Doctors and Politics

A graduate of Harvard and of the Harvard Medical School, DR. DAVID D. RUTSTEIN, aspecialist in internal and preventive medicine, has been Professor of Preventive Medicine and Head of the Department at the Harvard Medical School since 1947. Dr. Rutstein is a member of the staff of the Massachusetts General Hospital and five other Boston hospitals, and is Vice President of the American Heart Association. He is a member of the American Society for Clinical Investigation and serves on the Expert Advisory Panel on Chronic Degenerative Diseases for the World Health Organization.



ON APRIL 12, 1945, the world was shocked by the news of the sudden death from cerebral hemorrhage of President Franklin Delano Roosevelt. There had been rumors dating back to early 1944, each suggesting that the President, in addition to his old poliomyelitis, had one or another serious illness. But Vice Admiral Ross T. McIntire, the President’s physician, repeatedly denied the existence of any specific malady, and Mr. Roosevelt was nominated and re-elected for his fourth term. Photographs of the President, particularly those taken at Yalta, showed that he was noticeably thinner and frailer and even gave the impression that he suffered from a severe wasting disease, and a few months later he was dead. The Admiral subsequently ascribed his patient’s progressive deterioration to the continual strain of the Presidency. Indeed, up to this day the published medical reports concerning President Roosevelt’s illness are so vague as to yield no definite diagnosis. His illness consisted of chronic cough, “sinusitis,” abdominal distress and distention, profuse perspiration, elevated blood pressure, and progressive loss of weight and strength. One can only guess that his death was due to rapidly progressive blood vessel disease associated with high blood pressure.

This was not the first time that the American public had been taken unawares by an acute health problem in the President of the United States developing out of a situation where it had been felt necessary by the President or his advisers to minimize the news reports of his illness. Woodrow Wilson’s “stroke” was called a nervous breakdown. The suppression of the true nature of his disease led to all sorts of unfounded rumors which confused the American public at a very critical time. Actually the country was, practically speaking, without a President for at least several months and had at best a very ill part-time President for about a year and a half.

The news about the coronary thrombosis of President Dwight D. Eisenhower in September, 1955, was handled in a strikingly different way. After the announcement of the President’s heart attack on September 24, news bulletins appeared and press conferences occurred at regular intervals. These gave the appearance of full disclosure of all pertinent medical information. An optimistic picture of the President’s life-expectancy following recovery was a feature of all these conferences. However, the public was not informed of the published scientific evidence on the prognosis of patients surviving a coronary occlusion.

There have been three such studies in recent years. The first in 1941, by Drs. Edward F. Bland and Paul D. White of Boston, demonstrated that the five-year survival of such patients was approximately 50 per cent; that is, of a group of individuals who had recovered from the acute attack, one half were alive at the end of five years. More recent reports, one from the Michael Reese Hospital in Chicago in 1954 and the other from Vanderbilt University Medical School in Nashville, Tennessee, in 1955, verified the survival rate of the Boston study. The Chicago report demonstrated that the older the individual is at the time of the coronary thrombosis, the shorter his life-expectancy; ond that of those stricken at age 65, 50 per cent were alive five years later, a figure identical with that reported by Eland and White in 1941. It would seem that the optimistic statements made during President Eisenhower’s recovery from his coronary occlusion are at variance with the published scientific information in the medical literature, and that no other data were presented to justify the optimistic conclusions except Dr. White’s statement: “The majority of patients I see with this condition do well.”

When President Eisenhower’s recovery from his acute coronary thrombosis was practically complete, his physicians announced on February 13, 1956: “The President should be able to carry on an active life satisfactorily for another five to ten years.” This publicized decision by his physicians gave President Eisenhower no choice on medical grounds of refusing to run for re-election, and this in effect was confirmed by the President’s television announcement of February 29, 1956. This episode demonstrates the powerful influence a medical decision may have on our national history. It causes us to re-examine the process by which such decisions are reached and later interpreted to the public.


ON JUNE 8, 1956, President Eisenhower was suddenly taken with acute abdominal pain which was diagnosed by his physicians within twelve hours as “ileitis.” It is very doubtful that any physician can make an unequivocal diagnosis of this disease in a patient whose presenting symptom is intestinal obstruction unless the physician has had previous knowledge of the existence of this disease in the patient. During the course of President Eisenhower’s convalescence from acute coronary thrombosis, no mention had been made of this chronic illness. On May 13, less than one month before the President’s chronically inflamed and scarred small intestine became suddenly obstructed, an X-ray examination of his stomach and intestines (gastrointestinal series) was reported as showing a “normally functioning digestive tract,” but no mention was made of the presence or absence of any structural defect.

