President Biden's exit highlights presidential health standards: Are they too low?

President Biden’s exit from the presidential race has deepened complex conversations about the health standards we should expect from our presidents and presidential candidates. As it stands, President Biden, 81, has nearly six months left in office, but a growing number of people across the political spectrum are concerned that he isn’t fit to continue.

The President has been accused of being cognitively impaired despite his saying he is not.^[] 

The unique health challenges of the presidency

It isn’t surprising that both President Biden and former President Trump would be experiencing some level of cognitive decline. The American Academy of Neurology (AAN) says that patients 65 and older should be assessed for thinking and memory problems and that, worldwide, nearly 7% of people in their early 60s and 38% of people over 85 have mild cognitive impairment.^[]

So, when is removal from office due to mental or physical unfitness warranted? There’s no clear-cut line. Put simply, it’s up to the powers that be. To address this, the US Constitution set forth the 25th Amendment, which states that the Vice President and a “majority of either the principal officers of the executive departments or of such other body as Congress” may decide that a president is not fit for office and discharge his power and duty.^[]

The amendment was ratified after President John F. Kennedy’s assassination, although other presidents had died in office before the amendment’s birth.^[][]

However, some experts see a line between valid concerns regarding presidential health and issues like ableism and ageism.

Holly Bowen, MD, a cognitive neuroscientist at Southern Methodist University, says that the high-stress levels in the office could lead to age-related changes in cognition.

The presidency and advanced aging

While there aren’t any clinical statistics to back up the idea that the White House speeds up aging, plenty of articles have addressed the impacts of stress on presidents. “Doctors and aging specialists have long said that the rigors of the Oval Office can transform a spry president-elect into a craggy elder statesman in what seems like no time,” according to one CBC News article.^[] 

Dr. Bowen notes that, gray hair aside, being older doesn’t automatically mean that a president isn’t fit for office. “There is a large amount of heterogeneity in cognitive and physical function,” Dr. Bowen says. “Just because someone is 80 years old does not automatically mean that they are cognitively impaired or that they are developing dementia.” 

She notes that older adults bring a lot to the table, especially in politics: “Older adults generally have better emotion regulation abilities, they have more experience making big important decisions, and they have a longer lifetime of experience they can draw on,” she says. Donna A. Patterson, PhD, a professor in the departments of History, Political Science, and Philosophy and the director of Africana Studies at Delaware State University, tells MDLinx that it’s important not to fall back on stigmas against disability and age. 

Several presidents have lived with chronic illness, she says, noting John F. Kennedy’s Addison's disease and other health problems, as well as Franklin D. Roosevelt’s paralysis and wheelchair use. 

“Ronald Reagan displayed some cognitive decline while in office,” she says. “He was diagnosed with Alzheimer's disease a few years after his presidency, and some speculate that he might have been displaying Alzheimer 's-related symptoms while in office.”

But things have shifted. In today’s world, a president’s every move can be captured and scrutinized. “Today, with the advent of cell phones, social media, and all sorts of instantaneous media, perceived changes in physical or mental health are quickly disseminated,” she notes. 

Paterson says that ableism plagues society, including as it relates to how we perceive presidents. This is why, she says, “past presidents worked so hard to hide chronic illness and disability.”

Patterson adds that she isn’t sure where to draw the line between valid concern and ableism,  but she says that it’s important to remember that disabled Americans perform their jobs every day. “Some have accommodations and others do not. Furthermore…there are senators, governors, and other elected officials who work every day with disabilities. This includes those with wheelchairs, those who are blind, some who have cognitive impairment, and some with various mental health diagnoses…Like most humans, presidents will get sick, and some will have mental and physical decline. Yes, too, the presidency does tend to age a person.”

David Cutler, MD, a board-certified family medicine physician at Providence Saint John’s Health Center in Santa Monica, CA, says that he’s not sure a president’s health—whatever the concern—should be so deeply and publicly scrutinized. 

“Health matters are kept confidential normally,” Dr. Cutler says. “There's certainly a precedent for keeping [them] private. From a political point of view, is that information you want to be released or kept confidential? From a personal point of view, I'm not sure [the public] needs to be notified of the disease or specifics.” 

He says that unless someone’s health poses an inherent risk to their job, a president should have the right to keep the specifics of their health confidential. 

What others are saying

The Washington Post has reported that “administration officials, lawmakers from both parties and Democratic donors have raised questions about the president’s cognitive fitness, pointing to alarming moments in private in which Biden seemed distant or confused, and his repeated flubs in public.”^[] Biden has mixed up or forgotten names and important dates.^[] 

David Grabowski, a Harvard Medical School professor, told The Washington Post “President Biden’s decision to end his candidacy relates to carrying out his duties over the next four and [a] half years…From an aging and health perspective, that is different from his fitness to serve today through the end of his current term. The two must be evaluated independently.”^[] There are also concerns over former President Trump’s cognitive decline. Ramin Setoodeh, Co-Editor-in-Chief at Variety told MSNBC that President Trump has severe memory issues.^[]

Many questions about Trump’s mental health have also been raised over the years. In 2020, psychiatrist and author Bandy X. Lee, MD, penned a warning about Trump’s mental health for USA Today, saying, “When the right information became available, a peer-reviewed panel of independent experts performed a standardized assessment of mental capacity, to the highest rigor possible, in which the president failed every criterion. This means he would be unfit for any job, let alone president.”^[]