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Diseased, demented, depressed: serious illness in Heads of State

David Owen
DOI: http://dx.doi.org/10.1093/qjmed/hcg061 325-336 First published online: 1 May 2003

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

As both a physician and a politician, I was first touched by the question of how illness can affect the decision‐making of Heads of State or Government when I met the Shah of Iran in Tehran in May 1977.1 He appeared to be at the height of his power: self‐confident, and enjoying his global role in helping to determine world oil prices. It would have been a great help to have known then, and particularly a year later, that he had been suffering from chronic lymphocytic leukaemia. He had been diagnosed in April 1974 by the French haematologist Professor Jean Bernard, and eventually died from it in Cairo in July 1980. At that time, the Shah's own physician, Dr Abdol Karim Ayadi, asked Dr Bernard and his assistant Dr Georges Flandrin, not to tell the Shah he had cancer, which was then at Stage II and not requiring treatment. The Shah did not take chlorambucil until February 1975. Thereafter, Dr Flandrin flew 35 times in great secrecy to Tehran before the Shah was forced to leave in January 1979. In 1977, his doctors told the Empress he had leukaemia or cancer, but still those two words were never used to the Shah, who was told that he had Waldenstrom's disease. Apart from being tired, he had no obvious signs apart from an enlarged spleen, until he noticed a swollen lymph node in his neck in April 1979, when in exile in the Bahamas. The Shah was then told he had cancer and was given nitrogen‐mustard, vincristine, procarbazine and prednisolone. His health deteriorated, and pressure grew for him to leave Mexico and be admitted to an American hospital. He flew to the US on 22 October after President Carter 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 wrath of the new regime in Tehran, on humanitarian grounds the US Government could no longer refuse. He was admitted for treatment to New York Hospital‐Cornell Medical Center, and his arrival became public. On 4 November, hundreds of demonstrators in Tehran climbed over the wall into the US Embassy compound and captured 66 Americans. The hostages were eventually only released minutes after Jimmy Carter stepped down as US President on 20 January 1981, and Ronald Reagan took over.

Although there is no evidence that the CIA or MI6 ever knew that the Shah had leukaemia while he was in Tehran, there is some evidence that the KGB knew. The Shah had chosen French doctors deliberately: in the words of William Shawcross, who has brilliantly chronicled the story of the Shah's illness, ‘his distrust of the British was such that he was sure that somehow they would profit from whatever illness he might have. And he thought that if he saw a top American, then there would be a memo on the desk of the secretary of state or the director of Central Intelligence within days. If Washington knew he was ill, he could no longer expect the same unqualified American support he now enjoyed. He would be deserted by his allies’.2 That judgement was correct.

The French Foreign Minister Louis de Guiringaud told me later, when we had both left office, that he had known of the diagnosis. But he never told me when I was Foreign Secretary, or Cyrus Vance, the US Secretary of State.3 Had I known I would have pressed far more vigorously early in 1978, and certainly been adamant in the late summer and autumn of that year, that the Shah should stand down immediately on health grounds. We had already argued for appointing a Regent in our own internal debate in the Foreign Office. Leaving the country would have left the path open for the Shah's son to succeed when he became of age. We were then desperately searching for a way to defuse the personal animosity in the streets against the Shah. However, we were still treating him as an imperial leader, capable of making bold decisions, when in retrospect what he needed was to be told what to do and virtually forced to take treatment in Switzerland. If he had done so, the Revolution in Iran would not have taken place in the way that it did, President Carter might have won a second term, and certainly the history of the Middle East would have been very different.

Mental illness amongst political leaders is difficult to diagnose and often, even if it is diagnosed, it may be impossible to ensure treatment. The Ugandan President, Idi Amin, had burst on to the international scene in August 1974, when James Callaghan, then Foreign Secretary, had flown to see him to make a personal intervention, resulting in the release of Dennis Hills, a British national facing execution. Amin had been a sergeant in the British Army, seized power in a coup, and was well ensconced as a dictator by 1977, responsible for random killings and appalling abuses of human rights. 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 attending the Commonwealth Heads of Government meeting in London. We could not persuade African Commonwealth leaders to agree that he should be formally uninvited, but we told him that he would not be welcome to attend. So bizarre was his behaviour that we believed a wild story that he was in the air about to fly in, and the Home Secretary made arrangements for his flight to be refused permission to land, and diverted to Ireland. Because of the many brutal killings he authorized, questions were raised about his mental state. Some physicians hazarded the opinion in the newspapers that he might be suffering from general paralysis of the insane. That diagnosis, however, has never been substantiated, and is unlikely, since he is still alive today, having fled to Saudi Arabia after the Tanzanian Army invaded Uganda in 1979 with the full encouragement of the British government. At one point I even raised the question of assassination, so appalling were the atrocities he was ordering, only to be told rather haughtily that MI6 would not contemplate arranging such a thing. Eventually, in desperation we increased the Tanzanian aid budget, knowing it would provide ammunition for President Julius Nyerere to authorize a military attack, and he promised not to install Milton Obote, but a respected paediatrician who unfortunately did not last long as President. All because one dictator was deranged and we had no other means of ousting him.

