon cancer, with varying impacts on their ability to

govern.
These events raise troubling questions about the nature and quality of
the medical care provided to our political leaders. Since the time of President
William McKinley at the end of the nineteenth century, Presidents have em-
ployed personal, government-paid “physicians to the President” to care for
their medical needs.2 That system has evolved from a solitary physician-in -
residence under McKinley to today’s “While House Medical Unit,”3 a corps
of medical professionals under the direction of the White House Physician,
Air Force Lieutenant Colonel Dr. Richard Tubb. The modern incarnation is
responsible for the care of the President under circumstances ranging from
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annual checkups to assassinatio n attempts to pretzels lodged in the President’s

windpipe. The team controls mobile emergency and trauma units, keeps exam
rooms in the White House and Old Executive OfŽ ce Building, and scouts hos-
pitals on location during presidentia l trips.4 When President William Jefferson
Clinton traveled to Africa, for example, an eight-member surgical/intensive
care team accompanied him, carrying standard operating room equipment.5
Presidents, of course, also have at their disposal the entirety of America’s
well-developed health care system, in case they need a specialist’s opinion or
complicated emergency surgery.
Despite all these resources, however, the medical care of the President
frequently has been marked by incompetence, secrecy, and downright decep-
tion. Different White House Physicians have attempted to care for medical
problems beyond their areas of expertise, missed potentially signiŽ cant Ž nd-
ings, withheld pertinent information from the President and his family, been
complicit in schemes to suppress media knowledge of medical information,
and even directly lied to the public and Congress regarding the President’s
health. As a result, two sitting Presidents in the last century were later discov-
ered to have been quite disabled while in ofŽ ce—Wilson spent his last years
incapacitated from a stroke and Franklin Roosevelt suffered extreme fatigue
from his hypertensive cardiomyopathy. In numerous other instances, severe
presidential disability was either narrowly avoided or temporarily suppressed
until the President recovered.
Only relatively recently has the American legal system explicitly ad-
dressed presidential disability. RatiŽ ed in 1967, the Twenty-Fifth Amendment
established a process to transfer power to the Vice-President if the President

2
See EDWARD B. MACMAHON & LEONARD CURRY, MEDICAL COVER-UPS IN THE WHITE HOUSE 7 (1987)
(“Since the administration of William McKinley, American presidents have been provided with a
personal, governmen t paid physician.”).
3 See id. (detailing the growth of the role of the White House Physician).
4 See Sumana Chatter Jee, White House Doctors a Blend of “ER” and “The West Wing,” SAN DIEGO

UNION -TRIB., Apr. 8, 2001, at A-17 (describing the current White House medical unit).
5 See id. (noting the range of medical services offered to past Presidents).
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 525

otherwise “is unable to discharge the powers and duties of his ofŽ ce.”6 Yet the
basic way the President receives medical care has not changed. It remains a
tenuous marriage of secrecy and openness, an attempt to maintain the medi-
cal conŽ dentiality and privacy due to each and every American in the care of
perhaps the most important and public American of all.
On three different occasions in the last 20 years, expert commissions
have addressed presidential disability : the 1987 Miller Center Commission on
Presidential Disability;7 the 1997 Working Group on Presidential Disability;8
and, most recently, the 1999 College of Physicians of Philadelphia ’s Forum
on Presidential Disability.9 All concluded that, while the basic structure of the
Twenty-Fifth Amendment was sound, further guidelines were necessary to
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ensure that Presidents consistentl y receive the best possible medical care and
that medically informed decisions are made regarding a potentially disabled
President. Nonetheless, neither Congress nor the executive branch has taken
ofŽ cial action since 1967 regarding the medical care of the President to help
prevent a crisis of presidentia l disability.
This article addresses the basic problems that have emerged regarding the
medical care of the President of the United States and discusses the Twenty-
Fifth Amendment in light of those problems. Section I examines the scope
of the problem regarding the health care American Presidents have received.
Section II looks at the role of the Twenty-Fifth Amendment as a response to
concerns about presidential disability and its viability as a solution. Section
III considers plans for improving the structure set forth by the Twenty-Fifth
Amendment. Addressing presidentia l disability involves sensitive considera-
tions of medical ethics, physician/patient conŽ dentiality, personal autonomy,
and governmental secrecy, but one thing is certain—it is best to have con-
sidered the issue and set contingency plans ahead of time than to create new
policy in the time of an emergency.

I. THE HEALTH CARE OF PRESIDENTS

Illness has been widespread among United States Presidents, which may
be expected, given the combination of the advanced age of many Presidents
and the stressors associated with the job. One historical analysis even indicated

6
U.S. CONST . amend. XXV, x 4.
7 See WHITE BURKETT MILLER CENTER OF PUBLIC AFFAIRS AT THE UNIVERSITY OF VIRGINIA AND UNIVERSITY
PRESS OF AMERICA, REPORT OF THE MILLER CENTER COMMISSION ON PRESIDENTIAL DISABILITY AND THE
TWENTY-FIFTH AMENDMENT (1998) (recommending the promulgation of written guidelines under which
the Twenty-Fifth Amendment will be employed).
8
See DISABILITY IN U.S. PRESIDENTS : RECOMMENDATIONS AND COMMENTARIES BY THE WORKING GROUP, WORK-
ING GROUP ON DISABILITY IN U.S. PRESIDENTS (1995) (reporting commentary on the ideal implementation
of the Twenty-Fifth Amendment).
9 See XIX FORUM ON DISABILITY AND THE PRESIDENCY OF THE UNITED STATES, TRANSACTIONS & STUDIES OF

THE COLLEGE OF PHYSICIANS OF PHILADELPHIA 15-67 (Dec. 1997) (reporting results from a retrospective
and open forum on solutions to historical concerns about presidential health).
 526 KESSELHEIM

that Presidents tend to die sooner than the general public.10 This section Ž rst
looks at examples of modern Presidents who faced medical problems and then
examines how these instances elucidate inherent problems in the presidential
health care system.
A. Disabled Presidents
Presidents have faced a wide range of incapacity while in ofŽ ce, and,
remarkably, examples of such disability continue to the current day. Presidents
Woodrow Wilson, Franklin Delano Roosevelt, Dwight David Eisenhower,
John Fitzgerald Kennedy, and Ronald Reagan serve as good examples of
the scope of medical problems that have beset our Presidents and how the
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Presidents and their advisers have managed these situations .

1. Woodrow Wilson
After a number of years of Ž ghting high blood pressure, President
Wilson developed signs of cerebrovascular disease throughout the summer
and fall of 1919, his penultimate year in ofŽ ce.11 These had some systemic
effects—including personality changes, memory loss, and bizarre behaviors—
but Wilson continued his hectic post-World War I schedule, including ironing
out treaties and stumping for American support for the League of Nations.12
On October 2, 1919, however, President Wilson suffered a massive debilitat-
ing stroke that left him, in the analysis of White House Physician Dr. Cary
Travers Grayson, completely incapacitated and unable to carry on the “ofŽ cial
duties” of the presidency.13
Numerous attempts to hide President Wilson’s tenuous condition oc-
curred during the ensuing months. Dr. Grayson refused to tell the Cabinet the
extent of Wilson’s disease at an emergency October 6 meeting.14 First Lady
Edith Wilson helped ensure that Wilson’s inner circle of advisers remained
silent about his health, and as a result no one notiŽ ed the press—or even the
Vice-President, for that matter, who stayed away from the issue for fear of
appearing disloyal.15 When Secretary of State Robert Lansing questioned pri-
vately if President Wilson could carry out the duties of his ofŽ ce, he was soon

10 See Thomas C. Wiegele, Presidential Physicians and Presidential Health Care: Some Theoretical and
Operational Considerations Related to Political Decision-Making, PRES. STUD. Q., Winter 1990, at 71
(citing empirical studies that Presidents “tend to die prematurely compared to the general population”).
11 See Arthur S. Link, Woodrow Wilson: A Cautionary Tale, 30 WAKE FOREST L. R EV. 587, 587-88 (1995)

(citing “small strokes” that President Wilson suffered in April and July 1919).
12
See id. at 588 (describing the stressors leading up to President Wilson’s stroke).
13 Id. at 589 (quoting 63 THE PAPERS OF WOODROW WILSON 550 (Arthur S. Link ed. 1990)).
14 See id. at 590 (reporting that Dr. Grayson claimed that President Wilson’s mind was “not only clear,

but very active”).

