demented diseased and depressed Lord David Owens

8/13/2019 demented diseased and depressed Lord David Owens

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QJM

Diseased, demented, depressed: serious illness in Heads ofStateTHE RTHONLORD OWEN CH

Based on a lecture to the Autumn Scientific Meeting of the Association of British Neurologistsand the British Neuropsychiatry Association, 3 October 2002

As both a physician and a politician, I was firsttouched by the question of how illness can affectthe decision-making of Heads of State or Govern-ment when I met the Shah of Iran in Tehran in May

1977.1

He appeared to be at the height of hispower: self-confident, and enjoying his global rolein helping to determine world oil prices. It wouldhave been a great help to have known then, andparticularly a year later, that he had been sufferingfrom chronic lymphocytic leukaemia. He had beendiagnosed in April 1974 by the French haema-tologist Professor Jean Bernard, and eventually diedfrom it in Cairo in July 1980. At that time, the Shahsown physician, Dr Abdol Karim Ayadi, asked DrBernard and his assistant Dr Georges Flandrin, notto tell the Shah he had cancer, which was then

at Stage II and not requiring treatment. The Shahdid not take chlorambucil until February 1975.

Thereafter, Dr Flandrin flew 35 times in greatsecrecy to Tehran before the Shah was forced toleave in January 1979. In 1977, his doctors told theEmpress he had leukaemia or cancer, but still those

two words were never used to the Shah, who wastold that he had Waldenstroms disease. Apart frombeing tired, he had no obvious signs apart from anenlarged spleen, until he noticed a swollen lymphnode in his neck in April 1979, when in exile inthe Bahamas. The Shah was then told he had cancerand was given nitrogen-mustard, vincristine, pro-carbazine and prednisolone. His health deterio-rated, and pressure grew for him to leave Mexicoand be admitted to an American hospital. Heflew to the US on 22 October after PresidentCarter relented, having previously held out against

first the advice of his National Security Adviser,Zbig Brzezinski, and later his Secretary of State,Cyrus Vance. They felt that despite risking the wrathof the new regime in Tehran, on humanitariangrounds the US Government could no longer refuse.He was admitted for treatment to New YorkHospital-Cornell Medical Center, and his arrivalbecame public. On 4 November, hundreds ofdemonstrators in Tehran climbed over the wallinto the US Embassy compound and captured 66Americans. The hostages were eventually onlyreleased minutes after Jimmy Carter stepped down

as US President on 20 January 1981, and RonaldReagan took over.Although there is no evidence that the CIA or

MI6 ever knew that the Shah had leukaemia whilehe was in Tehran, there is some evidence that theKGB knew. The Shah had chosen French doctorsdeliberately: in the words of William Shawcross,who has brilliantly chronicled the story of theShahs illness, his distrust of the British was suchthat he was sure that somehow they would profitfrom whatever illness he might have. And hethought that if he saw a top American, then thereShah of Iran

Q J Med2003; 96:325336

doi:10.1093/qjmed/hcg061

Q J Med2003; 96:325336

doi:10.1093/qjmed/hcg061

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would be a memo on the desk of the secretary ofstate or the director of Central Intelligence withindays. If Washington knew he was ill, he couldno longer expect the same unqualified Americansupport he now enjoyed. He would be deserted byhis allies.2 That judgement was correct.

The French Foreign Minister Louis de Guiringaudtold me later, when we had both left office, thathe had known of the diagnosis. But he never toldme when I was Foreign Secretary, or Cyrus Vance,the US Secretary of State.3 Had I known I wouldhave pressed far more vigorously early in 1978, andcertainly been adamant in the late summer andautumn of that year, that the Shah should standdown immediately on health grounds. We hadalready argued for appointing a Regent in our owninternal debate in the Foreign Office. Leaving thecountry would have left the path open for the Shahs

son to succeed when he became of age. We werethen desperately searching for a way to defuse thepersonal animosity in the streets against the Shah.However, we were still treating him as an imperialleader, capable of making bold decisions, whenin retrospect what he needed was to be told whatto do and virtually forced to take treatment inSwitzerland. If he had done so, the Revolution inIran would not have taken place in the way thatit did, President Carter might have won a secondterm, and certainly the history of the Middle Eastwould have been very different.

Mental illness amongst political leaders is diffi-cult to diagnose and often, even if it is diagnosed,it may be impossible to ensure treatment. TheUgandan President, Idi Amin, had burst on to theinternational scene in August 1974, when JamesCallaghan, then Foreign Secretary, had flown to seehim to make a personal intervention, resulting inthe release of Dennis Hills, a British national facingexecution. Amin had been a sergeant in the BritishArmy, seized power in a coup, and was wellensconced as a dictator by 1977, responsible forrandom killings and appalling abuses of humanrights. It seemed nothing could be done to stop his

outrageous behaviour.In the summer of 1977 the British Government

decided to try to stop Idi Amin from attendingthe Commonwealth Heads of Government meetingin London. We could not persuade AfricanCommonwealth leaders to agree that he should beformally uninvited, but we told him that he wouldnot be welcome to attend. So bizarre was hisbehaviour that we believed a wild story that he wasin the air about to fly in, and the Home Secretarymade arrangements for his flight to be refusedpermission to land, and diverted to Ireland. Because

of the many brutal killings he authorized, questions

were raised about his mental state. Some physicianshazarded the opinion in the newspapers that hemight be suffering from general paralysis of theinsane. That diagnosis, however, has never beensubstantiated, and is unlikely, since he is stillalive today, having fled to Saudi Arabia after the