In October 1977, I was asked by the Intelligence Service to report on the health of the President of the Soviet Union, Leonid Brezhnev, following rumours that he had been treated for cancer of the throat. When I met him in Moscow and talked to him for some time I could find no obvious abnormality. My interpreter, who had previously been at frequent meetings with him, felt his speech might have changed, but it was not possible to be sure. Later in February 1984, having left office, I attended the funeral of President Andropov. After shaking the new President Chernenko's hand at a Reception in the Kremlin, I mentioned to some journalists that he had emphysema. Somewhat to my embarrassment, this aside was soon flashed around the world, and I spent days explaining that I had mentioned his condition, later confirmed, on little more than his wheezing chest. A doctor does not stop looking at people as patients just because they are politicians, but medical views are best kept private.

One of the questions most commonly asked by a concerned public about leaders committed to brutal policies is: are they mad? Hitler, Stalin, and more recently, Saddam Hussein, Milosevic and Mugabe have often been described as being mad in popular newspapers, when in fact they were far from being certifiable. In part the very question reflects a wish of those who live within democracies to underplay the latent evil within society, and to forget or ignore the brutalizing effect on personality that stems from living within, let alone presiding over, a Communist or Fascist dictatorship, or an ethnically divided country 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 consent but from imposition. National minorities within a divided country can give their leaders ethnic electoral support, but such leaders are vulnerable to coups or assassination. They tend to lead evermore secretive lives, become out of touch with the people they lead and the reality of the world around them, and develop paranoiac tendencies. In addition, such leaders almost always become corrupt. Never has there been a truer aphorism than that of Lord Acton: ‘all power corrupts, absolute power tends to corrupt absolutely’.

Saddam Hussein and Leonid Brezhnev

There was no evidence that Mugabe was mentally unstable when I negotiated continuously with him as joint leader of the Patriotic Front with Joshua Nkomo in the then Rhodesia from 1977 to 1979. Of the two, Mugabe was the more controlled and the less corrupt. Nonetheless, he displayed an aptitude for dictatorship which Nkomo did not, and this was one of the reasons that we unashamedly sought, by clandestine diplomacy and manipulation, to get Nkomo as the first democratically elected leader of Zimbabwe. Eventually it was Mugabe who won power, and he almost certainly would have won even without the intimidation from ZANU that lay beneath the surface in the rural villages during the Commonwealth supervised elections in 1980. What Mugabe had within him was an odd combination of Jesuit Catholicism and Chinese Communism. After an amazing period of reconciliation which surprised everyone and was unsurpassed by anything anywhere else in the world, Mugabe within a few years used North Korean troops in a brutal suppression of the population in Matabeleland, and in recent years he has presided over the ruination of his 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 be removed as President. The current sanctions have failed against the elites, but they should be maintained and there will have to be an internal political coup, supported or at least not disowned by neighbouring South Africa. South Africa has been adversely affected already in terms of investor attitudes to Africa.

Was President Milosevic mentally unbalanced? Some quote the history of mental illness in his family (both his parents committed suicide) to explain his attitude to the great brutality which took place in the break‐up of the former Yugoslavia. I saw no evidence of mental instability or any other medical diagnosis in our frequent meetings from 1992–95. The brutalizing effect of Tito's Communist dictatorship had had a deep effect on him, as on many others in the Balkans. When Milosevic came to exercise absolute power he still relied on elections, but he did not hesitate to manipulate them. He justified using the mechanisms of a totalitarian power, controlling the important media while leaving the less important relatively free, because to him and many surrounding him the Serbs were fighting for their existence. In the event after five wars it was the Croats, under Tudjman, who won, and the Serbs, under Milosevic, who lost. Tudjman died an acknowledged nationalist leader. Milosevic has ended up in a War Crimes Tribunal in The Hague, disowned by his own electorate. Whether the Court will find him guilty must be left to their judgement.