15 See JOHN R. BUMGARNER, THE HEALTH OF THE PRESIDENTS : T HE 41 UNITED STATES PRESIDENTS T HROUGH

1993 FROM A PHYSICIAN ’S POINT OF VIEW 184 (1994) (“All those around Wilson : : : were strictly charged
to maintain absolute secrecy about his illness.”).
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 527

dismissed from his position.16 For the remaining 15 months of his presidency,
Wilson was physically and mentally debilitated—exhibiting a short atten-
tion span, forgetfulness, and emotional lability—but brief public appearances
helped keep the American public conŽ dent in the President’s health.17
During this time, 28 different laws were passed, laws that arguably were
enacted without a President.18 Many have questioned whether Wilson actually
made any remaining policy decisions, or whether the First Lady Ž lled in for
him.19 Moreover, some have wondered what kind of impact his illness had
on world events at the time. For example, many wonder whether a healthy
Wilson—or an appropriate replacement—would have swayed Congress to
support the League of Nations, a proposed internationa l body that lacked
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United States support and failed, but that may have been useful in the days
leading up to World War II.20
2. Franklin Delano Roosevelt
President Roosevelt’s death in 1945, at the start of his fourth elected
term, might have been shocking and unexpected to the American people, but
to his physicians and closest advisers, it was not.21 From his inauguration
in 1933, Roosevelt suffered through many episodes of illness and inŽ rmity.
Roosevelt appointed ENT specialist and Navy Admiral Ross McIntire as his
White House Physician; Dr. McIntire was a close friend of Roosevelt’s who
had cared for his chronic head colds and sinusitis before he took ofŽ ce.22
McIntire missed many of President Roosevelt’s early warning signs of heart
disease, and so by 1941, Roosevelt suffered from progressive diastolic hyper-
tension, lack of oxygen supply to his heart, and iron-deŽ ciency anemia.23 No
public attention was brought to these Ž ndings, and McIntire later wrote that
Roosevelt’s “blood pressure remained on an excellent level : : : and his cardio-
vascular measurements were within normal standards for a man of his age.”24
Yet under McIntire’s direction, Roosevelt secretly visited the National Naval

16 See MAC MAHON & CURRY, supra note 2, at 74 (reporting that the dismissal did not come as a surprise).
17 See Bumgarner, supra note 15, at 185 (reporting that, even during his public appearances , he remained
emotionally unstable and was prone to sudden unexplaine d outbursts).
18 See Bert E. Park, Presidential Disability: Past Experiences and Future Implications, 7 POLITICS & L IFE

SCI. 50, 52 (1988) (“Fully twenty-eight acts of Congress became law in the absence of presidential
review.”).
19 See BUMGARNER, supra note 15, at 185 (noting that “at times [Mrs. Wilson] gave her own answer to

policy questions by writing on the margins of documents”).

20
See Park, supra note 18, at 52 (noting that the Wilson White House lost most of its in uence in Congress
after President Wilson’s stroke).
21 See ROBERT E. GILBERT, T HE MORTAL PRESIDENCY: ILLNESS AND ANGUISH IN THE WHITE HOUSE 43 (1998)

(“Contrary to the widespread belief at the time, his death was in no way sudden or unanticipated.”).
22 See BUMGARNER , supra note 15, at 211 (detailing President Roosevelt’s medical history).
23 See GILBERT, supra note 21, at 53 (describing President Roosevelt’s health in his third term of ofŽ ce

from 1941-1945).
24 Id.
 528 KESSELHEIM

Medical Center for treatment of hypertensive cardiomyopathy an astonishin g

29 times from 1941 to 1945.25 The most pertinent charts, tests, X-rays, and re-
ports from his health care during this time are missing—a result of McIntire’s
concern that his optimistic reports to the American public not be refuted.26
By the end of President Roosevelt’s third term, his cardiovascula r disease
affected his mental capacity, including his ability to concentrate on war-related
issues and actively engage in the debates with his fellow world leaders.27
When members of the media and Roosevelt’s family, concerned with the
President’s gaunt appearance in June of 1944, questione d McIntire whether
Roosevelt should run for a fourth term, he said, “Every possible check-up
proved [Roosevelt] organically sound,” and predicted that he could “stand up
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to the strain of four more years.”28 As it turned out, Roosevelt passed away in
March of the next year.29
The President’s physician, who made false and misleading reports to
the American people and destroyed medical reports, and the President’s close
advisers, who organized his public appearances, worked together to present
Roosevelt as a hearty and active leader.30 When rumors swirled during the 1944
presidential race of Roosevelt’s ill health, his aides rekindled conŽ dence in his
well-being with parades through inclement weather.31 Any public appearances
cancelled for medical reasons were excused with vague statements of pressing
war business, and outside visitors were often turned away when the President
looked or felt too ill.32
Such a concerted effort allowed the President’s health crises to continue,
unchecked and often untreated. Roosevelt ran for a fourth term of ofŽ ce against
rational medical judgment, and the public unknowingly elected a terminally
ill leader at a crucial point in American history.

3. Dwight David Eisenhower

Despite President Eisenhower’s image of a healthy war general, multi-
ple medical problems plagued him throughout his presidency. He developed

25 See KENNETH R. CRISPELL & CARLOS F. GOMEZ, HIDDEN ILLNESS IN THE WHITE HOUSE 118 (1988) (reporting
from an analysis of National Naval Medical Center records that “Roosevelt appeared at Bethesda as a
patient twenty-nine times under as many false names”).
26 See ROBERT H. FERRELL, ILL-ADVISED : PRESIDENTIAL HEALTH AND PUBLIC TRUST 38 (1992) (reporting

McIntire’s efforts to remove President Roosevelt’s health records from Bethesda hospital).
27 See Robert E. Gilbert, Disability, Illness, and the Presidency: The Case of Franklin D. Roosevelt, 7

