Welcome to Ethics Consult – an opportunity to discuss, debate (with respect) and learn together. We select an ethical dilemma from a genuine, but anonymized patient care case, and then provide expert commentary.

Last week you voted on whether a doctor should disclose a politician’s psychiatric history to the media.

Yes: 23%

No: 77%

And now bioethicist Jacob M. Appel, MD, JD, steps in.

There is no law requiring presidential candidates to disclose medical information to the public. In fact, for much of American history, the health of the occupants of the Oval Office was considered an entirely private matter. Important medical conditions, some debilitating, remained hidden from voters.

Historians say that Woodrow Wilson probably suffered strokes in 1896 and 1906, the last of those 6 years before assuming the presidency and 13 before a more severe stroke left him incapacitated for a long time. part of his last 2 years in office. Dwight Eisenhower battled Crohn’s disease from his early thirties. 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 US presidents between 1776 and 1974 – 49% – met diagnostic criteria for a psychiatric disorder. While President Eisenhower disseminated health information to the media, the health of political candidates first became a major national problem when Senator Thomas Eagleton of Missouri, running mate of 1972 Democratic presidential candidate George McGovern, Withdrew from the candidacy after admitting he had undergone electroconvulsive therapy for depression.

Over the past decades, presidential candidates have released their medical records to varying degrees, including the extensive disclosure of medical records by Republican candidate John McCain in 2000 and 2008. Yet at least one serious presidential candidate, the candidate Democrat Paul Tsongas, openly deceived the public into declaring himself cancer-free in 1992. In fact, a bone marrow transplant had failed to cure the non-Hodgkin lymphoma which ultimately killed the former senator in 1997.

While, as noted earlier, physicians generally have a fiduciary duty to protect patient confidential information, no duty is really absolute. Extraordinary circumstances may exist when the safety or public welfare demands a breach of this confidentiality. In the scenario posed in our ethical dilemma, retired psychiatrist Rick Eckleburg, MD, must decide whether the situation warrants such a violation – knowing that he may face professional and legal consequences.

A set of related questions arise regarding the medical secrets of deceased presidents. For example, several American presidents have reportedly fathered illegitimate children. The possibility that President Grover Cleveland fathered a boy, Oscar, with a woman named Maria Crofts Halpin made the song “Ma, Ma, where’s my father?” 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 married Harding was the father of his daughter, Elizabeth Ann. For many years, Harding’s surviving parents contested Britton’s claim. However, DNA testing in 2015 firmly established a strong genetic link between the two groups of heirs, solving a long-standing historical mystery.

Not all the interest in the DNA of historical figures is related to authorship. A prominent California cardiologist and medical historian John Sotos presented a plausible case that Abraham Lincoln suffered from a rare genetic condition, multiple endocrine neoplasia, type 2B. DNA testing of surviving Lincoln artifacts, such as the now bloodstained cloak he wore at Ford’s Theater on the night of his assassination, may shed light on this hypothesis and explain Lincoln’s psychological state in the later years of its utility, but the owners of these artifacts have been reluctant to allow such testing.

Revealing the secrets of former presidents could clarify historical records, but could also have an impact on living relatives, such as the discovery that the family may still be carriers of a genetic condition. Another factor in the ethics of revealing secrets related to deceased political leaders could be whether the survivors knew the deceased person personally or had some other direct connection to him. Over time, under this latter standard, survivors’ claims will become more tenuous.

While the specific ethical questions Eckleburg faces will rarely arise, the broader implications for public trust in physicians are important. Few people are likely to withhold confidences from their psychiatrists for fear they will be used against them in a presidential race, but many patients outside the public could withhold information if they fear their secrets will be shared with them. others.

People with bipolar disorder, when treated appropriately, can lead extremely productive lives, and many of these people hold senior positions in the public sector. Rather than violating the candidate’s confidentiality, another approach could be for Eckleburg to contact the candidate and his current doctors directly – to check if he is really not being treated or if he is simply deceiving the public about his treatment. If the candidate is untreated and is dangerous, then a reasonable case could be brought forward to reveal the diagnosis to the public. The argument for a breach of confidentiality is much weaker if the candidate is just lying, which unfortunately puts 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 of the Icahn School of Medicine at Mount Sinai in New York. He holds an MD from Columbia University, a JD from Harvard Law School, and an MA in bioethics from Albany Medical College.

And check out some of our previous ethics consultation cases:

Disclose Another Surgeon’s Higher Survival Rate?

“I want a white surgeon”

Bypass US rules and conduct research in Africa?

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