E47: A Very Important Patient / Art Caplan, George Annas, Joel Goldstein

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“What could be more political [than] the determination of whether the president can fulfill the powers and duties of his office.” —Prof. George Annas

Earlier this month, President Trump announced that he was COVID-positive and was hospitalized for treatment. Since then, a flurry of questions has been raised about his health, and his ability to lead moving forward. Though COVID is new, this is not the first time a president has been seriously ill while serving in office. On today’s episode of EPIDEMIC, we look to history to see how past presidents have handled their health while in office, and what impacts that had on government and politics.

“What we’re really after is not a medical condition that a doctor can make a judgment on, but, whether they’re able or not to discharge the powers and duties of the presidency.”

Celine Gounder: Welcome back to EPIDEMIC, the podcast about the science, public health, and social impacts of the coronavirus pandemic. I’m your host, Dr. Celine Gounder.

Celine Gounder: On Friday, October 2nd, the United States woke up to startling news.

Celine Gounder: President Trump was flown to Walter Reed National Medical Center in Bethesda, Maryland. He stayed there three nights. A small army of doctors oversaw his care, including an experimental treatment.Millions of Americans have been infected with the coronavirus this year… but things are different when you’re President.

Art Caplan: Presidents of the United States are off in their own zone of crazy when it comes to VIP care because people just lose it when a president shows up.

Celine Gounder: And… if something were to take a turn for the worse, questions would arise about who’s really in control.

Joel Goldstein: I don’t think that most American people thought very seriously about it, um, having a president hospitalized and on experimental medications.

Celine Gounder: It could even be seen as a national security threat.

George Annas: They were told it is a matter of national security, and you will go to jail for the rest of your life if you disclose this.

Celine Gounder: Donald Trump is not the first American President to find himself in the hospital. And with an election just weeks away… with the oldest candidates to ever run for President on the ballot… in the middle of a pandemic…well, let’s just say there are a lot of questions about the health of our leaders right now. But we’re going to take a step back from the news… to see how past presidents have handled their health while in office. We’ll find out why being a VIP in the hospital might lead to worse outcomes. And we’ll see how past health crises in the presidency have shaped the mechanisms that keep the government operating, even in the direst of moments. Today on EPIDEMIC… COVID-19 and a very important patient.

Celine Gounder: On October 3rd, White House physician Dr. Sean Conley walked out of Walter Reed Medical Center with a line of physicians behind him. He told the press…

Conley: This morning, the President is doing very well.

Celine Gounder: But soon after the press conference, White House Chief of Staff Mark Meadows told reporters the President’s condition was more serious than his doctors had let on.

George Annas: Well, historically, presidents have not been very happy to share with the public any information that makes them look compromised in any way.

Celine Gounder: This is Geoge Annas. He’s the director of the Center for Health Law, Ethics, and Human Rights at the Boston University School of Public Health.

George Annas: Probably the most well-known example is Franklin Delano Roosevelt, who, because of polio couldn’t walk, but the press was not permitted to photograph him in a wheelchair.  He thought it made him look non-presidential.

Celine Gounder: But FDR’s health concerns were more serious than using a wheelchair.

George Annas: When he ran for office the fourth time, which no other person has ever done, he had a very, very serious heart condition and his doctors did not believe he would survive a fourth term.

Celine Gounder: FDR ordered his physicians not to tell anyone.

George Annas: And beyond being ordered not to tell, they were told it is a matter of national security, and you will go to jail for the rest of your life if you disclosed this. And, even though I’m very skeptical of things like that, it was right at the end of World War II, and I think you could make the argument it was a matter of national security that the US troops in the field would have done worse if they knew how, how sick president Roosevelt was.

Celine Gounder: FDR won re-election, and took the oath of office in January 1945. He died four months later. Presidential physicians have to balance the health of their patients with the political realities of the office. Dr. Conley later acknowledged that he had not been upfront about President Trump’s experience with COVID during that October 3rd press conference because he wanted to present an “upbeat attitude.”