Another case where my medical background came into consideration was that of Francois Mitterrand. I had known Mitterrand since 1967, when I met him in Paris during a meeting of Gauche Europeane, and I had observed him in meetings in 1979 when he was in Opposition and in 1986 when President of the French Republic. In November 1981, Mitterrand was diagnosed as having disseminated cancer of the prostate, in circumstances of great secrecy. He had been elected President for the first time in May of that year, and the news was kept secret for nearly 11 years. His physician, Claude Gubiler, published an account of Mitterrand's illness, Le Grande Secret, in February 1996, but a court case brought by the family prevented publication in France, although it can be found on the Internet. Gubiler makes it clear that Mitterrand's early view that there should be the utmost transparency about his health, following the death of President Georges Pompidou from an undisclosed blood cancer, changed when he became ill. Mitterrand told his doctor that his illness must be considered a state secret.

Despite some rumours in the press in November 1981, and from time to time thereafter, his health was not commented on until 17 September 1992, when the news broke that the President had just emerged from a week in hospital following acute urinary retention, and was recovering from an operation on a cancerous prostate gland. I had talked with President Mitterrand in the Elysée just over two weeks before his operation, following my appointment as EU negotiator for the former Yugoslavia. While a shadow of his former self, he was intellectually still very sharp, and I had not guessed that he was ill. I later watched him closely over many hours in Paris in March 1993,4 and he appeared to have recovered very well, but he relapsed again in the summer of 1994. His doctors had been issuing periodic health bulletins giving the impression that the cancer was dormant, and the President's health was good, the most recent of which was 30 June 1994, stating that the tests showed ‘no particular problem’. Yet 18 days later he was back in hospital having an operation. This time it was widely known that he was being treated with hormonal therapy. From having had a lively interest in all aspects of the Yugoslav problem, he was became progressively disengaged until he retired as President in 1995, clearly dying. Mitterrand's illness once again raised questions as to the secrecy surrounding the health of Heads of Government and the extent to which their illnesses affect the way governments make decisions.

The most serious case of incapacity in a Head of State or Government over the last 100 years was that of President Woodrow Wilson. He had had hypertension for many years, and retinal changes had been recorded in 1906. He suffered a right middle cerebral artery stroke in 1919 while in his second term as President of the US.5 His consciousness became impaired on 2 October, with a complete paralysis of the left side of his body and a left homonymous hemianopia, his speech was weak and dysarthyric, and he developed hemi‐inattention and anosognosia. In not facing up to the seriousness of his illness, he referred to himself as being ‘lame’. This denial by the President was buttressed by his wife and by his personal physician, Admiral Grayson, who told the Cabinet on 6 October that Wilson was only suffering from a ‘nervous breakdown, indigestion and a depleted nervous system’. Grayson had made it clear he would not sign any certificate of disability. There is little doubt that Wilson should have stepped down at least for a period of time from October, until it was clear whether or not he was going to recover. Had he done so, it might have been possible to persuade Congress to ratify the Treaty establishing the League of Nations, which might have helped stop World War II. Between his wife and his doctor, the false image was given of a working President. As a result his wife is often spoken of as America's only woman President and his doctor has been much criticized for putting his patient before the needs of the country.

In the same year in France, President Paul Deschanel's wife was signing official acts for her husband. He was acting bizarrely, receiving the British Ambassador stark naked save only his decorations. The President resigned after only seven months in office on 21 September 1920, and is now thought to have developed frontotemporal dementia.6 Current levels of press scrutiny make it very unlikely that a cover‐up of the magnitude perpetrated by Wilson could be reproduced at the start of the 21st century. But there is worrying evidence that politicians wish to create laws ensuring greater personal privacy, so that even in sophisticated democracies with a vigilant and probing press, cover‐ups may still occur.

A new era of openness started after President Eisenhower's heart attack and stroke, when the public was given fairly full information. Even so, after President Kennedy's assassination, Senator Birch Bayh proposed an amendment to the US Constitution to deal with cover‐ups over Presidential health, and this became the Twenty‐fifth Amendment.7 It provided for two mechanisms to cover inability or impairment of Presidential faculties: one for a President to step down temporarily, the other to be removed by the Vice President and Cabinet.

There have been other cases like that of the Shah where the course of history has been influenced by not knowing about a serious illness in a leader. Lord Mountbatten felt that his decision to partition the Indian subcontinent when Viceroy of India would probably not have been taken if he had known that Jinnah, the Muslim leader, was dying of tuberculosis. Jinnah only lived for a short time as the new President of Pakistan and if the partition decision had been delayed until after his death, it might have been possible to keep India together, avoiding much loss of life, major wars and its fragmentation into three when Bangladesh split off from Pakistan.

