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2024-07-22 | WebClipping | 2024-07-22 | https://www.newyorker.com/science/medical-dispatch/doctors-are-increasingly-worried-about-biden | true |
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Doctors Are Increasingly Worried About Biden
From the moment that Joe Biden announced his candidacy for President, in 2019, he has been attacked as being too old. At the time, Biden was seventy-six and cast himself as a “transitional” figure—a “bridge” to the next generation. Since then, he has governed admirably, passing more meaningful legislation than almost anyone thought possible with flimsy Democratic majorities in Congress. But, in the past year, concerns about his fitness have gained traction and credibility. Staff, donors, and elected officials have divulged mental lapses; in February, the special counsel Robert Hur labelled the President a “well-meaning, elderly man with a poor memory” in a report about Biden’s handling of classified documents. Last month, with more than fifty million Americans watching, Biden delivered one of the worst Presidential-debate performances in history, stumbling over numbers and words, losing his train of thought, and struggling to finish sentences. He often appeared unfocussed, with a slack jaw and blank eyes; afterward, the First Lady gingerly helped him off the stage.
After the debate, Axios reported that before 10 A.M. and after 4 P.M. the President tends to tire and misspeak; Biden, who is eighty-one, said at a press conference, “I just got to pace myself a little more.” Meanwhile, supporters tried to excuse his performance by invoking jet lag, a cold, a busy schedule, poor preparation, too much preparation, and a blanket shield of “good days and bad days.” These are the kinds of difficult conversations one has when considering whether one’s grandfather can safely drive—not whether someone should run the country. Democrats, meanwhile, have damned the President with a mixture of tepid endorsements and outright defections. After Biden reaffirmed his intention to stay in the race, Representative Nancy Pelosi, who is eighty-four and announced in 2022 that she would not again pursue the House Speakership, told MSNBC, “It’s up to the President to decide if he is going to run.” At least twenty Democratic members of the House of Representatives have publicly called on Biden to withdraw from the race, and, last week, Peter Welch, of Vermont, became the first Democratic senator to do so.
We all experience fluctuations in how we feel and perform. But the frequency and the severity of fluctuations matter: occasionally misplacing your keys or forgetting a friend’s birthday is far less concerning than regularly losing your train of thought, which can be a sign of an evolving cognitive impairment. Trajectory and rapidity matter, too: a gradual descent may portend a different prognosis than a swift and jagged decline. Since the debate, I’ve asked nine doctors—including an internist, geriatricians, neurologists, and a neurosurgeon—to reflect on President Biden’s health. Most of them are, politically speaking, left of center; they practice in different parts of the country and range in age from their thirties to their sixties. They were careful to stipulate that they couldn’t diagnose the President from afar, and none wanted to be quoted by name. But almost all of them were concerned about the possibility that Biden’s symptoms might go beyond a gradual, aging-related decline, and could potentially be attributed to something more serious, such as a meaningful cognitive impairment or neurodegenerative condition. Most felt that an evaluation for neurological disorders would be reasonable. One neurologist, who practices on the West Coast and identifies as a Democrat, told me that Biden’s debate performance troubled a large number of her colleagues. “All of us had a gut reaction that this is not normal,” the neurologist told me.
In my own practice, I often review a patient’s clinical record before a visit, only to be surprised by the person I ultimately meet. Perhaps she’s healthier or sicker than her chart suggests; maybe a symptom she shares during my exam upends the expected diagnosis. This is good, careful medicine, and a reminder that no doctor should confidently diagnose someone based solely on video clips. Many medical professionals understandably prefer not to comment on public figures. Openly dissecting a person’s health feels intrusive and unseemly, and, even if a person is diagnosed as having a neurological condition, that is no reason to deny them participation in work and life. But it also seems reasonable, even unavoidable, for a different standard to apply when that person’s actions could affect the lives of millions of people for years to come. Talking to the specialists about the President’s health, I questioned whether their expertise should remain behind the veil of professional norms. My fellow-doctors were able to contextualize Biden’s symptoms; they refined my understanding of what tests might be informative and what the next few years might look like. Doesn’t the public deserve the same?
Perhaps the central hallmark of aging is that, over time, physiological stressors—a cold, a fall, a bad night’s sleep—have a deeper and more prolonged impact. Small disturbances start to make a big difference, an especially precarious prospect for those with jobs that require a steady hand—pilots and surgeons, yes, but also Presidents. One reason that performing at a debate is more difficult—and more telling—than performing at a rally is that the two draw on different cognitive resources. One is reading sheet music; the other, improvising a jazz solo. We prize mental agility in our leaders not only because it allows them to inspire and persuade but also because of what it implies about their proficiency when we’re not watching. What kind of performance can Biden still deliver, and for how much longer? “We’re all talking about it in the neuro world,” a neurosurgeon told me. “But I don’t think anyone wants to be the one to say something publicly.”