Other presidential physicians have been in similar situations. When President James Garfield was shot in 1881, his physician lied about the severity of the president’s wounds. He said that Garfield was well and would recover soon. Garfield died six weeks later. President Grover Cleveland had secret surgery on a yachtto remove a cancerous lesion from his mouth. He swore his doctors to secrecy. He thought news of his surgery would encourage an attack on the United States.But presidential physicians also make life-saving decisions, like Ronald Reagan’s physician, Dr. Daniel Ruge. In 1981, President Reagan was leaving a speaking engagement in Washington, D.C. when he was shot walking to his limousine.

Advise, we’ve had shots fired. Shots fired. There are some injuries, uh, lay one on.” 

Celine Gounder: The bullet ricocheted off President Reagan’s limousine and caused serious internal bleeding.

Roger. We want to go to the emergency room of George Washington.” 

Celine Gounder: Dr. Ruge could have personally taken over the president’s care. He could have insisted on famous surgeons coming to the ER to remove the bullet from Reagan’s body. But he didn’t. He stepped back and let the hospital’s team do their job.Many said that decision to not get involved…to not do anything special — for the President of the United States of all people! — may have saved Reagan’s life.

President Reagan was back at the White House twelve days later. He made a full recovery. Dr. Ruge saved Reagan from something called VIP syndrome.

Art Caplan: So what we’re talking about with VIP syndrome is the special treatment, breaking from routine care, breaking from what you usually do, because it’s a very important person.

Celine Gounder: This is Art Caplan. He’s the head of the Division of Medical Ethics at the NYU Grossman School of Medicine.

Art Caplan: When you break routine, you’re introducing the possibility of error in ways that wouldn’t happen if you followed your tried and true procedures to someone who presented with a health problem.

Celine Gounder: Art says there’re a lot of things that lead to this. The staff might be starstruck and get distracted from the task at hand. They might be nervous something will go wrong, and they’ll be blamed for killing a president or someone famous. Or the VIP might demand special treatment that results in suboptimal care. Before Art started working at NYU, he was at another hospital when a VIP from the Middle East arrived for a kidney transplant.

Art Caplan: And he came with a whole entourage. He must have brought thirty-five people with him, and they took up an entire floor of the hospital, private wing, his security people are everywhere.

Celine Gounder: He had special food, special sheets; the red carpet was rolled out. The hospital’s doctors met with the leader and explained the procedure and the team who would perform the operation.

Art Caplan: And he says, no, no, no, no. I want the department chairperson to do it because he’s the most famous person and that’s what I want. People are rolling their eyes. Cause he hasn’t really done that kind of transplant surgery in years. He’s been the department chair, doing budgets, doing administration, fundraising… whatever, but not doing kidney transplants anymore.

Celine Gounder: This is the other end of VIP syndrome… when the patient demands that the most famous doctor provide care, instead of the bestdoctor. The staff knew this was a bad idea. So they came up with a plan. They called down the department chair.

Art Caplan: They brought him down, and he scrubbed in, and he was omnipresent as they prepared to do the kidney donation and the kidney transplant surgery. But as soon as the guy was under anesthesia, he stepped back, got out of the way. They had the regular best team, uh, do the work. And then when he woke up, he was there again.

Celine Gounder: Basically, they tricked the VIP into getting the best medical care.

Celine Gounder: Art says ethically — and oftentimes practically — it’s better to treat patients the same. Remember Reagan’s care when he was shot? But that doesn’t always happen… especially when we’re talking about a President.

Art Caplan: The President gets whatever he needs whenever he needs it. When the President asks for a polyclonal antibodies for early use, his doctor somehow agreed that that would be a good thing to give him, even though it wasn’t an approved drug, no company is going to say no when the President, uh, his doctor is asking for that.

Celine Gounder: While President Trump was at Walter Reed, his COVID carewas hardly routine. He was given the antiviral remdesivir, a monoclonal antibody cocktail from Regeneron, and the steroid dexamethasone. A highly experimental combo. Remdesivir and monoclonal antibodies are thought most likely to work best early in the course of infection… while dexamethasone is typically used later, when patients have severe COVID disease. The monoclonal antibody therapy hasn’t even been approved for emergency use. And just this week, an Eli Lily trial of its monoclonal antibody… in combination with remdesivir… a combo similar to what the President received… was paused due to safety concerns.