Cancer and arteriosclerosis can lead to depressive illnesses, reduced energy and motivation, all of which can seriously affect decision‐making, particularly in making leaders more inclined to the status quo, indecisive, less open‐minded and readier to let the situation drift. These characteristics were all apparent in many of the elderly leaders of Europe between the two World Wars, particularly Prime Minister Ramsay Macdonald in Britain, the Polish President Marshal Pilsudski and the Reich President of Germany, Hindenberg, whose frailty paved the way for Hitler.8 Neville Chamberlain suffered from cancer of the stomach when Prime Minister. He was operated on in late July 1940, having only stepped down as Prime Minister on 10 May 1940, and continued as a member of the War Cabinet. He resigned on 3 October and died on 9 November. Interestingly, when Chamberlain took over from Stanley Baldwin in May 1937, Churchill did not see him as likely to be soft on Hitler. Even after the ill‐fated Munich meeting with Hitler in September, Churchill was surprisingly supportive of Chamberlain and careful to avoid blaming him. Only some time after Anthony Eden's resignation as Foreign Secretary in February 1938, when the policy of seeking peace by appeasement with Hitler and Mussolini was well established, did Churchill give up on Chamberlain and begin to turn his fire on him, attacking him publicly for the first time on 9 September 1938. It is impossible to prove whether Chamberlain's cancer had any effect on his decisions in government, but it seems likely.

Today attitudes to cancer have changed. In the US there has for a few decades been much greater openness. In July 1985, Ronald Reagan had cancer of the colon diagnosed and this was made known to be at stage B of Dukes' classification, which now has a 70% chance of a five‐year survival. Few would believe that discovering cancer is of itself a cause for a Head of Government to resign, and in part Mitterrand's experience supports this, but the public will have greater confidence if they believe that they are being told the truth about their leaders' health.

Another problem arises from drugs taken by Heads of State or Government, particularly in relation to Prime Minister Anthony Eden and President John F. Kennedy. Most of the descriptions of Anthony Eden's illness at the time of Suez in 1956 focus on his well‐known problems with inflammation of the bile duct or cholangitis. We know now that in the midst of the Suez Crisis, Sir Horace Evans, Eden's physician, packed the Prime Minister off to Jamaica to recuperate. He allegedly warned Eden that he could no longer afford to rely on the benzedrine, an amphetamine brain stimulant that he had been consuming in large quantities in the crisis up until then.9 Eden also told an adviser when the Suez Crisis blew up that he was practically living on benzedrine.10 Eden's medical records have never been fully disclosed, but on 5 October 1956 he had a shivering fever just two days after a critical meeting, running a temperature of 106 degrees. This has been put down to his cholangitis, but may have been heightened by high dosages of amphetamine.11 His Cabinet colleague, Lord Kilmuir, said ‘no‐one in public life lived more on his nerves' than Eden did, and it is hard to be certain, given his somewhat febrile personality, how much of his behaviour during Suez was due to fever or drugs, or the combination. But there is no doubt that during this time the machinery of democratic government virtually ceased to exist. The Joint Intelligence Committee Assessments were virtually ignored.12 The then Chief of the Naval Staff, Lord Mountbatten, who was against the military operation, believed that the Chiefs of Staff had ‘no standing’.13 Senior Foreign Office officials were not consulted and one of Eden's Ministers in the Foreign Office, Anthony Nutting, in a book entitled, No End of a Lesson, has written about how Eden, a man he had previously admired, conducted himself in the crisis in a way that was completely out of character, colluding with France and Israel and deceiving the US. The Suez policy was the most damaging British foreign and defence policy fiasco since Gallipoli, and there is little doubt that Eden's intemperate handling of the situation was influenced both by his health and by the amphetamines he was taking. He resigned in January 1957 and died in 1977, still convinced his policy was right and never admitting to collusion with Israel. The US, not the UK, was from Suez onwards the major power in the Middle East.

President John F. Kennedy is now known to have had adrenal insufficiency. At the post mortem, his adrenals were found to be greatly reduced in size, the result of disease and suppression following replacement therapy. Yet Kennedy, his doctors and his family consistently presented an image of him as being 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 had ‘classical Addison's disease’ using the word classical as a cover in that he did not have TB‐induced disease, then the most prevalent cause. There were rumours that Kennedy was on heavy doses of steroids, particularly on occasions when his face showed a degree of puffiness, but they were never followed through by the press. Most political commentators agree that if it had been known that Kennedy was suffering from Addison's and was on steroids he would not have beaten Vice‐President Richard Nixon in the very close Presidential election of 1960. Ironically, the American Medical Association's Archives of Surgery in an article published in 1955 entitled ‘Management of Adreno‐cortical Insufficiency During Surgery’ explained how a 37‐year‐old man had been operated on for serious back pain, and was the first Addisonian to survive such traumatic surgery. Only one small newspaper chain published the story in 1961 that this man was President Kennedy.

