By George J. Annas
Presidential candidate Paul Tsongas suggested that by making public all medical records and submitting to a medical examination by an expert medical panel, any presidential candidate could force all the other presidential candidates to do the same. To the extent that Tsongas was right, presidential candidates wind up playing a public game of chicken with their medical records and thus their medical privacy. Clinton's position as a candidate is the proper one: There should be limits on what presidential candidates should be expected to disclose about their physical and mental health. These limits cannot be imposed by law (since the candidates could always make voluntary disclosures) but must be imposed by the candidates themselves, and by their advisers and physicians. If these limits are seen as reasonable, they will be respected by the public even if they are challenged by the media, which seem much more interested in private medical information than the public is. The public will learn much more about a candidate's fitness for the presidency by the candidate's performance in the campaign than by the release of his or her medical records. Moreover, the public is likely to be best served by candidates and Presidents who seek medical care when they need it, without fear that doing so will jeopardize their political future.
Some medical information is obvious or nonstigmatizing, and its disclosure is probably harmless. Both Clinton and Dole, for example, have made public their serum cholesterol levels, weight, and blood pressure, and these numbers have already been used in presidential politics. Senator Dole remarked at the July 21995 meeting of the National Governors' Association, "My weight is lower than Clinton's. My cholesterol is lower than Clinton's. My blood pressure is lower than Clinton's. But I am not going to make health an issue in 1996." Clinton, who spoke to the same gathering a few hours later, said that he believed his resting pulse rate was actually lower than Dole's, but that this was not Dole's fault because "I don't have to deal with Phil Gramm every day." However, to the extent that cholesterol levels and weight are used as measures of virtue, all this is nonsense and is likely to distract us from focusing on the substantive policy differences between the candidates.
Much more serious issues are raised by sensitive medical information that is inherently embarrassing or invites irrational prejudice. The fact of having consulted a psychiatrist is one such area, and I believe this should not be disclosed by candidates. A history of institutional mental health care is even more prejudicial, as the Eagleton case illustrates. We should encourage our leaders to seek such help whenever they feel they need it, both for their own sakes and for ours, and protecting their medical privacy is essential if this is to happen. Three other types of sensitive information also deserve attention. The first is abortion. Since there have been few women candidates for the presidency, this issue has not yet come up; we should agree now that it never should. The second is status with respect to the human immunodeficiency virus (HIV). Presidential candidates may, of course, wish to know their own HIV status, but there seems no reason for anyone other than their personal physicians and their sexual partners to know it. Of course, at some point AIDS may develop in an HIV-positive person, and this would be difficult, if not impossible, to keep secret. The only suggested rationale for presidential candidates to be tested for HIV is that this test is routine in the military and the President will be the commander-in-chief of the armed services. But the military reasons (saving on disability benefits and-incredibly-the possibility of a battlefield transfusion) do not apply to the President.
Third, and perhaps most important, there is an entire new set of tests-genetic tests-that will soon become available and will be able to make at least some probabilistic, though not definitive, estimates of the odds of a person's having certain diseases, such as early-onset Alzheimer's disease, breast cancer, and colon cancer. These tests have the potential for much mischief in presidential politics. Their results could be used to play to the fears and prejudices of the electorate, even though by themselves they cannot accurately predict how good or bad a President will be or whether the person will be able to do the job. Everyone will die, and if they live long enough will die of a genetically influenced disease, because we all carry at least some genes predisposing us to death and mental disability. It would be pointless and distracting to search for those that evoke the most fear in the electorate, since this is a reflection not of the fitness of a person for the presidency but of our own fears of death and disability. A good rule to adopt now is for candidates (and their physicians and advisors) to put the results of genetic tests off limits in any disclosure of the health status of a candidate or of a President.
Conclusions: Senator Eugene McCarthy was right to protect his medical privacy in the 1976 presidential campaign. He was also right to insist that a President be elected "on the basis of his or her record of service, of thought about the issues and programs to deal with them, and not on the basis of any private status such as that of patient." US Presidents have always been more likely to be killed or disabled by assassins than by diseases, and the Secret Service thus has more to do with the President's health and safety than the President's physicians.
The things we want to know about the health of Presidents and presidential candidates tell us much more about ourselves than about the Presidents and would-be Presidents. They tell us what we fear, and what we hope for. Reasonable medical disclosures are now taken for granted and may not be too harmful. But we are rapidly approaching the point of diminishing returns, and unless we want to discourage our Presidents, presidential candidates, and possible presidential candidates from seeking medical assistance in times of physical and psychological distress, we must show at least some respect for their medical privacy by setting limits to expected disclosures. There is no simple legal or procedural rule that can ensure this. The 25th Amendment provides what is probably as good a set of procedures as we can devise to deal with temporary presidential disability. Presidents will have to disclose the details of actual injuries and illnesses in office. But the 1996 election provides an opportunity for us to begin to curb our tabloid-press-fed curiosity about the private medical information of presidential candidates. We should take this opportunity; it may be our last.
Excerpted from "The Health of the President and Presidential Candidates" by George J. Annas, JD, M.P.H. in October 5, 1995, issue of New England Journal of Medicine.