Fortunately, President Trump seems to be on the mend. But what happens if a sitting president didn’t fare as well as he has? What if a severe COVID infection were to force a president onto a ventilator, or worse? After the break, we’ll talk to constitutional scholars about the mechanism that keeps the government running in these situations: the 25th Amendment.

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OK, back to the show.

Celine Gounder: Joel Goldstein is a lawyer and scholar of the vice presidency and the 25th Amendment.

Joel Goldstein: The 25th Amendment was my senior thesis at Princeton in 1974-75. And I’ve been, uh, I’ve been studying it ever since.

Celine Gounder: The 25th Amendment deals with presidential power in the event that the President, for any reason, is unable to do the job. Even if it’s only for a few hours. You might not know this, but when the founders wrote the Constitution, they were pretty light on the details of the vice presidency.

Joel Goldstein: People don’t really think about the, the need for a vice president. The presidential inability problems were problems that once upon a time didn’t seem as serious.

Celine Gounder: It was clear that if the president died, the vice president would assume office, but the Constitution didn’t have clear rules about what to do if the president were alive but unable to do the job.

Joel Goldstein: There was also a lack of any procedures before the 25th amendment to indicate how a presidential inability should be determined and who should make that determination.

Celine Gounder: Remember when we talked about President Garfield getting shot? Well, that wasn’t just a PR problem for the White House. It created a serious problem of who was in charge. Garfield’s injuries were so bad, he physically couldn’t do the job of President. He signed only one official act in office. But the executive branch didn’t know what to do. And to make matters worse, President Garfield and his vice president, Chester A. Arthur, were political rivals, complicating any potential transfer of power.

Joel Goldstein: Ultimately the cabinet got to a point where it was going to go to President Garfield and suggest that power be transferred to Vice President Arthur and to advise him that that ran the risk that he might be permanently ousted. But before that conversation took place, President Garfield died and Vice President Arthur became, our 21st president.

Celine Gounder: The crisis with Garfield’s health resolved itself in the end. But in the 20th century, it became more urgent to figure out how a president would temporarily hand over power in an emergency.

Celine Gounder: It was the Cold War. The U.S. and the Soviet Union were pointing nuclear missiles at one another… and President Eisenhower had a bad heart.

Joel Goldstein: President Eisenhower had a heart attack in September of 1955 that [00:18:00] basically prevented him from  functioning as a full-time president, uh, until the beginning of, uh, 1956.

Celine Gounder: Later in 1956, Eisenhower had surgery for an intestinal blockage. In 1957, he had a stroke.

Joel Goldstein: So in 1958, President Eisenhower, who was really, I think to his credit was really very concerned about this issue, given the cold war and the atomic age. He entered into a letter agreement with vice president Nixon, that, in a way anticipated part of the 25th amendment, it provided that … If the president determined that he was disabled, that he would communicate that to Vice President Nixon, and Vice President Nixon would act as president. If the president was unable to make that determination himself for instance, if he was unconscious Vice President Nixon, after engaging in whatever consultation he deemed appropriate, would make the determination himself.

Celine Gounder: But this was a handshake agreement. There was no constitutional weight behind it.

Joel Goldstein: What really gave the 25th Amendment… really brought it to the final passage, um, was the Kennedy assassination on November 22, 1963.

Joel Goldstein: And not only did it raise the possibility of presidential succession, but it also raised the possibility of presidential inability, because some said that had President Kennedy been permanently disabled by the assassin’s bullet by the, by the shot to his brain. Rather than killed the, the situation would have been much more difficult constitutionally. And so there was a feeling that there was a need to adopt clear procedures.

The United States ratified the 25th Amendment in 1967. This ensures that the offices of the President and Vice President are always filled. The first three sections of the amendment are pretty straight forward. Section 1 says when the president dies, resigns, or is removed, the Vice President becomes President.

Section 2 says if there’s ever a vacancy in the Vice Presidency, the President can name a new Vice President to be confirmed by the House and Senate. And it didn’t take long before both these sections would be needed. In 1973,  Richard Nixon’s Vice President, Spiro Agnew, resigned, and Gerald Ford replaced him. And then, Gerald Ford replaced Nixon as President in 1974… and the amendment was invoked again to name Nelson Rockefeller as Ford’sVice President. Section 3 says the President can temporarily transfer power to the Vice President by alerting the House and Senate. Section 3 was invoked twice during President George W. Bush’s time in office. Both times were because the President was under anesthesia for colonoscopies. But then there’s Section 4…

Joel Goldstein: Section four of the 25th Amendment is the longest, most complicated provision.