Tanzanian Army invaded Uganda in 1979 withthe full encouragement of the British government.At one point I even raised the question of assassi-nation, so appalling were the atrocities he wasordering, only to be told rather haughtily thatMI6 would not contemplate arranging such athing. Eventually, in desperation we increased theTanzanian aid budget, knowing it would pro-vide ammunition for President Julius Nyerere toauthorize a military attack, and he promised not toinstall Milton Obote, but a respected paediatricianwho unfortunately did not last long as President. All

because one dictator was deranged and we had noother means of ousting him.In October 1977, I was asked by the Intelligence

Service to report on the health of the President of theSoviet Union, Leonid Brezhnev, following rumoursthat he had been treated for cancer of the throat.When I met him in Moscow and talked to him forsome time I could find no obvious abnormality.My interpreter, who had previously been at frequentmeetings with him, felt his speech might havechanged, but it was not possible to be sure. Laterin February 1984, having left office, I attended thefuneral of President Andropov. After shaking thenew President Chernenkos hand at a Reception inthe Kremlin, I mentioned to some journalists that hehad emphysema. Somewhat to my embarrassment,this aside was soon flashed around the world, andI spent days explaining that I had mentioned hiscondition, later confirmed, on little more than hiswheezing chest. A doctor does not stop looking atpeople as patients just because they are politicians,but medical views are best kept private.

One of the questions most commonly asked by aconcerned public about leaders committed to brutalpolicies is: are they mad? Hitler, Stalin, and more

recently, Saddam Hussein, Milosevic and Mugabehave often been described as being mad in popularnewspapers, when in fact they were far from beingcertifiable. In part the very question reflects a wishof those who live within democracies to underplaythe latent evil within society, and to forget or ignorethe brutalizing effect on personality that stems fromliving within, let alone presiding over, a Communistor Fascist dictatorship, or an ethnically dividedcountry such as Rhodesia or the former Yugoslavia.The longer a leader lasts in office in these regimes,the more their power stems not from popular con-

sent but from imposition. National minorities within

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a divided country can give their leaders ethnicelectoral support, but such leaders are vulnerable tocoups or assassination. They tend to lead evermoresecretive lives, become out of touch with the peoplethey lead and the reality of the world around them,and develop paranoiac tendencies. In addition,such leaders almost always become corrupt. Neverhas there been a truer aphorism than that of LordActon: all power corrupts, absolute power tends tocorrupt absolutely.

There was no evidence that Mugabe was men-tally unstable when I negotiated continuously withhim as joint leader of the Patriotic Front with JoshuaNkomo in the then Rhodesia from 1977 to 1979. Ofthe two, Mugabe was the more controlled and theless corrupt. Nonetheless, he displayed an aptitudefor dictatorship which Nkomo did not, and this wasone of the reasons that we unashamedly sought,by clandestine diplomacy and manipulation, to getNkomo as the first democratically elected leader ofZimbabwe. Eventually it was Mugabe who wonpower, and he almost certainly would have won

even without the intimidation from ZANU that laybeneath the surface in the rural villages during theCommonwealth supervised elections in 1980. WhatMugabe had within him was an odd combination of

Jesuit Catholicism and Chinese Communism. Afteran amazing period of reconciliation which sur-prised everyone and was unsurpassed by anythinganywhere else in the world, Mugabe within afew years used North Korean troops in a brutalsuppression of the population in Matabeleland, andin recent years he has presided over the ruination ofhis country. Commentators today refer to Mugabe

as mad: I doubt if he could be so diagnosed, but

he is undoubtedly acting evilly, and ought to beremoved as President. The current sanctions havefailed against the elites, but they should bemaintained and there will have to be an internalpolitical coup, supported or at least not disownedby neighbouring South Africa. South Africa has

been adversely affected already in terms of investorattitudes to Africa.

Was President Milosevic mentally unbalanced?Some quote the history of mental illness in hisfamily (both his parents committed suicide) toexplain his attitude to the great brutality whichtook place in the break-up of the former Yugoslavia.I saw no evidence of mental instability or anyother medical diagnosis in our frequent meetingsfrom 199295. The brutalizing effect of TitosCommunist dictatorship had had a deep effecton him, as on many others in the Balkans. When

Milosevic came to exercise absolute power hestill relied on elections, but he did not hesitateto manipulate them. He justified using themechanisms of a totalitarian power, controllingthe important media while leaving the less impor-tant relatively free, because to him and manysurrounding him the Serbs were fighting for theirexistence. In the event after five wars it was theCroats, under Tudjman, who won, and the Serbs,under Milosevic, who lost. Tudjman died anacknowledged nationalist leader. Milosevic hasended up in a War Crimes Tribunal in The Hague,disowned by his own electorate. Whether the Courtwill find him guilty must be left to their judgement.

