Who Decides If Presidents Are Unfit to Serve?

American presidents are not required to pass mental health exams or psychological and psychiatric evaluations before taking office in the United States. But some psychologists and members of Congress have called for such mental health exams for candidates following the 2016 election of Republican Donald Trump. Even members of Trump's own administration expressed concern about his "erratic behavior" in office. The president described himself as a "very stable genius."

The idea of requiring presidential candidates to undergo mental health exams is not new, though. In the mid-1990s, former President Jimmy Carter pushed for the creation of a panel of physicians who would routinely evaluate the most powerful politician in the free world and decide whether their judgment was clouded by a mental disability. "Many people have called to my attention the continuing danger to our nation from the possibility of a U.S. president becoming disabled, particularly by a neurologic illness," Carter wrote in a December 1994 issue of the Journal of the American Medical Association.

Monitoring a President's Health

Carter's suggestion led to the creation in 1994 of the Working Group on Presidential Disability, whose members later proposed a nonpartisan, standing medical commission "to monitor the president's health and issue periodic reports to the country." Carter envisioned a panel of expert physicians who were not directly involved in the care of the president determining whether he had a disability.

"If the president of the United States must decide within minutes how to respond to a dire emergency, its citizens expect him or her to be mentally competent and to act wisely," wrote Dr. James Toole, a professor of neurology at Wake Forest University Baptist Medical Center in North Carolina, who worked with the group. "Because the presidency of the United States is now the world's most powerful office, should its incumbent become even temporarily unable to exercise good judgment, the consequences for the world could be unimaginably far-reaching."

There is currently no such standing medical commission in place, however, to observe a sitting president's decision-making. The sole test of a candidate's physical and mental fitness to serve in the White House is the rigor of the campaign trail and election process.

Mental Fitness in the Trump White House

The idea of requiring presidential candidates to undergo mental health evaluations arose in the general election campaign of 2016, primarily because of Republican nominee Donald Trump's erratic behavior and numerous incendiary comments. Trump's mental fitness became a central issue of the campaign and became more pronounced after he took office. 

A member of Congress, Democrat Karen Bass of California, called for a mental-health evaluation of Trump before the election, saying the billionaire real-estate development and reality television star exhibits signs of Narcissistic Personality Disorder. In a petition seeking the evaluation, Bass called Trump "dangerous for our country. His impulsiveness and lack of control over his own emotions are of concern. It is our patriotic duty to raise the question of his mental stability to be the commander in chief and leader of the free world." The petition carried no legal weight.

A lawmaker from the opposing political party, Democratic Rep. Zoe Lofgren of California, introduced a resolution in the House of Representatives during Trump's first year in office encouraging the vice president and the Cabinet to hire medical and psychiatric professionals to evaluate the president. The resolution stated: “President Donald J. Trump has exhibited an alarming pattern of behavior and speech causing concern that a mental disorder may have rendered him unfit and unable to fulfill his Constitutional duties."

Lofgren said she drafted the resolution in light of what she described as Trump's "increasingly disturbing pattern of actions and public statements that suggest he may be mentally unfit to execute the duties required of him.” The resolution did not come up for a vote in the House. It would have sought the removal of Trump from office by employing the 25th Amendment to the Constitution, which allows for the replacement of presidents who become physically or mentally unable to serve. 

In December 2017, more than a dozen members of Congress invited a Yale University psychiatry professor, Dr. Bandy X. Lee, to evaluate Trump's behavior. The professor concluded: “He’s going to unravel, and we are seeing the signs.” Lee, speaking to Politico, described those signs as Trump “going back to conspiracy theories, denying things he has admitted before, his being drawn to violent videos. We feel that the rush of tweeting is an indication of his falling apart under stress. Trump is going to get worse and will become uncontainable with the pressures of the presidency.”

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Trump Declines to Make Health Records Public

Some candidates have chosen to make their health records public, particularly when serious questions have been raised about their well being. The 2008 Republican presidential nominee, John McCain, did so in the face of questions about his age (he was 72 at the time) and previous ailments, including skin cancer.