We are now discovering that the real scandal about President Kennedy's health does not relate to his Addison's disease but the concern of his own doctor, Janet Travell, about his treatment with amphetamines by Dr Max Jacobson. Jacobson was later found guilty by the New York State Board of Regents' Review Committee on Discipline on 48 accounts of unprofessional conduct.14 Secret Service files and the White House gate log substantiate that Jacobson visited Kennedy as President no fewer than 34 times through to May 1962. As a doctor, Jacobson was well known to use as much as 30–50 mg of amphetamine on his patients, and often to give larger doses. He would commonly supply his patients with injectable vials to be self‐administered and though amphetamines were more liberally used at this time, he supplemented them with heavy doses of steroids, garnished with vitamins, and even added ground‐up bone marrow, placenta, electric eels and whatever other solubilized particles he perceived to be beneficial.15 We know that the FBI uncovered five vials Jacobson had left at the White House that on analysis revealed high concentrations of amphetamine and steroids. Robert Kennedy, worried about Jacobson's relationship with his brother, had the FDA analyse 15 separate vials, and these coincided with what the state board later disclosed. The possible effects of steroids and amphetamines to look for in President Kennedy would have been impetuousness, irritability and tension. In fairness these were not displayed in his public life, even in the abortive Bay of Pigs invasion of Cuba early in his Presidency. His risk‐taking seems to have been mainly confined to his private life, such as seeing a Mafia leader's girlfriend in the White House.

Following Kennedy's assassination on 22 November 1963, there has been a natural reluctance to probe too much into the stranger aspects of his medical history, mainly because his personal handling of the Cuban Missile Crisis is generally acknowledged to have been extremely effective. In retrospect, few believe that the conduct of American policy was harmed or even affected by his medication. The crisis was, we now know, even more serious than was thought at the time since the Soviet's had deployed tactical nuclear weapons in Cuba and had granted permission for the Commander to use them: fortunately that was later countermanded. Yet both Eden and Kennedy demonstrate how easy it is for Heads of State or Government to cover up bizarre medical histories, and how a conspiracy of silence between their doctors and family can be buttressed by the climate of secrecy that surrounds Heads of State or Government.

Two political leaders in recent memory have developed Alzheimer's disease after leaving office: Prime Minister Harold Wilson and President Ronald Reagan. Harold Wilson left office on 16 March 1976. To most members of the British Cabinet, as well as to the country as a whole, his resignation was a complete shock. The evidence is that he decided while still in Opposition in 1973, that if he became Prime Minister again, he would do so only for the very short period of time sufficient to preside over a referendum that he would orchestrate to produce a ‘yes' for Britain to stay within the European Community. Thus he would vindicate his stance against the critics who were opposed to the terms of entry. The fact that his resignation was carefully planned is borne out by his having warned two Cabinet colleagues likely to succeed him in 1975 that he was going to step down in a few months time. There has been endless political speculation as to why Wilson resigned. Having talked to him in the House of Commons over a decade, I believe he did so because he became aware that his near‐photographic memory was no longer working effectively. His biographer summarized that frame of mind: ‘to slow up, to be at a loss for words or to grope for a statistic was not merely galling, but a blow to his confidence’. Four years after resigning, Harold Wilson had aged considerably. He had cancer of the bowel in the summer of 1980, and had three operations that year. A doctor records the clinical detail that while his memory of years gone remained excellent, he could not remember what he had had for breakfast on the same day.17 Although Wilson's last book, Memoirs 1916–1964, the Makings of a Prime Minister, was published in 1986, his mental function had then been declining for some years. He died on 24 May 1995. In retrospect, his decision to resign was an enlightened one, and the wider speculation regarding his motives looks completely unfounded. The lesson of his resignation is that even a mild memory failure should be taken seriously by a Head of Government and their medical advisers, as an indicator that it is time to consider retiring. Senior politicians linger too long in office.