POLITICS & LIFE SCI. 33, 49 (1988) (concluding that Roosevelt’s disabilities prevented him from carrying
out his responsibilities at Yalta and in the closing days of World War II).
28 GILBERT, supra note 21, at 57.
29
See BUMGARNER , supra note 15, at 217 (reporting the circumstances surrounding Roosevelt’s death).
30 See GILBERT, supra note 21, at 43 (noting that President Roosevel t projected an “image of energy and

strength”).
31 See id. at 59 (describing the tactics Roosevelt’s advisers used in the 1944 presidential campaign).
32 See CRISPELL & GOMEZ, supra note 25, at 81.
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 529

severe cardiovascula r and cerebrovascular disease as a result of long-standin g

hypertension and a three-packs-a-day smoking habit.33 He survived a major
myocardial infarction in 1955, a stroke in 1957, and runs of ventricular tach-
yarrhythmia in 1960.34 He also developed gastrointestina l problems; physi-
cians diagnosed him with Crohn’s Disease in May of 1956, and he required
abdominal surgery for an acute obstruction a month later.35
Yet Eisenhower’s physicians and advisers largely suppressed the extent
and frequency of the cardiovascula r and gastrointestina l disease that plagued
him throughout his tenure as President.36 For example, his May 1956 phys-
ical examination revealed Crohn’s Disease in his ileum.37 The White House
Physician, Major General Dr. Howard Snyder, reported to the press that the
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President had a “normal functioning digestive tract.”38 When in June of 1956,

the President developed an acute intestinal obstruction that required surgery,
however, Snyder was forced to come clean with Eisenhower’s true diagnosis.39
Eisenhower suffered other health problems in his last year of ofŽ ce, ranging
from hypertension to upper respiratory tract infections to emphysema, which
at times put his life in danger.40
In addition to leaving some episodes unreported, Eisenhower’s physi-
cians and advisers deliberately obfuscated public knowledge of his medical
status. They publicized only the barest essentials of required medical infor-
mation, and even then did so in the most favorable light possible .41 Snyder
initially diagnosed Eisenhower’s 1955 heart attack as “massive,” but Ž rst re-
ported to the press that the President had a “mild coronary thrombosis”42 and
then later changed the severity to “moderate.”43 Moreover, Snyder diagnosed
an extension of the initial infarction by electrocardiogra m a few days later,
but he told the press that there were “no complications ” and reported that
the President was “a little tired, but otherwise, his condition is good.”44 As

33 See BUMGARNER , supra note 15, at 228 (describing President Eisenhower’s general state of health as he
ascended to the presidency).
34 See GILBERT, supra note 21, at 114 (describing Eisenhower ’s health during the years 1958-61).
35 See FERRELL, supra note 26, at 118-23 (describing Eisenhower’s struggle with Crohn’s Disease).
36
See GILBERT, supra note 21, at 74, 104 (reporting Eisenhower’s public statements about his good health
during the 1956 re-election campaign, despite deep concern that he might be “too ill to carry out his
responsibilities during a second term”).
37 See FERRELL, supra note 26, at 118 (describing the results of Eisenhower’s comprehensive May, 1956

physical exam).
38 Id.
39 See id. at 119 (noting how the embarrassed Dr. Snyder had to reveal Eisenhower’s true diagnosi s of

Crohn’s Disease in the context of a later, more serious attack).

40 See GILBERT, supra note 21, at 114 (detailing Eisenhower’s ill-health in 1960).
41 See id. at 91 (noting that, despite evidence Eisenhower likely had developed a ventricular aneurysm

after his myocardial infarction, “the public was informed that Eisenhower had suffered a heart attack
without any complications”).
42 Id. at 89.
43 Id.
44 Id. at 90.
 530 KESSELHEIM

another example, in the aftermath of Eisenhower’s 1956 attack of Crohn’s

disease, the White House press ofŽ ce was not forthright with the information
they presented to the public, claiming that “ileitis is not something that en-
dangers the President’s life”45 and even claiming: “We think it improves his
life expectancy.”46
In Eisenhower’s two terms, some signiŽ cant medical events went unre-
ported and misleading statements and falsiŽ ed reports intentionally deceived
the public about the severity and consequences of other attacks. These efforts
helped maintain the image of an active President47 —a representation often far
from the truth.
4. John Fitzgerald Kennedy
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As with President Eisenhower, the public image of President Kennedy

diverged signiŽ cantly from his true health status. Unbeknownst to the pub-
lic, Kennedy struggled with Addison’s Disease, a potentially life-threatening
dysfunction of his adrenal glands.
In 1947, Kennedy was diagnosed with Addison’s Disease, and started
a regimen of corticosteroid injection treatments.48 This disease left him sus-
ceptible to infection and the steroid treatment had potential side effects such
as congestive heart failure and mood swings.49 During the 1960 campaign,
Kennedy’s personal physician, Dr. Janet Travell—who later became the White
House Physician—drafted an artfully worded statement claiming that his
“adrenal glands do function,” and that Kennedy “has not, nor has he ever
had : : : Addison’s Disease.”50 As President, while continuing to deny his con-
dition, Kennedy kept stashes of hormone replacement treatments in safety
deposit boxes around the country in the case of a sudden attack.51 He also
engaged in secret treatments with a physician who injected Kennedy with
corticosteroid s laced with amphetamines, a regimen never proven medically
sound. 52 Even after his assassination, his endorsed autopsy report made no
mention of his condition.53

45 Id. at 101.
46 FERRELL, supra note 26, at 122.
47 See GILBERT, supra note 21, at 105 (reporting that television helped his handlers project a robust image

of Eisenhower).
48 See BUMGARNER , supra note 15, at 240 (describing his Ž rst attack of Addison’s Disease while President

Kennedy was still a member of Congress).

49 See id. at 241 (noting the potential effects of Addison’s Disease on President Kennedy’s career).
50 Id. at 243.
51 See BERT E. PARK, AILING , AGING , ADDICTED: STUDIES OF C OMPROMISED LEADERSHIP 170 (1993).
52
See id. (describing President Kennedy’s care under controversial New York City physician Dr. Max
Jacobson).
53 See FERRELL, supra note 26, at 156 (noting that physicians “endorsed an autopsy report that scandalously

made no mention of Addison’s disease”).

 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 531

Kennedy also received novocaine injections from Dr. Travell for his
back pain, which some have claimed made him addicted to the painkillers.54
Although commentators have debated as to how much his medical care ulti-
mately affected his performance during his time in ofŽ ce,55 certainly President
Kennedy had signiŽ cant medical conditions that were excluded from public
scrutiny and may have been treated improperly as well.
5. Ronald Reagan
President Reagan suffered through two life-threatening events during
his tenure—a 1981 assassinatio n attempt and a 1985 partial colectomy for
cancer of the ascending colon—and a more minor surgery on his prostate.56
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In all three instances, the President was unconscious under anesthesia and
required signiŽ cant post-surgical recovery periods.
After John Hinckley shot President Reagan on March 30, 1981, Reagan
suffered severe blood loss and a collapsed lung, and he arrived at the hospital in
shock. 57 During his recovery, his handlers carefully screened media coverage
to present him vigorous and alert, revealing only the brief, unrepresentative
intervals of lucidity.58 Moreover, press reports did not divulge the physicians’
concerns at the various stages of Reagan’s recovery.59 Similar tactics were
used during Reagan’s next major medical crisis, the 1984 surgery to remove a
cancerous polyp in his ascending colon.60 Photos were restricted to particular
settings and poses, and First Lady Nancy Reagan refused to let the words
“cancer” or “masses” be used in press brieŽ ngs.61 Finally, Reagan underwent
prostate surgery in 1987.62 Again, the White House tightly controlled avail-
able information; at one point, Reagan’s advisers refused to let the press ask
Reagan’s surgeons questions regarding his condition.63

54 See BUMGARNER, supra note 15, at 244, 246 (describing Dr. Travell’s treatment of President Kennedy’s
back pain).
55 See Edwin M. Yoder Jr., Determining Presidential Health Under the Twenty-Fifth Amendment, 30 WAKE

FOREST L. REV. 607, 610 (1995) (noting that some commentator s have ascribed the strange behavior
of President Kennedy during a summit in Vienna as having been due to amphetamine psychosis, but
discounting these claims as inappropriate post hoc medicalization of history).
56 See BUMGARNER, supra note 15, at 282 (describing the circumstances of President Reagan’s assassination

attempt).
57 See id. (describing some of the early reports on President Reagan’s health).
58 See JERROLD M. POST & ROBERT S. ROBINS , WHEN ILLNESS STRIKES THE LEADER : T HE DILEMMA OF THE

CAPTIVE KING 12 (1993) (describing the attempt to portray President Reagan on the news as “vigorous,
alert, and in good spirits”).
59
See id. at 13 (noting that “the important power here is the discrepancy between reality and the image
conveye d to the public”).
60 See GILBERT, supra note 21, at 233 (describing the medical problems that plagued Reagan during his

second term in ofŽ ce).

