The Ailing Leader - A Suitable Case for Occupational Medicine

The ongoing health saga of Pres. Umar Yar’Adua begs the question of whether prospective political office holders should be made to undergo ‘occupational health assessment’. During the course of my reading, I came across an article on this subject.

So what are your views of this issue? Do you agree that our leaders should be made to undergo health assessment?

The article goes thus,

The public is, of course, interested in the details of the personal lives of heads of state, even if it is in a spirit of prurience and directed more towards stars and royals. Illness and its effects on heads of state have interested only a few serious medically qualified historians, notably Hugh L’Etang, who produced three extremely readable accounts of the pathology of leadership and also wrote about occupational health in Africa

There is no doubting the seriousness of the subject—Hugh L’Etang estimated that since 1908, 11 out of 13 British Premiers and 6 out of 10 American Presidents had illnesses whilst in office that incapacitated them to some degree. The issues are (i) Does this matter? (ii) What safeguards can be put in place to prevent adverse fallout?

No one denies that serious illness, mental or physical, or substance abuse can affect performance and decision making, but can one really predict the consequences for a nation, or even beyond that nation, other than with hindsight? Presumably, many leaders have been seriously ill and impaired but their illness had no impact whatsoever on events. This may be even truer these days, where absolute power is becoming rarer and checks and balances, especially in democratic societies, much stronger. Who is to say that the really important conditions that affected the big decisions of the past were not actually rather minor ones—a bad migraine or an attack of gout, a reaction to a gloomy horoscope, even a bad night’s sleep?

Openness about a disease such as cancer may be desirable, indeed admirable, but most leaders are unwilling to divulge such a diagnosis to the undiscerning press who, oddly enough, seem to regard the condition (along with mental illness) with much more alarm than, say, arterial disease.

The 25th amendment to the US Constitution (1967) allows for the Vice President to immediately assume the powers and duties of the President should the President be unable to discharge the powers and duties of his office. There is no mention of appraisal of the situation by medical professionals. In Britain, the Mental Health Act 1983 has a clause which involves ‘any registered medical practitioner’ reporting any Member of Parliament detained for mental illness under the Act to the Speaker of the House of Commons. The Speaker, receiving such a notification (or credible information from two members of the House of Commons to that effect), is obliged to arrange a visit to the MP by two specialists appointed by the President of the Royal College of Psychiatrists, who must report their findings to the Speaker. If, after 6 months, the MP is still mentally ill, the House of Commons is informed and the seat falls vacant (Mental Health Act 1983, section 141).

Apart from this sensible course of action, limited as it is in scope, very little else seems to exist, in an official sense, to deal with the problems of an ailing leader who becomes incapacitated, although other countries may have mechanisms. Dr Owen gives his opinion on this issue and it also involves doctors. He asks ‘Is it reasonable for the personal physicians of a Head of State or Government to be charged with the dual responsibility—both to the good of their patient and to the best interest of their nation?’ He thinks it is not. ‘The 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.’

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This is not to say that there should be no involvement by independent doctors in a Head of State’s health— simply that it does not work at the pre-placement stage. I believe, however, that there may be a case for an activity well known to occupational physicians: namely, health surveillance.

Surveillance would have to be performed by an independent physician or physicians on a regular basis—say, once a year—and involve a discussion of health-related issues, including health education, a physical examination and some validated screening tests. Any occupational physician will be familiar with the approach. This activity would provide some quality assurance for the public but any results would be disclosed only to the Head of State and their personal medical attendants. Heads of State are often very lonely, may find it difficult to confide in their personal doctors and deserve to have objective advice fed back to them out with the treating doctor–patient relationship. The confidentiality of the arrangement would have to be watertight, although there might have to be some capacity for an independent doctor to disclose dementia or severe psychiatric disorder serious enough to render the leader incompetent or on the verge of committing illegal or immoral acts. This is the public interest argument and would only occur in an extreme situation.

A more likely scenario is, as Lord Owen says, that the press or public realize that a leader’s health is failing, and I agree with him that for personal or independent doctors to release their detailed findings to politicians or the public puts too much authority into the doctor’s hands. Removal of a leader under such circumstances is really more of a political than a medical judgement and in any case it is, or has been, frequently difficult for doctors to agree with one another in these circumstances. I suggest this might be because a person specification for a Head of State has yet to be written.

In his piece, Lord Owen has revived an important debate about how ill-health in leaders should be dealt with and why doctors, feeling responsibilities to the public as well as their patient, have often found themselves negotiating a minefield. Serving two masters—patient and employer—is a fact of everyday life for occupational physicians, who have devised a code of ethics that serves all parties very satisfactorily. Occupational physicians who are expected to predict fitness for work, even fitness to achieve pensionable age, know just how difficult this is to do in practice. Illness, incapacity and death come to us all. Leaders deserve the best of care in their own interests, not ours. Details of their ailments can be kept confidential whilst ensuring that robust and independent mechanisms are officially in place should functional impairment become dangerous.

D. Snashall

Occupational Health Department,St Thomas’Hospital,
Lambeth Palace Road, London SE1 7EH,UK