Ronald Reagan looked very fit when he first took office in January 1981 at nearly 70. Yet while he left office eight years later as the oldest President, still very popular, many people were doubting his ability, attention span and memory. I spoke to him on a one‐on‐one basis in 1978 in the Foreign Office, and again in the White House in 1986. It was very hard to assess his mental capacity at the best of times, because of a self‐confident ignorance on some important matters and his charming gift of self‐deprecation. Reagan was a strong‐willed leader, but content to concentrate on presentation. His management style was to focus on a few big issues, which he then excelled at simplifying. There are detailed medical records in the Mayo Clinic of his mental state during the summer of 1990, a year after he left office, when he was given the whole range of formal mental and psychological tests following an earlier riding accident and surgery on his brain to remove a subdural haematoma. Those tests, we are told, gave no hint of impending Alzheimer's and his doctor during these crucial years, Dr Hutton, has said that ‘all parameters for his age absolutely were within the normal range’. This judgement is supported by other White House doctors who had, however, only done simple mental arithmetic tests, such as asking him to subtract 7 continually from 100, and other fairly standard questions. Yet in corroboration his official biographer, Edmund Morris, who wrote Dutch and who wrote two exceptional biographical volumes on Theodore Roosevelt, drew on the four leather‐bound volumes of Reagan's Presidential diary, some half a million words written over 8 years. Morris describes them as ‘uniform in style and cognitive content from beginning to end. There was no hint of mental deterioration beyond occasional repetitions and non sequiturs and if those were suggested for early dementia, many diarists including myself would have reason to worry.’18 Nevertheless by September 1992, Reagan could both make a campaigning speech for President Bush and that same night not recognize his former Secretary of State, George Schulz.19 On 5 November 1994, Reagan wrote a moving handwritten letter to ‘my fellow Americans' telling them that he was one of a million Americans who was afflicted with Alzheimer's disease, ending ‘I now begin the journey that will lead me into the sunset of my life.’ It is hard to believe that he was not suffering from some cognitive impairment while President.

Urho Kekkonen was elected President of Finland in 1956, at that time an office of some importance since it controlled foreign policy. While Kekkonen was never diagnosed as having Alzheimer's, he resigned in 1981 after a cover‐up of serious memory disturbance which had emerged as early as 1978, when he was last elected for the normal term of six years.20

The overriding question raised by all these case histories is how in a democracy it is possible to construct a mechanism whereby a Head of State or Government can be legitimately eased out of office. Doctors have to be very careful in formulating fixed structures for a political situation that will often be in considerable flux. First, we have to be clear as to whether it is reasonable for the personal physicians of a Head of State or Government to be charged with a dual responsibility—both to the good of their patient and to the best interests of their nation. I think it is not: although doctors cannot divorce themselves from their duties as a citizen, their primary purpose is to serve their individual patient. In that balancing act, they should not lie in public statements about their patients, but they have no mandate to disclose that which their patient refuses to sanction. They can, however, fall back on silence. If these criteria are accepted, a personal physician for a Head of State or Government can never be a substitute for independent medical assessment.

Some argue that the true meaning of the Hippocratic Oath is that a doctor should go to his 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 can sometimes gain from the medical insight of the personal physician of a Head of State or Government and that publication devoid of tittle‐tattle can be very valuable after the close family has died. The British 30‐year rule, during which period government records cannot be disclosed, is not a licence for doctors to tell all after it has expired. Disclosure well after this period may still help historians and seems to me compatible with the Hippocratic Oath.

Lord Moran, Churchill's personal physician, tried to have it both ways. In his book,21 he upheld an absolute duty to his patient, quoting himself saying to Churchill on 4 April 1955, two days before he was due to leave 10 Downing Street, that while others close to Churchill thought he was finished as a politician, he never pushed him to retire: ‘I felt from the first you were more likely to snuff it out if you retired’. This despite Churchill's two strokes in 1949 and a serious one in 1953, when he was not capable of governing properly for a few weeks, and when Churchill, Moran and his family conspired to hide his medical condition. Yet, when Churchill had a heart attack in Washington at the White House on 19 December 1941, just after Pearl Harbour, Lord Moran prides himself in upholding his duty to the nation, writing that ‘[at this] moment when America has just come into the war, and there is no‐one but Winston to take her by the hand I felt the effect of announcing that the PM had had a heart attack could only be disastrous.’ As a consequence, he let Churchill think he had strained one of his chest muscles and never told him that his chest pain was the result of coronary artery disease. In fact in both cases he was arguably serving the best interests of his patient.

In the British Parliamentary system, a Prime Minister always knows they have to be able to command the House of Commons and hold their party's allegiance. A directly elected President, however, has a different and direct mandate from the people. Was President Mitterrand entitled to suppress the knowledge of his cancer of the prostate? Probably yes, for in 1981 he had only just won the Presidency for the Left in France after a long period of Centre Right dominance, and his mental function at that stage was totally unimpaired. President Mitterrand had much less justification for withholding news of his cancer before putting himself forward for a second term in 1988.

