Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a doctor should leak a politician's psychiatric history to the media.
Yes: 23%
No: 77%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
No law requires candidates for the presidency to release medical information to the public. In fact, for much of U.S. history, the health of the occupants of the Oval Office was regarded as entirely a private matter. Significant medical conditions, some of them debilitating, remained concealed from voters.
Historians say that Woodrow Wilson likely suffered strokes in 1896 and 1906, the latter of these 6 years before assuming the presidency and 13 before a more severe stroke rendered him incapacitated for much of his final 2 years in office. Dwight Eisenhower struggled with Crohn's disease starting in his 30s. John F. Kennedy battled Addison's disease and chronic pain.
A 2006 study by Duke University psychiatrist Jonathan Davidson, MD, and others suggested that 18 U.S. presidents between 1776 and 1974 -- 49% -- met the criteria for the diagnosis of a psychiatric disorder. While President Eisenhower did release some health information to the media, the health of political candidates first became a major national issue when Senator Thomas Eagleton of Missouri, the running mate of 1972 Democratic presidential nominee George McGovern, withdrew from the ticket after he admitted that he had undergone electroshock therapy for depression.
Over the last few decades, presidential candidates have released their medical records to varying degrees, most notably the extensive disclosure of medical records by Republican candidate John McCain in 2000 and 2008. Yet at least one serious contender for the presidency, Democratic candidate Paul Tsongas, overtly deceived the public when declaring himself cancer-free in 1992. In fact, a bone marrow transplant had failed to cure the non-Hodgkin's lymphoma that ultimately killed the former senator in 1997.
Although, as noted previously, physicians generally have a fiduciary duty to protect the confidences of patients, no duties are truly absolute. Extraordinary circumstances may exist where the public safety or welfare requires a breach of such confidentiality. In the scenario posed in our ethical dilemma, retired psychiatrist, Rick Eckleburg, MD, must decide whether the situation justifies such a breach -- knowing that he may face professional and legal consequences.
A related set of questions arises regarding the medical secrets of deceased presidents. For instance, several U.S. presidents have been rumored to have sired illegitimate children. The possibility that President Grover Cleveland fathered a boy, Oscar, with a woman named Maria Crofts Halpin made the chant "Ma, Ma, where's my pa?" a rallying cry of the 1884 election campaign. President Warren G. Harding's reputation was tarnished by the posthumous accusation, leveled by Nan Britton in "The President's Daughter" (1927), that the married Harding was the father of her daughter, Elizabeth Ann. For many years, surviving relatives of Harding disputed Britton's claim. However, DNA testing in 2015 firmly established a close genetic link between both sets of heirs, solving a long-standing historical mystery.
Not all interest in the DNA of historical figures relates to paternity. A prominent California cardiologist and medical historian, John Sotos, has made a plausible case that Abraham Lincoln suffered from a rare genetic disorder, multiple endocrine neoplasia, type 2B. DNA testing on surviving Lincoln artifacts, such as the now-bloodstained cloak he wore to Ford's Theatre on the night of his assassination, might shed light on this hypothesis and might explain Lincoln's psychological state in the later years of his public service, but the owners of these artifacts have proven reluctant to permit such testing.
Revealing the secrets of past presidents might clarify the historical record but might also have an impact on living relatives -- such as the discovery that the family might still carry a genetic disorder. Another factor in the ethics of revealing secrets related to deceased political leaders might be whether survivors knew the deceased figure personally or hold some other direct connection to him. As time passes, under this latter standard, the claims of survivors will become more tenuous.
While the specific ethical questions Eckleburg faces will arise rarely, the broader implications for public trust in physicians are significant. Few people will likely withhold confidences from their psychiatrists for fear that they will be used against them in a presidential run, but many patients outside the public eye might withhold information if they fear their secrets could be shared with others.
Individuals with bipolar disorder, when appropriately treated, can live extremely productive lives, and many such individuals hold high positions in the public sector. Rather than breach the candidate's confidentiality, another approach might be for Eckleburg to reach out to the candidate and his current physicians directly -- to ascertain whether he is truly untreated or is merely deceiving the public about his treatment. If the candidate is untreated and dangerous, a reasonable case could then be advanced for revealing the diagnosis to the public. The argument for breaching confidentiality is far weaker if the candidate is merely lying, which, unfortunately, places him in the company of many other politicians.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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