Another case where my medical backgroundcame into consideration was that of FrancoisMitterrand. I had known Mitterrand since 1967,when I met him in Paris during a meeting ofGaucheEuropeane, and I had observed him in meetings in1979 when he was in Opposition and in 1986 whenPresident of the French Republic. In November1981, Mitterrand was diagnosed as having dissemi-nated cancer of the prostate, in circumstances ofgreat secrecy. He had been elected President for thefirst time in May of that year, and the news was kept

Saddam Hussein and Leonid Brezhnev

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secret for nearly 11 years. His physician, ClaudeGubiler, published an account of Mitterrandsillness, Le Grande Secret, in February 1996, buta court case brought by the family preventedpublication in France, although it can be found onthe Internet. Gubiler makes it clear that Mitterrands

early view that there should be the utmost trans-parency about his health, following the death ofPresident Georges Pompidou from an undisclosedblood cancer, changed when he became ill.Mitterrand told his doctor that his illness must beconsidered a state secret.

Despite some rumours in the press in November1981, and from time to time thereafter, his healthwas not commented on until 17 September 1992,when the news broke that the President had justemerged from a week in hospital following acuteurinary retention, and was recovering from an

operation on a cancerous prostate gland. I hadtalked with President Mitterrand in the Elysee justover two weeks before his operation, followingmy appointment as EU negotiator for the formerYugoslavia. While a shadow of his former self, hewas intellectually still very sharp, and I had notguessed that he was ill. I later watched him closelyover many hours in Paris in March 1993,4 and heappeared to have recovered very well, but herelapsed again in the summer of 1994. His doctorshad been issuing periodic health bulletins givingthe impression that the cancer was dormant, andthe Presidents health was good, the most recent ofwhich was 30 June 1994, stating that the testsshowed no particular problem. Yet 18 days laterhe was back in hospital having an operation. Thistime it was widely known that he was being treatedwith hormonal therapy. From having had a livelyinterest in all aspects of the Yugoslav problem,he was became progressively disengaged untilhe retired as President in 1995, clearly dying.Mitterrands illness once again raised questions asto the secrecy surrounding the health of Heads ofGovernment and the extent to which their illnessesaffect the way governments make decisions.

The most serious case of incapacity in a Head ofState or Government over the last 100 years wasthat of President Woodrow Wilson. He had hadhypertension for many years, and retinal changeshad been recorded in 1906. He suffered a rightmiddle cerebral artery stroke in 1919 while inhis second term as President of the US.5 His con-sciousness became impaired on 2 October, with acomplete paralysis of the left side of his body and aleft homonymous hemianopia, his speech was weakand dysarthyric, and he developed hemi-inattentionand anosognosia. In not facing up to the serious-

ness of his illness, he referred to himself as being

lame. This denial by the President was buttressedby his wife and by his personal physician, AdmiralGrayson, who told the Cabinet on 6 Octoberthat Wilson was only suffering from a nervousbreakdown, indigestion and a depleted nervoussystem. Grayson had made it clear he would not

sign any certificate of disability. There is little doubtthat Wilson should have stepped down at least for aperiod of time from October, until it was clearwhether or not he was going to recover. Had hedone so, it might have been possible to persuadeCongress to ratify the Treaty establishing the Leagueof Nations, which might have helped stop WorldWar II. Between his wife and his doctor, the falseimage was given of a working President. As a resulthis wife is often spoken of as Americas only womanPresident and his doctor has been much criticizedfor putting his patient before the needs of the

country.In the same year in France, President PaulDeschanels wife was signing official acts for herhusband. He was acting bizarrely, receiving theBritish Ambassador stark naked save only hisdecorations. The President resigned after onlyseven months in office on 21 September 1920,and is now thought to have developed frontotem-poral dementia.6 Current levels of press scrutinymake it very unlikely that a cover-up of themagnitude perpetrated by Wilson could be repro-duced at the start of the 21st century. But thereis worrying evidence that politicians wish to createlaws ensuring greater personal privacy, so thateven in sophisticated democracies with a vigilantand probing press, cover-ups may still occur.

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A new era of openness started after PresidentEisenhowers heart attack and stroke, when thepublic was given fairly full information. Even so,after President Kennedys assassination, SenatorBirch Bayh proposed an amendment to the USConstitution to deal with cover-ups over Presi-

dential health, and this became the Twenty-fifthAmendment.7 It provided for two mechanisms tocover inability or impairment of Presidential facul-ties: one for a President to step down temporarily,the other to be removed by the Vice President andCabinet.

