It sounds like the plot of an implausible television show. The U.S. president’s cabinet decides he isn’t healthy enough to execute the duties of office. Perhaps he is weakened by cancer or exhibiting clear signs of Alzheimer’s disease. With the president either unwilling or unable to make the decision to step down, and with the nation’s security in their hands, the cabinet must act. What do they do?
While unlikely, it’s not out of the realm of possibilities, especially given the fact that we’ve just inaugurated the oldest president ever.
The Oldest President in History
Born June 14, 1946, President Donald Trump was 70 years old and 220 days when he was sworn in as our 45th president. That makes him the oldest ever to assume the office.
Our recent presidential election was historic in many ways, chief among them the fact that three of the major candidates were the oldest in history.
Trump wasn’t running against a youthful John F. Kennedy, Barack Obama or even Bill Clinton. Like Ronald Reagan, former Secretary of State Hillary Clinton would have been 69 as she took the oath. Her rival for the Democratic nomination, Bernie Sanders, would have been 75 on inauguration day and on the cusp of 80 when his first term ended.
Before Trump and Reagan, William Henry Harrison was the oldest man to win the office in 1840 at age 67. He died of pneumonia just 31 days after his inauguration -- hardly an advertisement for the benefits of an older president.
Age was on the minds of voters back in 1840, and it’s on the minds of voters today.
Can a Presidential Candidate Be Too Old?
Considering the greater risk of health problems with age, is a candidate ever too old to assume the highest office in the land? After all, there’s a connection between age and incidences of serious conditions such as heart disease, cancer and Alzheimer’s disease.
“I don’t think so,” says Dr. Bruce Patsner, Vice Chair of Quality, Patient Safety, and Peer Review for INOVA Hospital. “As long as they can physically handle the rigors of the job and are mentally competent, there should no exclusions based on age.”
Of course, we’ve developed our knowledge base, technology and therapeutic interventions so people are living well through a variety of illnesses that they might not have years ago.
Life expectancy plays a role in our calculus, too. A president in 2017 can expect to live much longer than his counterpart in 1917, or even 1967. For the most part, life expectancy has risen (the latest National Center for Health Statistics show a small decline) and currently stands at 78.8 years.
Age and the 2016 Election
Compared to what most of us at any age experience, Trump, Clinton and Sanders exhibited warrior-like energy throughout the daily grind of their campaigns, slogging miles, talking for hours, and posing fresh-faced for thousands of selfies with those who flocked to their rallies.
“If you look at this past year’s slate of candidates, you see remarkable, passionate and energetic folks who put themselves up for the highest office of the land,” says Dr. Reid Blackwelder, a professor of family medicine at East Tennessee State University and past president of the American Academy of Family Physicians. “Sanders, Clinton and Trump are not young people, but were able to handle the stresses of the campaign very well. I don’t know if I could compare with them in terms of energy and stamina.”
Health-wise, their campaigns went off without a hitch until September 2016. For a brief period after Hillary Clinton appeared to faint at a 9/11 memorial service, her viability hung in the balance. When she told the world she’d been diagnosed with pneumonia several days before, I wondered if she’d have to step down.
She didn’t. She rallied. Who knows if the issue remained as a concern for voters, but within a week she was back on the stump, looking well and appearing strong.
In retrospect, and despite Trump’s comments about his rivals (“low-energy” Jeb Bush, “no stamina” Hillary), it’s surprising how little the age factor entered the recent public discourse about who was best suited to lead the country.
There appeared to be much more public concern about Sen. John McCain’s age when he ran against President Obama in 2008. McCain was 72 on Election Day in 2008, and had a history of melanoma and other medical issues. “Polls at the time showed that a sizable chunk of voters (as many as 32 percent in one survey) said McCain was too old to be president, according to U.S. News & World Report.
Could the nation rely on a man his age with his health history to carry out the vigorous duties of the office, with all health indications that he’d live out his term?
Has Age Always Been an Issue for the Presidency?