An important question (and it is not straightforward) is whether in democracies the electorate are entitled to an independent medical assessment of all of the candidates standing for the position of Head of State or Government. There would be even more scrutiny if there was medical disclosure before party primaries, or prior to any election for leader by political parties.

Against such provisions, one can ponder that if such a rule had existed certain leaders we have valued would never have served in the highest office. Would the effect of a public announcement of Abraham Lincoln's recurrent depression have made it impossible for Lincoln to have been voted in as President? Churchill's mood changes, which he called Black Dog, and doctors now call bipolar affective disorder, were known to Chamberlain and Halifax, and yet they made him Prime Minister, there being no question of their recommendation being rejected by Conservative MPs. We have to weigh the likelihood of any announcement of a depressive illness damaging any politicians' chance of being elected. Senator Eagleton was forced to resign from being George McGovern's Vice‐Presidential candidate when it was leaked that he had had three depressive episodes, including two treatments with electroconvulsive therapy.22 Public opinion today remains frightened of psychiatric illness, and this makes some doctors feel psychiatric information should be withheld, but it is hard to see any rule being made selective of certain categories of illness. In a democracy, potential leaders are meant to be accountable to the electorate, and as democrats we have to trust the good sense and the judgement of the electorate. We cannot protect the electorate by withholding pertinent information. In business, it is now commonplace for the Board of Directors to insist on a Chief Executive having an independent medical report prior to appointment, and some insist on regular updates. I see every case for those who seek the highest political office at least subjecting themselves to a medical prior to nomination.

What would the American people have done in November 1944 when Franklin Roosevelt stood for the fourth time as President, had he been compelled to reveal his true medical condition? I suspect they would have re‐elected him. Roosevelt, following his polio, had overcome the problems of being paralysed in both legs. But in the process of getting elected as Governor of New York and then President he had got used to hiding his disability from the electorate and, for example, he had practically never been photographed in a wheelchair. The impression was constantly given that he could stand up and he even designed a method of taking a few steps to give the impression that he could walk with just a little support usually from one of his sons or a bodyguard. All of this, one can argue, was perfectly reasonable conduct by Roosevelt. But this pattern of deception continued when he developed heart failure. On 28 March 1944 in Bethesda Hospital, a 39‐year‐old naval cardiologist, Dr Bruenn, made the first full medical examination of Roosevelt since he became President, on the insistence of Roosevelt's daughter Anna. This was done in the face of deep reluctance from Admiral McIntire, his personal physician. Bruenn diagnosed cardiac failure, and said the President's condition was ‘god awful’. McIntire was initially not even ready to accept Bruenn's judgement that Roosevelt had to be given digitalis, and Bruenn threatened to have nothing more to do with the case unless it was given, a brave act for a young naval officer. Though Bruenn continued to treat the President, he was never asked by McIntire or anyone else about whether Roosevelt should run for re‐election in November. Later he said that had he been asked, he would have said it was medically impossible. Harry Truman, an extraordinary ordinary man, proved to be a great President, and when Roosevelt asked him in as his running mate into the White House on 18 August 1944, Truman left saying to the press about the President that ‘he is keen as a briar’; in private he was telling his assistant ‘I am concerned about the President's health. His hands are shaking and he talks with considerable difficulty. It doesn't seem to be any mental lapse of any kind but physically he is just going to pieces’.23

To no‐one's surprise, Roosevelt won a fourth term and just before the election he appeared to recover his strength, campaigning in the rain in New York City with some of his old verve. President Yeltsin's vigorous dancing in his 1996 campaign in Russia despite his heart condition was in some ways a similar incident, and probably due to being given some brain stimulant by doctors. Those in Roosevelt's intimate circle knew that it would not be long, however, before he would be unable to cope with the burden of office. On 8 February 1945, while attending the Yalta conference and after a tough discussion about the future of Poland, a critical post‐war issue, Roosevelt developed pulsus alternans indicating left ventricular failure. Fortunately after a few days his pulse reverted. His daughter, who was also in Yalta, just before this incident, had been told for the first time not by McIntire but by Bruenn about her father's heart condition.24

Serious people who were closely involved in the negotiations at Yalta have defended Roosevelt's mental capacity, and I can find no strong evidence that he gave away any crucial ground to Stalin. It is also hard to conclude that a new President would have made much difference to the conduct of the War in the few months between the inauguration in January and when Roosevelt died in April 1945. The military decisions had been taken and the US Chiefs of Staff under General Marshall and General Eisenhower as Supreme Allied Commander were following up D‐Day. It was the US military who were the most reluctant to race the Soviet Union to Berlin. Of course in a rational decision‐making structure, Roosevelt should not have stood for President 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 might well have chosen him again that November. Politics is not a rational business, and democratically elected political leaders have often used dubious means of clinging on to office. Roosevelt was the greatest political wheeler and dealer this century, and a man never to be underestimated. He was to many a father figure, he wanted to continue as President and even if his health condition had been revealed, he would have downplayed its significance and fought by all possible means to convince the American people to vote for him.