There have been other cases like that of the Shahwhere the course of history has been influenced bynot knowing about a serious illness in a leader. LordMountbatten felt that his decision to partition theIndian subcontinent when Viceroy of India wouldprobably not have been taken if he had known that

Jinnah, the Muslim leader, was dying of tuber-culosis. Jinnah only lived for a short time as thenew President of Pakistan and if the partitiondecision had been delayed until after his death, itmight have been possible to keep India together,avoiding much loss of life, major wars and itsfragmentation into three when Bangladesh split offfrom Pakistan.

Cancer and arteriosclerosis can lead to depres-sive illnesses, reduced energy and motivation, all ofwhich can seriously affect decision-making, parti-cularly in making leaders more inclined to the statusquo, indecisive, less open-minded and readier tolet the situation drift. These characteristics were allapparent in many of the elderly leaders of Europebetween the two World Wars, particularly PrimeMinister Ramsay Macdonald in Britain, the PolishPresident Marshal Pilsudski and the Reich Presidentof Germany, Hindenberg, whose frailty paved theway for Hitler.8 Neville Chamberlain suffered fromcancer of the stomach when Prime Minister. He wasoperated on in late July 1940, having only steppeddown as Prime Minister on 10 May 1940, andcontinued as a member of the War Cabinet. Heresigned on 3 October and died on 9 November.

Interestingly, when Chamberlain took over fromStanley Baldwin in May 1937, Churchill did notsee him as likely to be soft on Hitler. Even afterthe ill-fated Munich meeting with Hitler inSeptember, Churchill was surprisingly supportiveof Chamberlain and careful to avoid blaming him.Only some time after Anthony Edens resignationas Foreign Secretary in February 1938, when thepolicy of seeking peace by appeasement with Hitlerand Mussolini was well established, did Churchillgive up on Chamberlain and begin to turn his fireon him, attacking him publicly for the first time

on 9 September 1938. It is impossible to prove

whether Chamberlains cancer had any effect on hisdecisions in government, but it seems likely.

Today attitudes to cancer have changed. In theUS there has for a few decades been much greateropenness. In July 1985, Ronald Reagan had cancerof the colon diagnosed and this was made known to

be at stage B of Dukes classification, which now hasa 70% chance of a five-year survival. Few wouldbelieve that discovering cancer is of itself a causefor a Head of Government to resign, and in partMitterrands experience supports this, but the publicwill have greater confidence if they believe that theyare being told the truth about their leaders health.

Another problem arises from drugs taken byHeads of State or Government, particularly inrelation to Prime Minister Anthony Eden andPresident John F. Kennedy. Most of the descriptionsof Anthony Edens illness at the time of Suez in

1956 focus on his well-known problems withinflammation of the bile duct or cholangitis. Weknow now that in the midst of the Suez Crisis, SirHorace Evans, Edens physician, packed the PrimeMinister off to Jamaica to recuperate. He allegedlywarned Eden that he could no longer afford torely on the benzedrine, an amphetamine brainstimulant that he had been consuming in largequantities in the crisis up until then.9 Eden also toldan adviser when the Suez Crisis blew up that he waspractically living on benzedrine.10 Edens medicalrecords have never been fully disclosed, but on

5 October 1956 he had a shivering fever just twodays after a critical meeting, running a temperatureof 106 degrees. This has been put down to his

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cholangitis, but may have been heightened by highdosages of amphetamine.11 His Cabinet colleague,Lord Kilmuir, said no-one in public life lived moreon his nerves than Eden did, and it is hard to becertain, given his somewhat febrile personality,how much of his behaviour during Suez was due

to fever or drugs, or the combination. But there isno doubt that during this time the machinery ofdemocratic government virtually ceased to exist.The Joint Intelligence Committee Assessments werevirtually ignored.12 The then Chief of the NavalStaff, Lord Mountbatten, who was against themilitary operation, believed that the Chiefs of Staffhad no standing.13 Senior Foreign Office officialswere not consulted and one of Edens Ministers inthe Foreign Office, Anthony Nutting, in a bookentitled,No End of a Lesson, has written about howEden, a man he had previously admired, conducted

himself in the crisis in a way that was completelyout of character, colluding with France and Israeland deceiving the US. The Suez policy was the mostdamaging British foreign and defence policy fiascosince Gallipoli, and there is little doubt that Edensintemperate handling of the situation was influ-enced both by his health and by the amphetamineshe was taking. He resigned in January 1957 anddied in 1977, still convinced his policy was rightand never admitting to collusion with Israel. TheUS, not the UK, was from Suez onwards the majorpower in the Middle East.

President John F. Kennedy is now known to havehad adrenal insufficiency. At the post mortem, hisadrenals were found to be greatly reduced insize, the result of disease and suppression followingreplacement therapy. Yet Kennedy, his doctors andhis family consistently presented an image of him asbeing fully fit, apart from a wartime back injury,both prior to and after his election. His brother,Bobby Kennedy, went as far as to deny he hadclassical Addisons disease using the word classicalas a cover in that he did not have TB-induceddisease, then the most prevalent cause. There wererumours that Kennedy was on heavy doses of

steroids, particularly on occasions when his faceshowed a degree of puffiness, but they were neverfollowed through by the press. Most politicalcommentators agree that if it had been knownthat Kennedy was suffering from Addisons andwas on steroids he would not have beaten Vice-President Richard Nixon in the very close Presi-dential election of 1960. Ironically, the AmericanMedical Associations Archives of Surgery in anarticle published in 1955 entitled Managementof Adreno-cortical Insufficiency During Surgeryexplained how a 37-year-old man had been

operated on for serious back pain, and was the

first Addisonian to survive such traumatic sur-gery. Only one small newspaper chain publishedthe story in 1961 that this man was PresidentKennedy.