When we think of presidents who haven’t finished out their terms, our minds go to assassinations like those of Kennedy and Lincoln. But the U.S. has seen illness-related presidential deaths in office, too. William Henry Harrison, the ninth POTUS, was 68 when he took office. That made him both the oldest president at the time as well as the one who served the shortest tenure in U.S. presidential history when he died soon after.
What’s more, younger presidents have been the exceptions. Theodore Roosevelt, John F. Kennedy, Bill Clinton and Barack Obama were in their 40s when they took the oath of office (42, 43, 46 and 47, respectively). Most presidents have been in their 50s or mid-60s on their inauguration days – George H.W. Bush was 64 when he took office and his son George W. Bush was 54. The nation’s first, third, fourth and sixth presidents – George Washington, Thomas Jefferson, James Madison and John Q. Adams – were all 57.
It wasn’t until Ronald Reagan, the 40th U.S. president, that a 69-year-old just a few days away from turning 70 entered the White House.
Age was certainly an issue in his campaign. At the time, age questions seemed to hang in the air like the sword of Damocles, threatening to vivisect his chances with one swift swing. Ruddy-faced Reagan took the age debate on several times, but never so effectively as when he vied for his second term.
“I will not make age an issue of this campaign,” Reagan quipped to great applause during 1984’s second presidential debate when he was 73, seeking a second term and facing opponent Walter Mondale, who was then 58. “I am not going to exploit, for political purposes, my opponent’s youth and inexperience.”
It was a remarkable comeback from Reagan’s earlier debate disaster, in which he made rambling allusions to driving down the Pacific Coast Highway. According to Slate, “When Mondale left the stage, he confided to an aide that ‘This guy is gone’ - as in mentally not all there.” Mondale lost. Did age win?
A Close Call
You could certainly argue that Reagan’s deft approach to handling age-related questions diffused a lot of worry. Unquestionably, he set a precedent for the viability of an older president that we just saw play out on the national political stage.
Looking back, many think we came close to a moment when the president would’ve needed to step down.
In 1994, five years after leaving office, Reagan announced his Alzheimer’s disease diagnosis through a letter to the public. "I now begin the journey that will lead me into the sunset of my life,” the statement read. “I know that for America there will always be a bright dawn ahead. Thank you, my friends. May God always bless you."
President Reagan’s son Ron suggests in his memoir My Father at 100 that his late dad’s Alzheimer's battle may have started while he was still in the White House. There may be something to that. Many experts believe, for example, that amyloid plaque build-up, a precursor to Alzheimer’s, starts years before shifts in behavior are detected. But there’s no documented proof that Reagan suffered from the disease while in office, other than anecdotes about the president’s forgetfulness, which could’ve been dementia-related or just a symptom of old age.
It’s clear that Reagan had contemplated the possibility of having to leave office due to an age-related illness. In his New York Times article “When Alzheimer’s Waited Outside the Oval Office,” Lawrence K. Altman writes that he “reported on Mr. Reagan’s health, and he told me that his mother, Nelle, had died of senility — and that if he were to develop it in office he would resign.”
Is Disclosing Health Information a Duty?
Do presidential candidates have a duty to disclose their health information?
“Duty is a tricky word,” says Patsner. “Despite the fact that they are public figures, their health information is protected. The question is whether we have a right to know their health conditions by virtue of the positions of authority they seek.”
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), the federal statute protecting confidentiality around personal medical information, has been in place since 1996. There’s no law requiring a candidate to disclose their medical records and share with the world all their private information, from weight to medications to health history.
History shows that most presidential candidates have kept their medical information private, and many of them had conditions we’d look upon today with concern. It’s only in the last century that the press and public inquired, and candidates have opted to release letters from personal physicians. In this last election, we knew that Trump, Clinton and Sanders had clean bills of health since they had medical checkups. But each candidate’s released medical records were incomplete. For example, records for both Hillary Clinton and Donald Trump were missing some health information. Nowadays, candidates tend to issue short summaries from personal physicians and be done with it.