61 BUMGARNER, supra note 15, at 284.
62 See FERRELL, supra note 26, at 158 (describing the secrecy surrounding Reagan’s prostate surgery).
63 See id. at 158-59 (reporting on how the First Lady speciŽ cally made the President’s team of surgeons

unavailable for questioning by the press).

 532 KESSELHEIM

These instances show that even as recently as the 1980s, the President,
his physicians, and his advisers could deftly manipulate public knowledge of
his medical status.

B. DifŽ culties in Managing Presidential Health

These examples of presidentia l disability reveal some of the inherent
difŽ culties in medically managing a United States President. Issues such as
con ict of interest, national security, conŽ dentiality, and individual prestige all
serve to distinguis h the relationship between the White House Physician and
the President from other physician/patient relationships . By elucidating and
studying these concerns, we can begin to understand the root of the controversy
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surrounding presidential disability and help ensure that the President always
receives safe and effective health care.

1. White House Physicians’ Con icts of Interest

As commentator Herbert Abrams notes: “If the Attorney General has
a con ict of interest when investigatin g executive branch issues, why does
the White House Physician not in medical issues?”64 In fact, the many con-
 icts of interest inherent in the position of White House Physician create
signiŽ cant ethical problems. First, White House Physicians are often drawn
from the military.65 As a result, they see the President as their Commander-in-
Chief, and disobeying orders from a superior military ofŽ cer is difŽ cult. The
same principle applies for lower-ranking military medical consultants who
might be employed by the White House Physician. So, for example, in 1944,
Dr. McIntire ordered an extensive consultatio n on President Roosevelt from
Dr. Howard Bruenn, a junior ranking naval cardiologist .66 Bruenn diagnosed
left ventricular congestive heart failure, hypertension, hypertensive cardiomy-
opathy, and acute bronchitis; he concluded that Roosevelt did not have long to
live. 67 McIntire, however, ordered Bruenn to keep these Ž ndings secret, even

64 Herbert L. Abrams, The Vulnerable President and the Twenty-Fifth Amendment, with Observations on
Guidelines, a Health Commission, and the Role of the President’s Physician, 30 WAKE FOREST L. REV.
453, 476 (1995).
65 Commentators have argued that the White House Physician is basically a routine and unchallengin g job,

in which most days are spent giving “aspirin to the White House staff,” and so few civilian physicians
would Ž nd such work challenging. See MAC MAHON & CURRY, supra note 2, at 8. This trend may be
even more troublesome because military physicians generally are not the country’s top medical minds.
The top military physicians are administrators rather than practitioners, and military physicians are
not accustomed to civilian hospitals that the President could use in times of crisis. See Wiegele, supra
note 10, at 80 (describing aspects of military medicine that might negatively impact presidential health).
66
See Gilbert, supra note 21, at 55 (describing the circumstances surrounding Roosevelt’s Ž rst compre-
hensive physical examination by cardiologist Dr. Howard Bruenn).
67 See BUMGARNER, supra note 15, at 213 (“Bruenn, from his examination and report, viewed the President

as a desperately ill man.”).

 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 533

from Roosevelt and his family, and Bruenn complied out of a sense of duty.68
Instead, McIntire reported to the press that the President had “a moderate
degree of arteriosclerosis , although no more than normal for a man his age.”69
A second con ict of interest regards the prestige associated with the
position of White House Physician. White House Physicians serve a delicate
dual obligation when it comes to the President’s health, as they bear respon-
sibility not only to the President, but also to a public counting on neutral
evaluations of the President’s health. Yet the White House Physician’s place
within the inner circle is one that few people can claim. The White House
Physician is a nationally recognized medical Ž gure, receives an ofŽ ce in the
White House, and close access to the President. Some even hope to affect
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national policy matters. Former President George H.W. Bush’s White House
Physician, Dr. Burton J. Lee III, noted when he was appointed that the “time
has come for me to try to move on some of these issues [health care Ž nanc-
ing, medical research Ž nancing, and others] and see what I can do. I’m in an
unusual position because I have the ear of the President.”70 The potential for
being dismissed and losing such privileges makes for quite a con ict of inter-
est if a difference of opinion arises between the White House Physician and
the President regarding health management. Dr. McIntire, for one, guarded
jealously the prerogatives associated with his ofŽ ce and his close association
with President Roosevelt.71 As a result, when Roosevelt’s health began failing,
McIntire helped orchestrate a signiŽ cant portion of the medical cover-up.
A third con ict of interest arises because of the lack of professional dis-
tance between the White House Physician and the President. Since McKinley’s
time, Presidents have a long history of appointing long-time personal physi-
cians and trusted friends to the job. Dr. Grayson was so close to President
Wilson that he wrote a whole biography about him.72 That precedent has
persisted to the modern times—for example, Dr. Lee was an old acquain-
tance of former President Bush’s.73 The intimate relationship between the
White House Physician and the President erodes the professional detachment
normally requisite of a strong physician/patient relationship .74 Oftentimes,

68 See POST & ROBINS , supra note 58, at 30 (reporting that Dr. Bruenn’s “code of military discipline”
prevented him from breaking Dr. McIntire’s imposed silence).
69 BUMGARNER, supra note 15, at 215.
70 White House Physician Lee to Be Active in Health Policy, 81 J. NAT’L CANCER INST. 659, 659 (1989).
71 See BUMGARNER , supra note 15, at 212 (noting that McIntire was “jealous of his prerogatives”).
72
See generally CARY T. GRAYSON, WOODROW WILSON : AN INTIMATE MEMOIR 1 (1960) (“It was my privilege
to be in constant association with Mr. Wilson from March 3, 1913, the day before his inauguration,
until February, 3, 1924, the day of his death.”).
73 White House Physician, supra note 70, at 659 (reporting that Dr. Lee knew President Bush well and

had served on some of President Reagan’s health committees).