We are now discovering that the real scandalabout President Kennedys health does not relate

to his Addisons disease but the concern of hisown doctor, Janet Travell, about his treatment withamphetamines by Dr Max Jacobson. Jacobsonwas later found guilty by the New York StateBoard of Regents Review Committee on Disciplineon 48 accounts of unprofessional conduct.14 SecretService files and the White House gate log sub-stantiate that Jacobson visited Kennedy as Presidentno fewer than 34 times through to May 1962. Asa doctor, Jacobson was well known to use as muchas 3050 mg of amphetamine on his patients, andoften to give larger doses. He would commonly

supply his patients with injectable vials to beself-administered and though amphetamines weremore liberally used at this time, he supplementedthem with heavy doses of steroids, garnished withvitamins, and even added ground-up bone marrow,placenta, electric eels and whatever other solubi-lized particles he perceived to be beneficial.15 Weknow that the FBI uncovered five vials Jacobson hadleft at the White House that on analysis revealedhigh concentrations of amphetamine and steroids.Robert Kennedy, worried about Jacobsons relation-ship with his brother, had the FDA analyse 15separate vials, and these coincided with what thestate board later disclosed. The possible effects ofsteroids and amphetamines to look for in PresidentKennedy would have been impetuousness, irrit-ability and tension. In fairness these were notdisplayed in his public life, even in the abortiveBay of Pigs invasion of Cuba early in his Presidency.His risk-taking seems to have been mainly confinedto his private life, such as seeing a Mafia leadersgirlfriend in the White House.

Following Kennedys assassination on 22 Novem-ber 1963, there has been a natural reluctance toprobe too much into the stranger aspects of his medi-

cal history, mainly because his personal handling ofthe Cuban Missile Crisis is generally acknowledgedto have been extremely effective. In retrospect, fewbelieve that the conduct of American policy washarmed or even affected by his medication. The crisiswas, we now know, even more serious than wasthought at the time since the Soviets had deployedtactical nuclear weapons in Cuba and had grantedpermission for the Commander to use them: for-tunately that was later countermanded. Yet bothEden and Kennedy demonstrate how easy it is forHeads of State or Government to cover up bizarre

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between their doctors and family can be buttressedby the climate of secrecy that surrounds Heads ofState or Government.

Two political leaders in recent memory havedeveloped Alzheimers disease after leaving office:Prime Minister Harold Wilson and President Ronald

Reagan. Harold Wilson left office on 16 March1976. To most members of the British Cabinet, aswell as to the country as a whole, his resignationwas a complete shock. The evidence is that hedecided while still in Opposition in 1973, that ifhe became Prime Minister again, he would do soonly for the very short period of time sufficient topreside over a referendum that he would orches-trate to produce a yes for Britain to stay within theEuropean Community. Thus he would vindicate hisstance against the critics who were opposed to theterms of entry. The fact that his resignation was

carefully planned is borne out by his having warnedtwo Cabinet colleagues likely to succeed him in1975 that he was going to step down in a fewmonths time. There has been endless politicalspeculation as to why Wilson resigned. Havingtalked to him in the House of Commons over adecade, I believe he did so because he becameaware that his near-photographic memory was nolonger working effectively. His biographer summa-rized that frame of mind: to slow up, to be at a lossfor words or to grope for a statistic was not merelygalling, but a blow to his confidence. Four yearsafter resigning, Harold Wilson had aged consider-ably. He had cancer of the bowel in the summer of1980, and had three operations that year. A doctorrecords the clinical detail that while his memoryof years gone remained excellent, he could notremember what he had had for breakfast on thesame day.17 Although Wilsons last book,Memoirs19161964, the Makings of a Prime Minister, waspublished in 1986, his mental function had thenbeen declining for some years. He died on 24 May1995. In retrospect, his decision to resign wasan enlightened one, and the wider speculation

regarding his motives looks completely unfounded.The lesson of his resignation is that even a mildmemory failure should be taken seriously by a Headof Government and their medical advisers, as anindicator that it is time to consider retiring. Seniorpoliticians linger too long in office.