Celine Gounder: It has the power to remove a President who is unwilling … or unable to recognize they’re not able to do the job. Section 4 has never been invoked. One of the trickiest parts of writing the amendment was figuring out who was going to make that judgment.  John Feerick was a lawyer in 1964 who helped draft the 25th Amendment. He’s currently a law professor at Fordham University.

John Feerick: That question has been debated back and forth for a hundred years. from 1881 when President Garfield was assassinated, through, uh, discussions of the 25th Amendment, and the debate was, who should make these decisions?

Celine Gounder: Congress? The Supreme Court?

John Feerick: So when it came down to the final, uh, days of making a decision, a sense was taken that the president is elected for a fixed term of four years as is the Vice President and that he should not be removed from his powers and duties by anybody that would not have the confidence of the American people.

Celine Gounder: John and the other drafters of the Amendment decided that trust lies with the Vice President. If the Vice President and a majority of the Cabinet agree the President is incapable of doing the job, they could notify Congress and temporarily transfer power to the Vice President. It gets complicated from there and — since it’s never been done before — no one really knows how it would work… but ultimately the President could be removed from office.

Joel Goldstein: I mean, if the, the cabinet decides with the vice president, that the president is unable to discharge the powers and duties of the office, It’s pretty hard to argue with that conclusion since the President has played a role in selecting the Vice President and the cabinet.

Celine Gounder: There’s no set definition for what makes a President unable to fulfill their duties under the 25th Amendment. But George Annas says it would most likely be invoked if the president’s state of mind was in doubt.

George Annas: Congress would agree with the vice president, uh, to take away his, uh, his powers, if he thought he was not able to deal with reality, for example, because of mental condition, rather than even if he was, you know, quadriplegic he was in an accident, but you know, made him unable to walk or to use his arms. You know as long as his brain was functioning, he talks and give orders that he would not be considered disabled for the purpose of the 25th Amendment.

Celine Gounder: Age is not a disability but it brings up a lot of health questions for the American President. Donald Trump was the oldest person ever to become president back in 2016 at the age of 70. If Joe Biden wins the election, he would become president at the age of 78. Art Caplan, the bioethicist, thinks older candidates need to be more transparent about their health when running for high office.

Art Caplan:  We don’t need to learn every medical problem. If they have a fungal infection, I don’t think that’s going to impair their ability to serve as president or vice president or a Senator. Um, but if they have these cognitive issues emerging or, if they’re on medication that might impair them, I think we do need to know that

Celine Gounder: But there’s also a level of privacy needed to make sure the President gets the care they need. Here’s George Annas.

George Annas: Whether the public should have access to information from most specialists is a different question and a much harder one. I have always argued, I could be wrong, that you’re much more likely to get the President to see psychiatric help or to have more help from a Alzheimer’s specialist, if he knows, or she knows that it’s going to stay secret, that nobody’s going to find out about it and nobody’s going to get access to that medical information.

Celine So what is the role of the President’s physician in all this?

John Feerick: The role of the medical profession is advisory. But the decisions on, uh, of inability are ultimately made by the cabinet, the Vice President and the, and, and, and those in Congress have to deal with it. It’s not made by the, the medical community.

Celine Gounder: The President’s physician could consult with the Vice President and Cabinet, but they don’t have any decision-making authority. There’ve been calls to create a medical panel to independently review the president’s health, but it’s never gotten much support. It’s just too political.

George Annas: Is this a medical decision or is this a political decision?

George9 Annas: I mean, what could be more political, than the determination of whether the president can fulfill the powers and duties of his office.

Celine Gounder: When it comes to the President, nothing is apolitical, not even their health.

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I’m Dr. Celine Gounder. Thanks for listening to “Epidemic.”

Guests
Art Caplan Art Caplan
George Annas George Annas
Joel Goldstein Joel Goldstein
Host
Dr. Celine Gounder Dr. Celine Gounder