And in the 2016 election, Trump released a letter from his physician that described the candidate as being in "extraordinary" health, both mentally and physically. "If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency," wrote Trump's doctor. Trump himself said: "I am fortunate to have been blessed with great genes — both of my parents had very long and productive lives." But Trump did not release detailed records about his health.

Psychiatrists Can't Diagnose Candidates

The American Psychiatric Association banned its members from offering opinions about elected officials or candidates for office after 1964 when a group of them called Republican Barry Goldwater unfit for office. Wrote the association:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

The policy became known as the Goldwater Rule.

Who Decides If a President Is Unfit to Serve?

So if there's no mechanism in place by which an independent panel of health experts is able to evaluate a sitting president, who decides when there might be a problem with his decision-making process? The president himself, which is the problem.

Presidents have gone out of their way to hide their ailments from the public and, more importantly, their political enemies. Among the most notable in modern history was John F. Kennedy, who didn't let the public know about his colitis, prostatitis, Addison's disease, and osteoporosis of the lower back. While those ailments certainly would not have precluded him from taking office, Kennedy's reluctance to disclose the pain he suffered illustrates the lengths to which presidents go to conceal health problems.

Section 3 of the 25th Amendment to the U.S. Constitution, which was ratified in 1967, allows a sitting president, members of his cabinet, or, in extraordinary circumstances, Congress, to transfer his responsibilities to his vice president until he has recovered from a mental or physical ailment.

The amendment reads, in part:

Whenever the President transmits to the President pro tempore of the Senate and the Speaker of the House of Representatives his written declaration that he is unable to discharge the powers and duties of his office, and until he transmits to them a written declaration to the contrary, such powers and duties shall be discharged by the Vice President as Acting President.

The problem with the constitutional amendment, however, is that it relies on a president or his cabinet to determine when he is unable to perform the duties of the office.

The 25th Amendment Has Been Used Before

President Ronald Reagan used that power in July 1985 when he underwent treatment for colon cancer. Though he did not specifically invoke the 25th Amendment, Reagan clearly understood his transfer of power to Vice President George Bush fell under its provisions.

Reagan wrote to the House Speaker and Senate President:

After consultation with my Counsel and the Attorney General, I am mindful of the provisions of Section 3 of the 25th Amendment to the Constitution and of the uncertainties of its application to such brief and temporary periods of incapacity. I do not believe that the drafters of this Amendment intended its application to situations such as the instant one. Nevertheless, consistent with my longstanding arrangement with Vice President George Bush, and not intending to set a precedent binding anyone privileged to hold this Office in the future, I have determined and it is my intention and direction that Vice President George Bush shall discharge those powers and duties in my stead commencing with the administration of anesthesia to me in this instance.

Reagan did not, however, transfer the power of the presidency despite evidence that later showed he might have been suffering from the initial stages of Alzheimer's. 

President George W. Bush used the 25th Amendment twice to transfer powers to his vice president, Dick Cheney. Vice President Cheney served as acting president for about four hours and 45 minutes while Bush underwent sedation for colonoscopies.

Key Takeaways

• Presidents and candidates seeking election to the White House are not required to pass mental health exams or psychological and psychiatric evaluations.
• The 25th Amendment to the U.S. Constitution allows members of a president's cabinet or Congress to remove a president from office if he is mentally or physically unable to serve. The provision has never been used to permanently remove a president from office.
• The 25th Amendment remained a relatively obscure provision in the Constitution until Presidential Donald Trump took office. Members of Congress and even his own administration grew concerned about his behavior.

Sources

• Barclay, Eliza. "The psychiatrist who briefed Congress on Trump's mental state: this is 'an emergency.'" Vox Media, January 6, 2018.
• Bass, Karen. "#DiagnoseTrump." Change.org, 2020.
• Foiles, Jonathan. "Is Donald Trump Unfit to Be President?" Psychology Today, Sussex Publishers, LLC, September 12, 2018.
• Hamblin, James. "Is Something Neurologically Wrong With Donald Trump?" The Atlantic, January 3, 2018.
• Karni, Annie. "Washington's growing obsession: The 25th Amendment." Politico, January 3, 2018.