Ronald Reagan looked very fit when he firsttook office in January 1981 at nearly 70. Yet whilehe left office eight years later as the oldest President,still very popular, many people were doubting hisability, attention span and memory. I spoke tohim on a one-on-one basis in 1978 in the ForeignOffice, and again in the White House in 1986. Itwas very hard to assess his mental capacity at thebest of times, because of a self-confident ignoranceon some important matters and his charming giftof self-deprecation. Reagan was a strong-willedleader, but content to concentrate on presentation.His management style was to focus on a few bigissues, which he then excelled at simplifying. Thereare detailed medical records in the Mayo Clinic of

his mental state during the summer of 1990, a yearafter he left office, when he was given the wholerange of formal mental and psychological testsfollowing an earlier riding accident and surgeryon his brain to remove a subdural haematoma.Those tests, we are told, gave no hint of impendingAlzheimers and his doctor during these crucialyears, Dr Hutton, has said that all parameters forhis age absolutely were within the normal range.This judgement is supported by other White Housedoctors who had, however, only done simplemental arithmetic tests, such as asking him to

subtract 7 continually from 100, and other fairlyHarold Wilson

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standard questions. Yet in corroboration his officialbiographer, Edmund Morris, who wroteDutchandwho wrote two exceptional biographical volumeson Theodore Roosevelt, drew on the four leather-bound volumes of Reagans Presidential diary, somehalf a million words written over 8 years. Morris

describes them as uniform in style and cognitivecontent from beginning to end. There was no hintof mental deterioration beyond occasional repeti-tions andnon sequitursand if those were suggestedfor early dementia, many diarists including myselfwould have reason to worry.18 Nevertheless bySeptember 1992, Reagan could both make a cam-paigning speech for President Bush and that samenight not recognize his former Secretary of State,George Schulz.19 On 5 November 1994, Reaganwrote a moving handwritten letter to my fellowAmericans telling them that he was one of a million

Americans who was afflicted with Alzheimersdisease, ending I now begin the journey that willlead me into the sunset of my life. It is hardto believe that he was not suffering from somecognitive impairment while President.

Urho Kekkonen was elected President of Finlandin 1956, at that time an office of some importancesince it controlled foreign policy. While Kekkonenwas never diagnosed as having Alzheimers, heresigned in 1981 after a cover-up of serious memorydisturbance which had emerged as early as 1978,when he was last elected for the normal term ofsix years.20

The overriding question raised by all these casehistories is how in a democracy it is possible toconstruct a mechanism whereby a Head of State orGovernment can be legitimately eased out of office.Doctors have to be very careful in formulating fixedstructures for a political situation that will often bein considerable flux. First, we have to be clear as towhether it is reasonable for the personal physiciansof a Head of State or Government to be chargedwith a dual responsibilityboth to the good of theirpatient and to the best interests of their nation. Ithink it is not: although doctors cannot divorce

themselves from their duties as a citizen, theirprimary purpose is to serve their individual patient.In that balancing act, they should not lie in publicstatements about their patients, but they have nomandate to disclose that which their patient refusesto sanction. They can, however, fall back on silence.If these criteria are accepted, a personal physicianfor a Head of State or Government can never be asubstitute for independent medical assessment.

Some argue that the true meaning of theHippocratic Oath is that a doctor should go tohis grave with the secrets of his patients and not

even leave behind any paper records for posterity.

Another view, which I share, is that history cansometimes gain from the medical insight ofthe personal physician of a Head of State orGovernment and that publication devoid of tittle-tattle can be very valuable after the close family hasdied. The British 30-year rule, during which period

government records cannot be disclosed, is not alicence for doctors to tell all after it has expired.Disclosure well after this period may still helphistorians and seems to me compatible with theHippocratic Oath.

Lord Moran, Churchills personal physician, triedto have it both ways. In his book,21 he upheld anabsolute duty to his patient, quoting himself sayingto Churchill on 4 April 1955, two days before hewas due to leave 10 Downing Street, that whileothers close to Churchill thought he was finishedas a politician, he never pushed him to retire: I felt

from the first you were more likely to snuff it outif you retired. This despite Churchills two strokesin 1949 and a serious one in 1953, when he was notcapable of governing properly for a few weeks, andwhen Churchill, Moran and his family conspiredto hide his medical condition. Yet, when Churchillhad a heart attack in Washington at the WhiteHouse on 19 December 1941, just after PearlHarbour, Lord Moran prides himself in upholdinghis duty to the nation, writing that wat thisxmomentwhen America has just come into the war, and thereis no-one but Winston to take her by the hand Ifelt the effect of announcing that the PM had hada heart attack could only be disastrous. As aconsequence, he let Churchill think he had strained

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one of his chest muscles and never told him that hischest pain was the result of coronary artery disease.In fact in both cases he was arguably serving thebest interests of his patient.

In the British Parliamentary system, a PrimeMinister always knows they have to be able to

command the House of Commons and hold theirpartys allegiance. A directly elected President,however, has a different and direct mandate fromthe people. Was President Mitterrand entitledto suppress the knowledge of his cancer of theprostate? Probably yes, for in 1981 he had only

just won the Presidency for the Left in Franceafter a long period of Centre Right dominance, andhis mental function at that stage was totallyunimpaired. President Mitterrand had much less

justification for withholding news of his cancerbefore putting himself forward for a second term

in 1988.An important question (and it is not straight-forward) is whether in democracies the electorateare entitled to an independent medical assessmentof all of the candidates standing for the position ofHead of State or Government. There would be evenmore scrutiny if there was medical disclosure beforeparty primaries, or prior to any election for leaderby political parties.