On Saturday, June 9, the date of the President’s operation, a group of physicians meeting informally were discussing the President’s illness prior to the announcement Saturday afternoon of the precise findings at operation. All agreed that the history of the acute illness as released to the public up to that time was inconsistent with the diagnosis of ileitis, because ileitis is a chronic disease which very rarely has obstruction as its first symptom. Since the presence of cancer had been flatly denied and the simple explanation of mechanical obstruction due to a twisted segment of intestine had not been mentioned at the press conference early Saturday morning, this group of doctors agreed that in a patient with a previous history of blood vessel occlusion (coronary thrombosis) the most likely diagnosis was an obstruction of one of the blood vessels supplying the intestine — that is, mesenteric thrombosis. When information of previous gastrointestinal attacks was made public at the afternoon press conference, together with confirmation at operation of the previous diagnosis of ileitis, it became clear that the acute obstruction was merely a late episode in the course of a chronic illness and not a new disease beginning at age 65.

The acute onset of the President’s second chronic disease, regional ileitis, again focused attention on the President’s physicians. After the first twentyfour hours, when the operation was decided upon and effectively performed, the newsmen immediately asked the doctors whether the President would be able to run again, as pointed out in the following quotation from Editor and Publisher for June 16, 1956:—

Mr. Hagerty recognized the question that was plaguing the newsmen for answer. When the correspondents successfully resisted the impulse but seemed on the verge of putting it to the panel of doctors, Mr. Hagerty sidetracked it in his introductory: “Remember, please, these are medical men, not politicians.”

but only about 10 hours after they had performed the successful operation on the President, the doctors relieved themselves of pressure by giving it as their considered medical opinion that nothing that had happened should prevent Ike from following his planned life, candidacy included.

The statement issued at that time by the President’s physicians was not limited to the medical facts and their interpretation. They apparently were perfectly willing, even before the immediate effects of the operation were known, to issue a statement assuring the country that the President’s health would in no way prevent him from carrying out his previous plans. At no time did they give any indication that ileitis is a chronic disease with a rate of recurrence varying between one third and two thirds of those on whom operation is performed, depending on the stage of the disease, the type of surgery, and the duration of follow-up. Neither did they indicate that the majority of recurrences come within the first year after operation. Nor was there any mention of the medical fact that difficulty might be anticipated in maintaining the President’s nutrition and weight, or the further likelihood of future periods of disability from the disease.

When the doctors were asked if the President’s life-expectancy had been affected, they replied, “We certainly don’t think so,” and added, “We think it improves his life-expectancy.” There is no question that the relief of the intestinal obstruction improved the health of the President. On the other hand, the emergence of a second chronic illness cannot by any stretch of the imagination improve the total health status of the patient.

When the President’s physicians were faced with statements of other physicians throughout the country that ileitis is a chronic disease; that recurrence at the site of the sidetracking operation is a likely possibility; and that although this second disease would probably have little effect on life-expectancy, it might cause recurrent periods of disability, refuge was taken in the statement that patients aged 65 do not have recurrences of this disease. Actually, the scientific reports in the medical literature refer to age of onset of disease and not to age at operation. Moreover, at all ages where enough cases have been collected for analysis, as, for example, in the studies at the Mayo clinic, age has had no effect on the recurrence rate. The statement by an individual surgeon that he has seen no recurrences at age 65 has no predictive value unless one knows how many cases in this age group have been under study by that particular surgeon.

After this controversy developed, the policy of free and open discussion of the health status of the President was suddenly changed. On June 19 Mr. Hagerty announced that the physicians “have no intention of engaging in controversy with other doctors who have no personal knowledge of the case.” This new policy in effect insulates the President’s physicians against all criticism of any of their statements by any other physician.


THE occurrence of severe illness in three Presidents of the United States within a period of some forty years raises the important question of the responsibility to the public of the physicians attending the President.

It is clear that the first responsibility of the physician is to his patient. A physician must diagnose and treat his patient to the best of his ability and do everything possible to prevent complications and to prolong life. By medical ethics he is bound not to divulge confidential information given to him by the patient, particularly when release of such information might be harmful to the patient. The physician may also be prohibited by law from testifying in a court on any medical information given to him by a patient unless he has the permission of the patient to do so. Moreover, if he releases information to the public, he may be sued by the patient in the event that such release were harmful to his patient.

Although no basis for the principle of the confidential patient-physician relationship is established in the common law, approximately one half of the states have affirmed this principle by statute. It is of interest that both Pennsylvania and the District of Columbia have such statutes.