Presidential health has always been a matter of intrigue and obfuscation. Grover Cleveland once boarded a friend’s yacht, ostensibly for a fishing trip, and had an oral tumor excised. (Surgeons removed part of his jaw but were careful to preserve his walrus mustache.) After Woodrow Wilson suffered an incapacitating stroke, his wife, Edith, shielded him from scrutiny and assumed many of his daily responsibilities. Ronald Reagan, who was given a diagnosis of Alzheimer’s disease after leaving office, reportedly showed such significant signs of impairment during his second term that his closest aides considered invoking the Twenty-fifth Amendment.
Doctors were once much less hesitant to comment on the health of public figures. In 1964, the magazine Fact surveyed more than twelve thousand psychiatrists about the mental fitness of Barry Goldwater, the Republican nominee for President. Around twenty-five hundred responded; nearly half said that he was unfit. In a forty-one-page article, the magazine published the results along with sensational quotes. (“I believe Goldwater has the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders,” one psychiatrist speculated.) Goldwater won a libel suit against the magazine, but he lost the election in a landslide. Some years later, the American Psychiatric Association advanced the Goldwater Rule, which holds that it is unethical for psychiatrists to offer their professional opinion about public figures whom they have not examined, and about whom they have not been granted permission to speak. It was intended, in part, to prevent speculative, unverifiable commentary under the guise of scientific expertise.
Some physicians believe that the Goldwater Rule is in tension with another obligation: one’s duty to use her knowledge to educate the public about issues of societal importance. In 2017, amid rampant speculation about Donald Trump’s mental fitness, the A.P.A. reaffirmed its position, and the American Medical Association adopted a guideline stating that physicians in all specialties should refrain “from making clinical diagnoses about individuals . . . they have not had the opportunity to personally examine.” That year, however, Bandy X. Lee, an assistant clinical professor of psychiatry at Yale, convened dozens of mental-health specialists at a conference called “Duty to Warn” to discuss the ethics of speaking out about Trump’s psychology. Afterward, she edited and published a collection of essays, titled “The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President,” in which writers discussed such conditions as sociopathy, malignant narcissism, and antisocial personality disorder. The book became a Times best-seller. John Kelly, Trump’s second chief of staff, reportedly consulted it when trying to constrain the former President’s erratic behavior.
Lee’s contract at Yale, where she’d attended medical school and taught for nearly two decades, was not renewed. But she told me that the Declaration of Geneva, adopted by the World Medical Association in the wake of the Second World War, compels doctors to speak out in the face of a looming threat. “It’s not about diagnosing a person,” Lee said. “It’s about protecting the public health. A President has the power to destroy the world several times over. A leader who is unstable presents a clear and present danger. How can we stay silent?” Lee argued that Trump’s behavior was more worrying than Biden’s current health, and she may be right. Her argument about the duty to warn, however, seems to apply equally to Biden.
Most of the doctors I spoke with said that comprehensive neuropsychological and motor testing, along with imaging, would be needed to secure or dismiss a particular diagnosis. This would involve a suite of tests—administered in the course of hours, possibly days—that examine a person’s attention, memory, mood, and semantic fluency. (Such tests would go beyond the one that Trump often brags about having “aced”—the Montreal Cognitive Assessment, a screening test, not a diagnostic exam, whose results are influenced by a person’s educational background. “A Nobel laureate with dementia could score perfectly on that test,” one geriatrician in the Northeast told me.) When I asked another doctor whether pressure to receive testing could fuel ageism, she told me that much of her work aims to fight age-related biases. But, “in recent months, this has clearly become a question of function, not just of chronological age,” she said. She added that she had treated many patients with similar symptoms who ultimately deteriorated.
The President’s medical team, which has actually evaluated him, has consistently said that he does not show signs of a neurodegenerative condition. In February, Biden’s physician, Kevin O’Connor, attributed the President’s stiff gait to spinal arthritis. He wrote that the President had undergone an “extremely detailed” neurological exam, and that there were “no findings which would be consistent with” a central neurological disorder such as Parkinson’s. He did not say whether a cognitive assessment was performed; he noted that Biden had received “radiologic imaging,” but didn’t specify which kind, or what parts of the body were being scanned. (An MRI of the brain can sometimes detect neurological abnormalities.) Earlier this month, the Times reported that a motor-disorders expert had repeatedly visited the White House in the past year; the White House said that most of these visits were to treat other personnel, not Biden, and that the President has met with the expert no more than three times, as part of his annual physicals. Biden’s physician also emphasized that the expert was selected “not because he is a movement disorder specialist, but because he is a highly trained and highly regarded neurologist.” Then, in an interview released on Wednesday, the President said for the first time that he would consider withdrawing from the race if he had “some medical condition that emerged . . . if doctors came to me and said, ‘You got this problem.’ ” No such diagnosis has been rendered. (That day, Biden also tested positive for COVID and cancelled a campaign event in Las Vegas. O’Connor indicated that the President has experienced only mild symptoms so far.)
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