Against such provisions, one can ponder that ifsuch a rule had existed certain leaders we havevalued would never have served in the highest

office. Would the effect of a public announcementof Abraham Lincolns recurrent depression havemade it impossible for Lincoln to have been votedin as President? Churchills mood changes, whichhe called Black Dog, and doctors now call bipolaraffective disorder, were known to Chamberlainand Halifax, and yet they made him Prime Minister,there being no question of their recommendationbeing rejected by Conservative MPs. We have toweigh the likelihood of any announcement of adepressive illness damaging any politicians chanceof being elected. Senator Eagleton was forcedto resign from being George McGoverns Vice-

Presidential candidate when it was leaked that hehad had three depressive episodes, including twotreatments with electroconvulsive therapy.22 Publicopinion today remains frightened of psychiatricillness, and this makes some doctors feel psychiatricinformation should be withheld, but it is hard to seeany rule being made selective of certain categoriesof illness. In a democracy, potential leaders aremeant to be accountable to the electorate, and asdemocrats we have to trust the good sense and the

judgement of the electorate. We cannot protect theelectorate by withholding pertinent information. In

business, it is now commonplace for the Board of

Directors to insist on a Chief Executive having anindependent medical report prior to appointment,and some insist on regular updates. I see every casefor those who seek the highest political office atleast subjecting themselves to a medical prior tonomination.

What would the American people have done inNovember 1944 when Franklin Roosevelt stood forthe fourth time as President, had he been compelledto reveal his true medical condition? I suspect theywould have re-elected him. Roosevelt, followinghis polio, had overcome the problems of beingparalysed in both legs. But in the process of gettingelected as Governor of New York and thenPresident he had got used to hiding his disabilityfrom the electorate and, for example, he hadpractically never been photographed in a wheel-chair. The impression was constantly given that hecould stand up and he even designed a method oftaking a few steps to give the impression that hecould walk with just a little support usually from

one of his sons or a bodyguard. All of this, onecan argue, was perfectly reasonable conduct byRoosevelt. But this pattern of deception continuedwhen he developed heart failure. On 28 March1944 in Bethesda Hospital, a 39-year-old navalcardiologist, Dr Bruenn, made the first full medicalexamination of Roosevelt since he became Presi-dent, on the insistence of Roosevelts daughterAnna. This was done in the face of deep reluctancefrom Admiral McIntire, his personal physician.Bruenn diagnosed cardiac failure, and said thePresidents condition was god awful. McIntire

was initially not even ready to accept Bruenns

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judgement that Roosevelt had to be given digitalis,and Bruenn threatened to have nothing more to dowith the case unless it was given, a brave act for ayoung naval officer. Though Bruenn continued totreat the President, he was never asked by McIntireor anyone else about whether Roosevelt should run

for re-election in November. Later he said that hadhe been asked, he would have said it was medicallyimpossible. Harry Truman, an extraordinary ordi-nary man, proved to be a great President, and whenRoosevelt asked him in as his running mate intothe White House on 18 August 1944, Truman leftsaying to the press about the President that heis keen as a briar; in private he was telling hisassistant I am concerned about the Presidentshealth. His hands are shaking and he talks withconsiderable difficulty. It doesnt seem to be anymental lapse of any kind but physically he is just

going to pieces.23

To no-ones surprise, Roosevelt won a fourthterm and just before the election he appeared torecover his strength, campaigning in the rain inNew York City with some of his old verve. PresidentYeltsins vigorous dancing in his 1996 campaign inRussia despite his heart condition was in someways a similar incident, and probably due to beinggiven some brain stimulant by doctors. Those inRoosevelts intimate circle knew that it would notbe long, however, before he would be unableto cope with the burden of office. On 8 February1945, while attending the Yalta conference andafter a tough discussion about the future of Poland,a critical post-war issue, Roosevelt developedpulsus alternans indicating left ventricular failure.Fortunately after a few days his pulse reverted. Hisdaughter, who was also in Yalta, just before thisincident, had been told for the first time not byMcIntire but by Bruenn about her fathers heartcondition.24

Serious people who were closely involved in thenegotiations at Yalta have defended Rooseveltsmental capacity, and I can find no strong evidencethat he gave away any crucial ground to Stalin. It is

also hard to conclude that a new President wouldhave made much difference to the conduct of theWar in the few months between the inauguration in

January and when Roosevelt died in April 1945.The military decisions had been taken and the USChiefs of Staff under General Marshall and GeneralEisenhower as Supreme Allied Commander werefollowing up D-Day. It was the US military whowere the most reluctant to race the Soviet Unionto Berlin. Of course in a rational decision-makingstructure, Roosevelt should not have stood forPresident in the 1944 election. But even if the full

information had been given about his health that

summer, a nation for whom he was a hero mightwell have chosen him again that November. Politicsis not a rational business, and democraticallyelected political leaders have often used dubiousmeans of clinging on to office. Roosevelt was thegreatest political wheeler and dealer this century,

and a man never to be underestimated. He was tomany a father figure, he wanted to continue asPresident and even if his health condition had beenrevealed, he would have downplayed its signifi-cance and fought by all possible means to convincethe American people to vote for him.