A grave responsibility is borne by a physician to any presidential candidate, whether he be a President running for re-election or a candidate seeking the office. The doctor not only owes primary allegiance to his patient but, as a citizen with special information and skills, he has a duty to the public. It matters not whether he is concerned with Mr. Eisenhower’s coronary thrombosis and ileitis, Mr. Averell Harriman’s recently reported prostate operation, or Mr. Adlai Stevenson’s previously reported kidney stones: the withholding of information could conceivably bring great harm to the nation as a whole. This event ually leads us to ask: When do the practice of medicine and medical decisions resulting therefrom become matters of political influence?

There are a number of different questions which must be considered in attempting to solve this important problem. First, what is the responsibility of the physician in the event that he is instructed by his patient that he is to divulge no information about his illness regardless of the effect on the country? Second, what are his responsibilities if he is told that certain, but not all, information may be divulged? Third, what kind of information should he give to the public if he is free to tell everything he knows about the patient ?

The answers to these questions have to be related to the potential danger to which the country may be exposed by the withholding of essential information or by the distortion attendant on the release of partial information. It might be argued that it would be justifiable to withhold essential information about the health of the President if that would seriously affect negotiations in process with other countries, or if during a war there still remains a long period of time in a presidential term. Also an acute domestic situation might justify deferment of information on the President’s health for a short period of time. But how are these questions to be answered in the case of the health of a candidate for high office?

A most difficult situation exists for the physician when he is told that he is not permitted to divulge any information. This, however, is likely to happen only when the illness of the President is so subtle that the public does not know that he is ill at all, as was the case with Franklin D. Roosevelt. When the President is ill enough to require hospital admission it is almost impossible for him, or his representative, to instruct his physician that no information is to be given out. In a democratic society with newspaper reporters at hand, hospitalization of the President cannot be concealed.

To what extent do medical ethics insist that the leadership of the nation be jeopardized because of the physician-patient relationship? In this connection it is worth noting that The Principles of Medical Ethics of the American Medical Association (1949) in Section 2, headed “The physician’s responsibility,” quotes Sir Thomas Watson as follows: “The profession of medicine having for its end the common good of mankind knows nothing of national enmities, of political strife, of professional dissensions. . . .” There is, however, no clear-cut statement in these Principles to guide a physician in deciding when the public interest may require him to divulge information if the patient does not give him permission.

Where the physician, either on his own responsibility or acting on advice, releases only partial information, we may ask again whether medical ethics would require him to withhold important information about the health status of the President, particularly if the national safety is affected.

If the physician is given permission to discuss all aspects of the patient’s illness, the restrictions on the patient-physician relationship no longer exist. The physician is then on his own, and he speaks with all the authority of a professionally trained individual with a unique opportunity to provide essential information to the people in their selection of the leader of their country. Should he restrict his information to medical facts and their interpretation, or should he go on from there and attempt to evaluate the political implications of his statements? There can be little disagreement that the physician should present the medical facts and their interpretation to the best of his ability. He should also be expected to interpret such facts in the light of all available documented scientific knowledge concerning the disease in question. Moreover, if his interpretation of the facts is at variance with such scientific evidence in the medical literature, he should be expected to produce in detail the data which just ify his own interpretation and permit him to disregard published evidence.

Once having presented the medical facts and their interpretations, if the physician goes beyond this point, he then ceases to be an expert. He becomes just an ordinary citizen subject to political influences in a field in which he has no expert qualifications. Indeed the political interpretation of medical information by a physician can only weaken the credibility of the original data. Once a physician’s credibility is questioned, his status as an expert disappears. Political judgments by physicians have as little merit as medical judgments by politicians on the ability of a candidate to run for office. If the physician goes outside his field, the average citizen whose medical care is dependent upon his personal confidence in the physician-patient relationship begins to wonder. Meanwhile the headline writers take over and distort not only the statements of the physicians but also those of their critics, and confusion reigns.

If on the other hand the physician limits his statements to the medical facts and in his interpretation relates them precisely to the scientific information in the medical literature on the disease, he will automatically resolve any possible conflicts between his responsibility to his patient and his duty to his country. When the demands of the Presidency exceed the physical capacity of an incumbent or a presidential candidate, the physician would so inform his patient. If the patient accepted this advice, his health would be protected and the country would not be called upon to continue in office or to choose a President who was not well enough to serve. If the patient refused the advice, the physician would then have to inform the press that the ethics of the physicianpatient relationship did not permit him to discuss the case. But if his patient were able to carry on, the physician would give the facts and indicate the documented scientific medical information which would justify his decision. Thus, in any case, if the physician remains within the area of his competence and adheres to the code of medical ethics, the interests of both parties — the patient and the public — are safeguarded.

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