74 See Robert S. Robins & Henry Rothschild, Ethical Dilemmas of the President’s Physician, 7 POLITICS

& LIFE SCI. 1, 10 (1988) (“An intimate relationship with a patient inevitably decreases professional
distance.”).
 534 KESSELHEIM

this asymmetry adversely affects the patient—here, the President—because

the physician might avoid potentially embarrassing questions or treatment
options. 75
As a result of these con icts of interest, White House Physicians’ per-
sonal interests may not align with the national interest of the American people.
If the White House Physician feels beholden to the President for the prestige
of the job, or believes that orders of the Commander-in-Chief must be obeyed,
then it is unclear whether the public can trust that physician’s evaluation of
the President. History bears out these concerns, showing how these con icts
of interest deleteriously affect the medical care the President receives.
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2. Third Parties’ In uence on Medical Care

Another major hurdle that White House Physicians must navigate is the
presidential entourage of Cabinet members, chiefs of staff, the First Lady,
and other inner circle advisers. These people in uence the course of medi-
cal treatment because of the signiŽ cant social and political ramiŽ cations of
changes in presidential health. They have open access to the health care pro-
cess, can second-guess the diagnosis or treatment, and have even bullied the
White House Physician into endorsing claims about presidential health that
may not be accurate.76
These advisers can in uence recommendations regarding treatment and
determine whether consultation s will be called. Shortly after President
Wilson’s stroke, Dr. Grayson suggested that it would be in his best physi-
cal interest—not to mention the country’s interest—to resign, but the First
Lady refused to agree with that plan.77 She concluded that it would be better
for his psychologica l health to remain President and keep the trappings of the
ofŽ ce.78 As another example, in the wake of President Reagan’s assassinatio n
attempt, presidentia l physician Dr. Daniel Ruge met with the White House
political liaison to review the plan for managing and disseminatin g informa-
tion about Reagan’s condition.79 Throughout the nearly six months of recov-
ery time that followed Reagan’s shooting, to the deteriment of prudence and

75 See Wiegele, supra note 10, at 81 (noting that “White House medical arrangements probably violate
this fundamenta l patient-physicia n relationship”).
76 See Robins & Rothschild, supra note 74, at 7-8 (describing how the great in uence of the people around

the President can in uence medical judgment).

77
See Link, supra note 11, at 590-91 (noting that the First Lady “was much opposed to the idea of her
husband’s resignation”).
78
See C. Knight Aldrich, Memory, Information and Denial in Public Life, in PAPERS OF PRESIDENTIAL
DISABILITY AND THE TWENTY-FIFTH AMENDMENT 83, 95 (Kenneth W. Thompson ed. 1988) (noting that
Dr. Grayson believed that “the president’s health requires the continued challenge of ofŽ ce”).
79 See GILBERT, supra note 21, at 223 (describing the planning sessions concerning dissemination of

information that occurred between the physicians and the President’s advisers after Reagan Ž nished in
surgery and was transferred to the recovery room).
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 535

safety, no outside medical consultants were brought in to evaluate Reagan’s

condition. 80
One root of this problem may be that the White House Physician is a
bureaucratic appointee, often selected from among the President’s social con-
nections. Because the White House Physician is not, for example, the most
talented physician in the country, and does not have the stamp of approval
of the Congress, the physician will unquestionabl y rank below other close
advisers, and so will have less of a say in the President’s medical decision-
making. In addition, a shroud of national security vests all health reports. This
can signiŽ cantly impact the delivery of health care, because the White House
Physician may not have access to all information, may not be able to speak
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freely with the President, and may have to Ž lter recommendations through
layers of executive bureaucracy. In President Roosevelt’s case, the F.B.I.
even got involved. When White House Press Secretary Steven Early became
concerned as the 1944 election approached that the press’s medical reports
were too accurate, he enlisted F.B.I. Chief J. Edgar Hoover to investigate the
source of the perceived leaks.81
Practicing medicine in such a group environment interferes with the
physician/patient relationship between the White House Physician and the
President. Truly, this is medicine performed by collaboration between polit-
ical advisers and medical professionals.82 Not only does the White House
Physician’s voice offer only one of a number of opinions regarding the
President’s well-being, it is a voice that tends to be less signiŽ cant. As a
result, medically appropriate intervention s the White House Physician may
desire may not be undertaken for political or other reasons, and the White
House Physician has little recourse if the recommendations are rebuffed. As
commentator George Annas noted, the reality of the situation is that “[i]t is
not up to the White House Physician to determine whether a certain con-
dition makes the President unable to discharge his duties. If the Cabinet or
President’s staff believes the President can, who is the doctor to disagree?”83

II. THE ROLE OF THE TWENTY-FIFTH

AMENDMENT
To address some of the worries surrounding presidentia l disability, the
Twenty-Fifth Amendment was passed and then ratiŽ ed in 1969. This section
examines the political atmosphere leading up to the passage of the amendment,

80 See id. at 228 (“Medical access to Reagan remained tightly controlled and limited.”).
81 See FERRELL, supra note 26, at 46 (noting that the F.B.I. was put on the case when detailed stories about
Roosevelt’s ill-health began to appear in the press).
82 See Wiegele, supra note 10, at 73 (describing presidential physicians’ lack of autonomy).
83 George J. Annas, The Health of the Presidents and Presidential Candidates, 333 NEW ENG . J. MED.

945, 947 (1995).

 536 KESSELHEIM

the procedures promulgated in the amendment, and whether those procedures

can effectively address the failings of the medical care of the President enu-
merated in section I.
A. Enacting the Twenty-Fifth Amendment
The original Constitutiona l provision dealing with presidential disability
allowed Presidents to be removed from ofŽ ce if they showed an “Inability to
discharge the Powers and Duties” of the ofŽ ce.84 Yet no one further deŽ ned
“inability.” One prescient Senator, John Dickinson of Delaware, asked: “What
is the extent of the term : : : and who is to be the judge of it?”85 There is no
record of any ofŽ cial response from the Framers. Several reasons may account
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for this void, including the fact that extended disability was unknown in the
colonial world because of the relatively poor state of medical science and the
fact that the members of the Constitutiona l Convention did not anticipate that
Presidents would be the central governmental Ž gures as they have become
today.86
Over 150 years later, however, Congress began to Ž ll the void. In 1955,
on the heels of President Eisenhower’s myocardial infarction, a House Judi-
ciary Committee under the lead of New York Congressman Emanuel Celler
addressed the question of who determines presidential inability.87 The com-
mittee held hearings, distributed questionnaires , heard reports from scholars,
and debated a number of alternative arrangements for determining presidential
disability.88 Although no legislation emerged from these early hearings, they
had substantive impact, as in 1958, when President Eisenhower and Vice-
President Richard Nixon institute d the Ž rst informal agreement between a
President and a Vice-President regarding evaluation of presidential health in
times of crisis and then made the agreement available to the public.89
In the early 1960s, more congressiona l hearings attempted to construct
legislation on the issue of clarifying the constitutiona l term “inability.”90
Congress Ž rst concluded that disability decision-makin g was best centralized
within the executive branch, among the Vice-President and Cabinet members,
because it was efŽ cient, reduced the possibilit y of political plays by Congress,

84 U.S. CONST. art. II, x 1.

85 Birch Bayh, The Twenty-Fifth Amendment: Dealing with Presidential Disability, 30 WAKE FOREST L.
REV. 437, 440 (1995).
86 See MAC MAHON & CURRY, supra note 2, at 15-16 (noting that “it was hard to imagine a President being

disabled” during the late 1700s).

87
See John D. Feerick, The Twenty-Fifth Amendment: An Explanation and Defense, 30 WAKE FOREST L.
REV. 481, 489 (1995) (describing the legislative history of the Twenty-Fifth Amendment).
88 See Calvin Bellamy, Presidential Disability: The Twenty-Fifth Amendment Still an Untried Tool, 9 B.U.

PUB. INT’L L.J. 373, 378 (2000) (describing the procedures of the Celler committee).
89 See Feerick, supra note 87, at 492 (remarking that the Eisenhower/Nixon agreement was the “Ž rst

signiŽ cant attempt : : : at meeting the inability problem”).