For many similar reasons, if the British Cabinethad known about Churchills heart attack inDecember 1941 they would have been very sensi-tive to the effect on public morale of letting him stepdown. They would probably have been contentfor him to go away for a rest which would not

have been made public, and let Clement Atleetemporarily step into the breach. The fact thatAmerica had just come into the war and eventualvictory seemed then more probable, combined withChurchills reputation being at an all-time high,would have been decisive. Certainly Churchillwould have resisted any suggestion of retirementwith all the means available to him.

Political leaders are usually, by nature of theoffice they hold and the slippery pole which theyhave climbed to get there, exceptional people. Theyare often paranoid about the press, they frequentlyget by on far too little sleep, and many have ahistory of taking rather more alcohol than is goodfor them. Alcohol, along with heart failure, was thedownfall of President Yeltsin, although we nowknow that the 1994 incident at Shannon Airport,when he failed to come off his plane, was due to aheart attack rather than being drunk. Everyone inRussia knew about his health problems, but despitethis they voted for him in 1996 rather than seethe Communist leader Gennady Zyuganov win.Yeltsin will go down in history not just as the firstdemocratic leader of Russia, but as the man whoenabled a broadly peaceful and democratic tran-

sition to take place from Communism, and ensureda democratic election for his successor VladimirPutin. At many stages, independent doctors wouldno doubt have said that it was unwise, if notimpossible, for Yeltsin to continue in office. This isbut yet another salutary warning of making medicalassessment the determining factor in democraticpolitics.

For many decades alcohol appeared to doChurchill no harm. In WWII, although his inebri-ated condition in the early hours of the morningoften understandably strained the patience of

wartime Chiefs of Staff, they did not want him




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replaced. In May 1953, Churchill as Prime Ministerwas standing in for Eden as Foreign Secretary weeksbefore he had a very serious stroke. A diplomat fromthe Foreign Office records lunching with him andhis Private Secretary, The lunch lasted for threeand a quarter hours. A varied and noble procession

of wines with which I could not keep pacechampagne, port, brandy, cointreau; Winston dranka great deal of all and ended with two glasses ofwhisky and soda. It is hard to imagine functioningon such an input, but he had been used to it for overfifty years. Churchill would have been forced outafter his stroke in 1953 but the key politicians whoknew his true condition after the stroke never acted.Anthony Eden was still sick. Harold Macmillan hadalso been ill and was not yet in a powerful enoughposition to strike, and Rab Butler was not ruthlessenough to insist on being made Prime Minister,

although he probably could have done so. Churchilleventually retired, far too late, in April 1955 anddied in January 1965 after his last and most severestroke.

ConclusionOn balance, I believe there should be provisions inplace in a democracy to ensure that before votingany candidate for Head of State or Governmentinto office, whether for the first or for subsequentelections, the general electorate should knowthe results of an up-to-date independent medicalexamination. Relying on a politician, ambitious foroffice, to reveal their true health or on their ownpersonal doctor, family or friends is not sufficient.Nor can electors depend on probing journalistsor fellow politicians to know the medical conditionof a candidate, particularly those who have notalready been subjected to the intrusive scrutinysurrounding a Head of State or Government. TheElectoral Commission in the UK, on advice fromthe Royal College of Physicians, could appointtwo panels of general physicians and neurologists.Provided the doctors had no medical or personal

knowledge of the candidate concerned, two doctors,one from each panel, could be chosen by thecandidate. The Electoral Commission could thensupervise the content and manner of the publicationof their findings.

Reluctantly, I must also conclude that if a Headof State or Government becomes ill in office, differ-ent considerations apply and there can be no setrules. Removal from office must ultimately dependon the judgement of senior political leaders in theirCabinet and in the elected legislative chambers.These politicians would informally consult leaders

of the medical profession, and weigh their

confidential advice amongst many other factorsbefore insisting that a duly-elected Head of State orGovernment step down. Alerting them to anymedical problems will depend on a vigilant press,a sense of duty amongst the Head of State orGovernments own medical advisers, and perhaps

on the leaders of the medical profession, who areoften in the know. Any automaticity involvingpanels of independent doctors examining electedHeads of State or Government at regular intervalsand releasing their findings to politicians or thepublic puts too much authority into the handsof doctors, I fear. Too many times, historically,democracy has been better served through lettingmedical events take their place in a spectrum ofconsiderations on whether to force a Head of Stateor Government out of office. Formal proceduresfor fixed medical examinations for an elected

incumbent is a process with a pseudo-objectivitywhich can be blind to the complexities anddynamics of government, as well as the uncertainrelationship between disease and the capacity tomake decisions.

AcknowledgementsI am grateful to my son, Dr Gareth Owen, for all hishelp with regard to this paper.

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demented diseased and depressed Lord David Owens