For many similar reasons, if the British Cabinet had known about Churchill's heart attack in December 1941 they would have been very sensitive to the effect on public morale of letting him step down. They would probably have been content for him to go away for a rest which would not have been made public, and let Clement Atlee temporarily step into the breach. The fact that America had just come into the war and eventual victory seemed then more probable, combined with Churchill's reputation being at an all‐time high, would have been decisive. Certainly Churchill would have resisted any suggestion of retirement with all the means available to him.

Political leaders are usually, by nature of the office they hold and the slippery pole which they have climbed to get there, exceptional people. They are often paranoid about the press, they frequently get by on far too little sleep, and many have a history of taking rather more alcohol than is good for them. Alcohol, along with heart failure, was the downfall of President Yeltsin, although we now know that the 1994 incident at Shannon Airport, when he failed to come off his plane, was due to a heart attack rather than being drunk. Everyone in Russia knew about his health problems, but despite this they voted for him in 1996 rather than see the Communist leader Gennady Zyuganov win. Yeltsin will go down in history not just as the first democratic leader of Russia, but as the man who enabled a broadly peaceful and democratic transition to take place from Communism, and ensured a democratic election for his successor Vladimir Putin. At many stages, independent doctors would no doubt have said that it was unwise, if not impossible, for Yeltsin to continue in office. This is but yet another salutary warning of making medical assessment the determining factor in democratic politics.

For many decades alcohol appeared to do Churchill no harm. In WWII, although his inebriated condition in the early hours of the morning often understandably strained the patience of wartime Chiefs of Staff, they did not want him replaced. In May 1953, Churchill as Prime Minister was standing in for Eden as Foreign Secretary weeks before he had a very serious stroke. A diplomat from the Foreign Office records lunching with him and his Private Secretary, ‘The lunch lasted for three and a quarter hours. A varied and noble procession of wines with which I could not keep pace—champagne, port, brandy, cointreau; Winston drank a great deal of all and ended with two glasses of whisky and soda’. It is hard to imagine functioning on such an input, but he had been used to it for over fifty years. Churchill would have been forced out after his stroke in 1953 but the key politicians who knew his true condition after the stroke never acted. Anthony Eden was still sick. Harold Macmillan had also been ill and was not yet in a powerful enough position to strike, and Rab Butler was not ruthless enough to insist on being made Prime Minister, although he probably could have done so. Churchill eventually retired, far too late, in April 1955 and died in January 1965 after his last and most severe stroke.

Conclusion

On balance, I believe there should be provisions in place in a democracy to ensure that before voting any candidate for Head of State or Government into office, whether for the first or for subsequent elections, the general electorate should know the results of an up‐to‐date independent medical examination. Relying on a politician, ambitious for office, to reveal their true health or on their own personal doctor, family or friends is not sufficient. Nor can electors depend on probing journalists or fellow politicians to know the medical condition of a candidate, particularly those who have not already been subjected to the intrusive scrutiny surrounding a Head of State or Government. The Electoral Commission in the UK, on advice from the Royal College of Physicians, could appoint two 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 the candidate. The Electoral Commission could then supervise the content and manner of the publication of their findings.

Reluctantly, I must also conclude that if a Head of State or Government becomes ill in office, different considerations apply and there can be no set rules. Removal from office must ultimately depend on the judgement of senior political leaders in their Cabinet and in the elected legislative chambers. These politicians would informally consult leaders of the medical profession, and weigh their confidential advice amongst many other factors before insisting that a duly‐elected Head of State or Government step down. Alerting them to any medical problems will depend on a vigilant press, a sense of duty amongst the Head of State or Government's own medical advisers, and perhaps on the leaders of the medical profession, who are often in the know. Any automaticity involving panels of independent doctors examining elected Heads of State or Government at regular intervals and releasing their findings to politicians or the public puts too much authority into the hands of doctors, I fear. Too many times, historically, democracy has been better served through letting medical events take their place in a spectrum of considerations on whether to force a Head of State or Government out of office. Formal procedures for fixed medical examinations for an elected incumbent is a process with a pseudo‐objectivity which can be blind to the complexities and dynamics of government, as well as the uncertain relationship between disease and the capacity to make decisions.

Acknowledgments

I am grateful to my son, Dr Gareth Owen, for all his help with regard to this paper.

References