90 See Park, supra note 18, at 54 (describing the character of the pre-Twenty-Fifth Amendment hearings).
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 537

and allowed the decision to be made by people accountable to the public.91

Congress rejected, for example, a proposal whereby the Vice-President in-
formed the Chief Justice of the Supreme Court of suspected inability, who
then appointed a civilian panel to evaluate the President, because such a panel
lacked public accountability and involving the Supreme Court imposed a non-
judicial role on the Court and violated the principle of separation of powers.92
Congress also considered the role medical professionals should play in
monitoring presidential health. Congress ultimately rejected ofŽ cially em-
paneling physicians in this role, because it would prevent immediate action
in the case of an emergency, and because legally forcing the President to have
a physical exam represented an “affront” to his personal dignity.93 Notably,
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in making these determinations , Congress did not consider the point of view
of medical professionals —the hearings did not include testimony from orga-
nized medicine or anyone skilled in the determination of disability.94 In the
end, the blueprint for a constitutiona l amendment emerged, setting down a
framework for mediating disagreement over the health status of the President
and whether the President can continue to discharge the responsibilitie s of the
ofŽ ce.
B. The Parameters of the Twenty-Fifth Amendment
In 1967, after more than 10 years of discussions , the states ratiŽ ed the
Twenty-Fifth Amendment. It addressed presidentia l disability in two different
sections.
Section 3 allows Presidents to anticipate their inabilities . It authorizes the
President to submit to the heads of Congress a “written declaration that he can-
not discharge the powers and duties of his ofŽ ce” and thereby transmit power
to the Vice-President for a period of time “until he transmits : : : a written dec-
laration to the contrary.”95 For example, this provision for a voluntary transfer
of power conceivably could be invoked when a President undergoes elective
surgery involving a number of hours of general anesthesia and post-anesthesi a
recovery, as President Reagan did in 1985. In July of 2002, President George
W. Bush invoked this section prior to undergoing a routine colonoscopy.
Section 4, on the other hand, allows for transfers of power when Pres-
idents, for any reason, cannot predict or confront their disability. In these

91 See Katy J. Harringer, Who Should Decide? Constitutional and Political Issues Regarding Section 4
of the Twenty-Fifth Amendment, 30 WAKE FOREST L. REV. 563, 566 (1995) (arguing that members of
the executive branch are more directly accountabl e than “members of Congress, the Supreme Court,
or private sector medical experts”).
92 See id. at 580 (describing the effect of the separation of powers doctrine).
93 See Feerick, supra note 87, at 499 (quoting Attorney General Rogers).
94 See Park, supra note 18, at 54 (noting that “a review of the lengthy transcripts : : : fails to uncover any

meaningful testimony either from organized medicine or individual physicians skilled in the determi-
nation of disability”).
95 U.S. CONST . amend. XXV, 3.
x
 538 KESSELHEIM

cases, the amendment initiates a multistep procedure that can lead to the ul-
timate removal of a disabled President from ofŽ ce. First, the Vice-President
along with a majority of the Cabinet or “such other body as Congress may
by law provide”96 must announce that the President cannot fulŽ ll the powers
and duties of the ofŽ ce, at which point the Vice-President becomes President.
Presidents who afterwards declare that they are not disabled can resume their
duties, unless the Vice-President and the Cabinet—or the “other body” in
place of the Cabinet—disagree, at which point the matter moves to Congress
for an ofŽ cial vote. In this way, for example, a President who suffers a sudden
massive debilitatin g stroke, like President Wilson, or who is the target of an
assassinatio n attempt and remains on a respirator can be ofŽ cially replaced
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under the Constitution .

Numerous principles help justify the terms of the Twenty-Fifth
Amendment. The basic approach of Ž rst trying to resolve questions of dis-
ability within the executive branch—the President with a personal declaration
or by the Vice-President and Cabinet members—is a strict functionalis t read-
ing of the separation of powers doctrine.97 Only after unremitting disagree-
ment exists within the executive branch does congressional analysis enter
the process.98 As such, the amendment strives to protect the President from
forces outside the executive branch that would use the President’s health sta-
tus for political goals.99 In the wake of the Monica Lewinsky scandal, it is
not far-fetched to envision a hostile Congress attempting to play up a minor
presidential disability to usurp the President’s authority. Finally, the amend-
ment guarantees that the decision made will be a political one, not a medical
one. Although the amendment framers expected the acquisition of medical
advice, from the White House Physician or some independent source,100 no
part of the process explicitly invokes medical consultatio n or guarantees that
medical information will be part of the ultimate decision-makin g process.101

C. Shortcomings of the Twenty-Fifth Amendment

The Twenty-Fifth Amendment is the most signiŽ cant piece of legislation
addressing presidential disability. But how well do its precepts resolve the

96
Id. x 4.
97 See Harringer, supra note 91, at 570 (describing the interplay between the branches of government and
its effect on the political process).
98
See Bellamy, supra note 88, at 398 (“[C]ongressiona l involvemen t is triggered only after a referral from
the Executive Branch.”).
99 See Feerick, supra note 87, at 502 (promoting the idea of stability during the time of succession).
100 See id. at 499 (“[V]irtually every proposal submitted for congressional consideration expected that the

body determining presidential inability would seek and obtain independent medical advice.”).
101 See Paul B. Stephan III, History, Backgroun d and Outstanding Problems of the Twenty-Fifth Amendment,

in DISABILITY PAPERS, supra note 78, at 63, 80 (“There is no body of understanding, custom, nor process
in place to guarantee that medical information will be part of the ultimate decision-making process.”).
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 539

difŽ culty of presidential health care that has led to problems ranging from
those of President Wilson to those of President Reagan?
A number of facets of the Twenty-Fifth Amendment make it unsuited
to addressing the deception, secrecy, and incompetence that historically has
marked presidentia l health care. First, the amendment’s process is entirely
permissive, in that no single event automatically invokes its protections. As
a result, the power to initiate it remains within the executive branch, and
speciŽ cally under control of the people most beholden to the President.102 So,
for example, the Twenty-Fifth Amendment was not invoked during President
Reagan’s recovery from his assassinatio n attempt, nor was it invoked before
his 1985 colon surgery.103 Neither he nor his advisers decided to utilize it and
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Vice-President Bush maintained a deferential posture, not wanting to appear

power hungry or reduce American conŽ dence in President Reagan.104 For
similar reasons—a deferential Vice-President Marshall and an inner circle
committed to keeping the President in power—it is not hard to imagine the
Twenty-Fifth Amendment being ignored had it been in place at the time of
President Wilson’s debilitatin g stroke.105 Those same people who must initiate
the Twenty-Fifth Amendment procedure are those whose power it most likely
affects, and so, as with President Reagan, it is likely to remain unused.
Second, while section four of the Twenty-Fifth Amendment contem-
plates a decision by the Vice-President that the President cannot fulŽ ll the
duties of the ofŽ ce, and then potentially a congressional vote on the same
question, nowhere does it make medical evaluation a requirement of the pro-
cess. In the past, the White House Physician has shouldered most disability
determinations . In the past, however, some presidential physicians have been
unqualiŽ ed while others have been complicit with the President in hiding dis-
abilities. As indicated in section I, White House Physicians are often picked
for political or personal reasons, rather than based on their qualiŽ cations, and
many times come from the armed forces, which look upon the President as
their Commander-in-Chief. Still, the amendment does not require looking be-
yond the walls of the White House for a neutral physician’s examination, nor
does it explicitly require that the opinion of any physician be factored into
Ž nal disability decision-making .
More fundamentally, the Twenty-Fifth Amendment does not address the
underlying problem of the medical care that leads up to the point of disability.
In the years preceding a crisis of disability, the medical care delivered to
the President can be subpar. If President Roosevelt’s hypertension had been
better controlled, then he may have functioned at a higher capacity during

102
See Bellamy, supra note 88, at 398 (noting the “iron[y]” of this state of affairs).
103 See Bayh, supra note 85, at 442 (describing the failures to apply the Twenty-Fifth Amendment).
104 See Abrams, supra note 64, at 460 (arguing that “Ronald Reagan could not possibly have made critical

decisions at the time”).