Should There be a Standard Test to Assess Older Candidates’ Health?
Will this change in the future with a law requiring full disclosure? Should there be standardized medical exam pre-election, which would be fair and equal for all candidates, and would allow the public to judge their health according to a similar set of criteria?
Several experts said they don’t see that happening.
“I am concerned about the implications of who asks the standardized questions,” says Blackwelder. “Is there a formal process? For example, in this last election with the older candidates, we had three different candidates, three different sources, and three different sets of answers. How could we standardize? Maybe there’s a general question for all candidates’ doctors to answer, such as: ‘Does this person have any health issues that would impair their ability to lead?’ That’s a reasonable question. If I am going to vote you in, candidates should answer that.”
In these politically contentious times, should we stop looking for trouble without a cause? You can see a scenario in which detailed medical information would be picked over and dissected by those with partisan political agendas.
With more access to extremely detailed health information such as genetic testing and predictive tests, where would our demands for disclosure stop?
“We should focus more on disqualifying conditions and less on details that are probably irrelevant, “says Patsner. “For instance, you’d want to know if a politician has amyotrophic lateral sclerosis (ALS), because the life expectancy is around two years and you may not fill out your term.”
Physical vs. Mental Health
When we ask about presidential candidate health and age, is the assumption just about physical health?
“I am more concerned about a candidate’s mental health history than someone with diabetes or another physical condition,” Patsner says. “I would expect any politician over the age of 50 to have some physical condition, such as high blood pressure. Why shouldn’t they have medical problems we’d all have? These are more easily treatable and don’t effect behavior for the most part. Getting psychiatric information on politicians is probably harder than getting their physical health information. We tend to protect that aspect more.”
It’s worth noting that a 2006 Duke University study led by psychiatrists took a look back at 37 presidents in history. When viewed though a modern diagnostic lens, the study retroactively diagnosed 18 of them with psychiatric disorders, mainly anxiety and depression. They went even further with Teddy Roosevelt and Lyndon Johnson, stating that these two met the standard for bipolar disorder.
What Happens If an Ill President Doesn’t Voluntarily Step Down?
There’s an order of federal government leaders who could become president if our current president dies, quits, is unable to fulfill the duties or is removed from office. The lines of succession from President to Vice President to Speaker of the House and so on are clear.
While we’ve seen presidents impeached for ethical and even criminal lapses, what happens if the president needs to be removed for health (physical or mental) reasons? There’s no precedent. How would that happen?
Conservative political commentator David Frum said in a tweet on November 16, 2016: “Twenty-Fifth Amendment to the Constitution. Article 4. We’re all going to be talking a lot more about it in the months ahead.” He was right. Some are contemplating a radical but conceivable scenario in which the president’s cabinet would exercise their rights under the 25th Amendment to the Constitution, and hand the presidency to the vice president.
But that’s all conjecture at this point. Our views of presidential effectiveness based on perceptions of their health remain complicated.
Franklin D. Roosevelt, inaugurated at 51, died in office at just 63, broken by sicknesses kept secret from voters who ushered him into his fourth term. It’s hard to imagine now that he used a wheelchair, but never let the public see him in it. He famously declared in his first inaugural address that “the only thing we have to fear is fear itself.” In today’s more transparent world, would citizens have bought that had they known how sick he was?
Beloved President Kennedy had Addison's disease, which can negatively impact a person’s ability to handle stress. If we had known, would this have kept us from voting him in, and did this disease impair him in any way?
Roosevelt and Kennedy are both seen now as effective, dynamic presidents. Perhaps there’s your answer. If there’s one silver lining to older presidential candidates, it might be renewed respect for the wisdom and experience an older candidate brings.
“From a cultural perspective in this country, we have a history of not respecting our elders in a way that some other cultures do,” says Blackwelder. “So this is a good trend. With all the examples we’re seeing of vibrancy later in life, it seems appropriate for vibrant older candidates to run.”