105 See Link, supra note 11, at 592 (noting that the Vice-President was a “passive person”).
 540 KESSELHEIM

his Ž nal year in ofŽ ce.106 After President Reagan’s assassination attempt, the
issue was not whether he would survive, but when he was functional enough
to resume the activities of ofŽ ce. Would Vice-President Bush have been in
a better position to make some of the important post-assassinatio n attempt
decisions? The Twenty-Fifth Amendment is designed for acute incapacity,
not chronic, insidiousl y developing conditions .107
D. Addressing Presidential Disability Within the Scope
of the Twenty-Fifth Amendment
Some have argued that concerns about the decision-makin g of the White
House Physician can be addressed with directed legislation under section 4
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of the Twenty-Fifth Amendment. As indicated above, section 4 says that

Congress may “by law” provide for an “other body” to assist the Vice-
President in making decisions regarding presidential disability. Some com-
mentators have suggested legislativel y creating an “other body” consisting of
a blue-ribbon panel of physicians108 —including, inter alia, a world-renowned
neurologist and a world-renowned internist—or a more politically neutral
combination of medical and governmental actors. This expert disability panel
could evaluate the physical or mental Ž tness of the President and proffer an
independent judgment on the issue. The disability determination would be
more trustworthy and medically sound than if made solely by those within
the President’s inner circle of advisers.
Yet this solution is inadequate. The legislative history of the amend-
ment indicates that its authors speciŽ cally rejected involving such physician
panels in the disability determination.109 The framers then constructed the
amendment in such a fashion that, even if Congress did create such a body,
it would largely be ineffectual, because it is still constitutionall y mandated
that the Vice-President must initiate the Twenty-Fifth Amendment process
and, as indicated in section I, Vice-Presidents historically have not stepped
forward in times of presidentia l disability for political reasons. In addition,
practically speaking, implementing such an “other body” may be impossible.
For example, nonpartisanship , especially at such high levels of government,
is illusory. Even if both political parties appointed physicians to the panel,
that may engender split votes on disability decisions, which would not inspire

106 See Robert E. Gilbert, Disability, Illness and the Presidency: The Case of Franklin D. Roosevelt, 7
POLITICS & LIFE SCI. 33, 40-42 (1988) (describing the medical care of President Roosevelt’s last year in
ofŽ ce).
107 See Aldrich, supra note 78, at 94 (noting that “conditions not acknowledged by the president” are

perhaps of greatest concern).

108
See Bert E. Park, Protecting the National Interest: A Strategy for Assessing Presidential Impairment
Within the Context of the Twenty-Fifth Amendment, 30 WAKE FOREST L. REV. 593 (1995) (supporting
the idea of a body of expert physicians to examine the President and monitor his health).
109 See Bayh, supra note 85, at 444 (noting that the drafters considered that the disability determination

involves ramiŽ cations beyond typical medical diagnosis).

 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 541

any conŽ dence.110 Medical opinion can be divided even on the facts, as the
so-called “objective Ž ndings” of a physical exam are not guaranteed to pro-
duce solid answers.111 Moreover, conceptually, it is unlikely that developing
expertise in medical disability would help a lay physician understand the
complex environment in which the President works and thus be able to judge
whether a President can remain in ofŽ ce.112
In the Ž nal analysis, the Twenty-Fifth Amendment serves a number
of useful purposes. It protects the President by making it difŽ cult to oust
him with specious claims of inability.113 The process is efŽ cient and ensures
that people in the executive branch who are most aware of the President’s
condition make the initial disability determinations. This prevents political
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maneuvering from other branches of the government. Most importantly, it

provides the government with a stable, constitutiona l process to call on in
times of true, severe presidential disability. The amendment, however, does
not resolve many of the historical failures regarding presidentia l health and the
management of presidentia l disability, and the effort to address these concerns
via the “other body” language likely is inadequate. Section III examines a
number of alternative mechanisms that can be employed instead.

III. UNTANGLING THE PROBLEM OF PRESIDENTIAL

HEALTH CARE
Short of changing or adding to the Twenty-Fifth Amendment—and re-
quiring the full constitutiona l ratiŽ cation process—a number of steps can be
taken that may help better manage the President’s health and provide stability
in the American governmental system in times of presidential disability. Many
of these options involve a more formalized process for medical evaluation of
Presidents, whether or not the physicians evaluating them ultimately have the
Ž nal disability determination.
In analyzing these options, we must keep in mind the almost paradoxical
nature of the President as patient. On one hand, the President is the leader
of the most powerful country in the world, but that power does not deprive
him or her of the basic privacy rights that all people should expect when
receiving medical care. If we make the medical examination of Presidents
too open and intrusive , then the natural reaction will be for them to withhold

110
See id. at 447 (discussing the ramiŽ cations of split votes by the “other body”).
111 See Harringer, supra note 91, at 582 (noting that, in medical malpractice cases, it is commonplac e for
“experts” to testify to opposite conclusions).
112 See Bayh, supra note 85, at 447 (noting that physicians would not have access to the intimate environ-

ment where the President works).

113 See Birch E. Bayh Jr., The Twenty-Fifth Amendment: Its History and Meaning, in DISABILITY PAPERS,

supra note 78, at 1, 11 (describing the drafters’ strong concern about a “palace coup” during times of
crises in presidential health).
 542 KESSELHEIM

their complaints and concerns from the medical establishment, which is just
as dangerous for society. In fashioning a solution, we should try to balance
the public right to be assured that the President (and the country ) are being
properly evaluated and treated with the President’s personal dignity.
A. An Independent Panel of Physicians
A Ž rst option, proposed by such commentators as Bert Park and Herbert
Abrams, would be to create an independent panel of physicians outside the
framework of the Twenty-Fifth Amendment.114 This panel would be composed
of physicians from a range of specialties, who were chosen for limited terms
before each new administration . The physicians would be called upon during
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a potential disability crisis to “impartially gather medical facts needed to assist

the Vice-President in making an informed decision,” but would have no ofŽ -
cial vote or function in the decision-makin g process.115 The group would also
periodically, perhaps yearly, evaluate the health of the President to gather
baseline information about functional status and detect subtle changes in
health. 116
This solution has a number of favorable features.117 An informed, neutral
medical evaluation of the President during times of disability may help combat
the White House Physician’s potential con icts of interest. Submitting the
results to the Vice-President and Cabinet for analysis removes the physicians
from any Ž nal political decision-making . The experts’ independence helps
the American people feel more conŽ dent in the ultimate response from the
executive branch than they would be if the members of the President’s inner
circle were the only ones with full access.
Concerns remain, however, about the potential breach of conŽ dentiality
and affront to personal dignity involved in subjecting Presidents to examina-
tion by physicians not of their own choosing.118 Also, it may be hard, if not
impossible, to organize a group of physicians to decide when the President’s
judgment is impaired because, for example, the President’s mental status may

114 See Park, supra note 108, at 596 (proposing a panel of medical consultants to safeguard the national
interest and provide the American public with a second opinion on presidential health). See also Abrams,
supra note 64, at 464 (proposing a “Commission on the Health of the President” to assure the public
of objective assessment and accurate reports concerning presidential health).
115 See Park, supra note 108, at 596.
116 See Park, supra note 18, at 57 (suggesting that a yearly physical before this body be mandatory and

that the Ž ndings be reported to the Vice-President).

117
In fact, former President Jimmy Carter has lent his voice in support of a team-based approach to assist
in the President’s care and determine objectively physical or mental impairment that might lead to a
subsequen t consideration of disability. See Park, supra note 108, at 605 (reporting President Carter’s
positive reaction to his proposal).
118 But see Abrams, supra note 64, at 467-68 (arguing that neither conŽ dentiality nor the physician/patient

relationship is absolute—in general practice, medicine by committee is the rule, not the exception—and
the President must expect to give up some amount of personal rights to help increase the conŽ dence
the electorate has in him).
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 543

fade in and out and physicians have a notoriously difŽ cult time agreeing in
general about many aspects of medical science.119 If the panel cannot emerge
with a single recommendation, then a divided panel will be of little use to
the Vice-President, and may even diminish the public’s conŽ dence. Finally,
selecting the members of the panel could involve the open examination of cre-
dentials and interviews before Congress, or even Secret Service background
checks. Many physicians may not want to disclose so much of their private
lives. 120
B. Uplifting the OfŽ ce of the White House Physician
As indicated in section I, White House Physicians have traditionall y
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Ž lled an ill-deŽ ned role within the President’s inner circle. The White House
Physician holds a government-funde d position, with an ofŽ ce in the White
House, and is responsible for the day-to-day medical care of the President.
Yet the White House Physician historically has been chosen by the President
for personal ties or political reasons, rather than for medical experience or
expertise. One solution, then, could involve raising the stature of this position
to that of other high-level executive ofŽ cials, who go through a presidential-
nomination and Senate-conŽ rmation process.121 This would involve far less
legislative wrangling than the creation of an expert medical panel, but still
would address some of the basic problems.
First, formalizing the ofŽ ce of the White House Physician would allow
Presidents to initially select their personal physician. At the same time, such
a process would ensure that the prospective physician is qualiŽ ed for the job,
unlike, for example, President Roosevelt’s Dr. McIntire. It also would remove
the White House Physician, if he or she is drawn from the military, from the
role of subordinate to the Commander-in-Chief. More signiŽ cantly, the White
House Physician would be invested with political clout and a more indepen-
dent voice within the President’s inner circle. As a separate consideration , if
congressional committees have questions about the President’s health, then
they can summon the White House Physician, who, as a federal ofŽ cial, would
be under greater duty to provide reliable information.122
Undertaking such a step, however, would raise concerns from a more
personal point of view. Such a process may drive a wedge between Presidents
and their personal physicians, whom they would no longer see as physicians,

119
See Stephan, supra note 101, at 76 (predicting chaos regarding organizing physicians to perform a
mental disability examination of the President).
120 See Harringer, supra note 91, at 582 (noting the remote chance that such a panel would be employed

argues against many physicians wanting to put themselves through such a process).
121
See id. at 567 (arguing that to subject the White House Physician to Senate conŽ rmation would help
check against an overly personal relationship).
122 See MAC MAHON & C URRY, supra note 2, at 170 (arguing for the formalization of the White House

Physician in law).
 544 KESSELHEIM

but as Cabinet members or, even worse, arms of Congress. This may lead them
to conŽ de less in their physicians and instead hide any troubling symptoms
that may be key to treating potential problems, like cancer. This solution also
leaves unresolved the concern that the President, during a crisis of disability,
would not receive a second, independent opinion apart from those within the
inner circle.
C. Formal Disability Guidelines or Agreements
Perhaps the least radical change to the current system of medical man-
agement of the President, but one that may still help secure a proper response
during a crisis of presidential health, would be to formalize the procedures
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already in place. Modern Presidents and Vice-Presidents make contingency

plans for theoretical crises of presidentia l disability, but these plans are con-
sidered top secret.123 Given the plentiful history of presidential disability and
the numerous efforts to mislead the public, however, Congress could mandate
making these plans available for public consumption . Congress also could set
down the content and require that the plans cover general events that would
necessitate a Twenty-Fifth Amendment section 3 voluntary transfer of power,
the types of physical or mental changes that would suggest the need for a
section 4 involuntar y transfer, and the form of professional medical assis-
tance that must be sought to help make these decisions.124 It could simply be
required that the executive branch publish the plans. Alternatively, each newly
elected administratio n could be mandated to consult with outside health, po-
litical, and security experts before each inauguration to set up the guidelines.
Simply publicizing these plans might inspire more public conŽ dence
in the handling of presidential health, both on a day-to-day level and during
crises. These blueprints could be made  exible enough to allow the personal
health and security preferences of the President to be honored while, at the
same time, providing the public with security that a widely known, expert-
approved plan is in place for times of presidential disability.
Although this solution may be the most politically viable, it is also the
least radical and most preserves the status quo. Standards and guidelines are
notoriousl y malleable during the course of crises, especially if presidential
health, as it has been in the past, continues to be marked with secrecy and
deceptive practives on the part of the President’s inner circle of medical and

123
See Christopher Mario, Volunteers Draw Road Map for Decisions on Presidential Disability,
126 ANNALS INTERNAL MED. (Mar. 15, 1997), available at http://www.acponline.org/journals/annals/
15mar97/currmap.htm (noting that the Clinton/Gore and Bush/Quayle plans were kept conŽ dential).
124 See MILLER CENTER , supra note 7 (promulgating establishment of 3 and 4 guidelines as the centerpiece
x x
of an effort to uplift presidential disability managemen t). The Working Group on Disability in U.S.
Presidents supported the development of “formal contingency plans pre-inauguratio n for voluntary or
involuntary transfers of power” but did not emphasize publicizing them or involving outside experts in
their creation. WORKING GROUP, supra note 8.
 PRESIDENTIAL HEALTH AND THE WHITE HOUSE PHYSICIAN 545

political advisers. Although the quality of the guidelines may be establishe d

through use of expert analysis, the execution of such guidelines by medically
incompetent or untrained personnel cannot be guaranteed.

CONCLUSION
Despite numerous episodes of presidential disability over the course
of more than 200 years, America has been fortunate that the failing health
of a President has not thrown the country into a constitutiona l crisis. The
Twenty-Fifth Amendment helped provide some structure to the determination
of presidential disability, but historical analyses and experiences since its
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ratiŽ cation indicate that still more reforms are needed. Yet continuing to work
under the rubric of the Twenty-Fifth Amendment does not appear efŽ cacious.
Rather, instead of taking part directly in the constitutiona l debates, the best role
for medical experts may be merely in informing the political decision-makers.
Institutin g an expert board of physicians for the President, uplifting the
role of the White House Physician, or setting down blueprints for public dis-
ability contingency plans are but a few viable alternatives to help ensure public
conŽ dence that presidential health during times of crisis will be handled prop-
erly from political and medical points of view. The difŽ culty implementing
such procedures is the unique role that Presidents of the United States play as
medical patients who demand personal dignity and privacy in their medical
discussion s while, at the same time, attracting signiŽ cant scrutiny as the pre-
eminent public Ž gures in America. Yet history makes clear that, because of the
potential for abuse, some effort must be taken to balance those interests and
emerge with a coherent plan for handling presidentia l disability. From Presi-
dent Josiah Bartlett to President George W. Bush, before a true crisis emerges,
the proper management of presidential health needs to be addressed.