I’ve been debating whether to write about this for a while now, given that the first article that I noticed about it was first published a week and a half ago. Part of the reason for my reluctance is that it would be too easy for politics to be dragged into this more than I generally like. Of course, I don’t make a secret of my political leanings, but I usually don’t go out of my way to be an explicitly political blogger. I do, however, frequently write about areas where science and medicine intersect, and when I do I always come down on the side of science and rationality.
This brings us to a trope that has popped up in the media that Hillary Clinton is somehow “medically unfit” to be President. I first learned of this smear on August 10, when I found the latest e-mail release from the American Association of Physicians and Surgeons (AAPS), written by its executive director Dr. Jane Orient and entitled Is Hillary Clinton Medically Unfit to Serve? I thought about writing about it at the time, but unfortunately this Dug the Dog saw a squirrel. Next, I was made aware of an article by Martin Shkreli (yes, that Martin Shkreli) using his “expertise” as a pharmaceutical executive to claim that Hillary Clinton has Parkinson’s disease. Even though I was honored to appear as a guest rogue on The Skeptics’ Guide to the Universe and the topic came up, with Steve Novella delivering a forceful denunciation of such speculation, featuring Shkreli’s speculation as the “dumbest thing of the week,” still I didn’t write about it. Then, three days ago, the AAPS dumped another e-mail into my in box, this time in the form of a post by Dr. Gerard J. Gianoli entitled Is Clinton’s Health Less Important than Trump’s? That was the last straw. I made up my mind that I had to address the issue of the armchair diagnosing of the health of Presidential candidates, particularly since my good blog bud and fellow “Walking Dead” fan, Skeptical Raptor, took on the issue just the other day.
It’s not as though I haven’t done this before, of course, although it’s been a long time. The last time I discussed speculations about the health of a Presidential candidate was in 2008, when the issue of John McCain’s history of melanoma came up. I basically said that it was unlikely that his melanoma would recur, and time has proven me correct, as McCain is running for another term as senator this year and doing fine—physically, that is; politically is another question—as he approaches 80.
Finally, I decided that all this idiotic and uninformed speculation about Hillary Clinton’s health was getting on my nerves, as the speculation about Donald Trump’s mental health had done before. As I told Steve Novella on SGU, few people despise Donald Trump or as alarmed at the prospect of a Donald Trump Presidency as I have been, but even so I was profoundly uncomfortable with all the psychological diagnoses being thrown around about him, seemingly without much care. At first, I even thought that it had been a lot of this speculation about Donald Trump’s mental health that had lead Trump supporters to fight fire with fire with even more ignorant speculation about Hillary Clinton’s health, but I soon learned that the “Hillary Clinton is medically unfit to serve” meme had been appearing on Breitbart.com at least as far back as January 6, when a story entitled Law Enforcement Officials, Medical Professionals: There’s Something Seriously Wrong With Hillary Clinton’s Health was published.
Let’s take a look at some of these claims. First, Dr. Orient laid down an op-ed clearly designed to be picked up by as many newspapers as she could get it picked up in (given that it’s only around 700 words long) that consists mainly of a whole lot of JAQing off. After praising Trump for his bluntness and noting that some liberals are throwing around psychiatric diagnoses about Trump, noting, “…keep in mind that a lot of them think conservatives, Christians, and pro-life advocates are crazy too,” Orient lets loose the JAQing off:
There’s the photograph of Secretary Clinton’s difficulty walking up some steps. Now inability to climb stairs does not necessarily disqualify a person for public office. However, neither she nor people with her apparently anticipated a problem. The people helping her seem to be preventing a fall. Did she simply trip? Or was it a seizure or a stroke?
Videos widely circulated on the internet are, if authentic, very concerning. One shows prolonged, inappropriate laughter; another, strange head movements. In a third, she appeared momentarily dazed and confused, and lost her train of thought. Reportedly, she has a volcanic temper. (This is probably not new.)
A man who stays close to her, who is reportedly not a Secret Service officer, was photographed carrying something in his hand that purportedly might have been an autoinjector of Valium.
While we don’t have Mrs. Clinton’s medical records, it is widely stated that she experienced a fall that caused a concussion. Since then, she is sometimes seen wearing eyeglasses with prisms, as are used to correct double vision.
Evidence for these speculations? Almost none. Just a photo and some videos claiming “strange head movements,” a moment of looking “dazed and confused” (Orient’s age may be showing, given the obvious Led Zeppelin reference), and “inappropriate laughter.” There are, of course, also second and third hand reports where the primary witness is never identified, several of which can be found in this Breitbart.com piece and one of which Orient was cited by Orient in the passage above.
Meanwhile, another “brave maverick” doctor of AAPS, Dr. Gerard Gianoli, tries to provide Dr. Orient with tactical air support but only embarrasses himself spectacularly with some really stupid JAQing off:
What are the symptoms of increased intracranial pressure? The most common are headaches, visual problems, and dizziness/balance problems. We know that Ms. Clinton has had all three of these. Less commonly known are “brain fog,” problems with concentration, and short-term memory problems. Sounds familiar?
Why has the media not been inquiring about Mrs. Clinton’s health records as aggressively as they did when GOP candidate John McCain had skin cancer? What do her visits to ophthalmologists and neurologists show? Has she had any neuropsychological testing, as is routinely done in traumatic brain injury cases?
Actually, the media didn’t really inquire that aggressively about John McCain’s skin cancer. Rather, it was a couple of really far out left-wingers who gained notoriety for using McCain’s history of successfully treated melanoma to drive a narrative that McCain was a “dead man walking” (which, obviously, he wasn’t, given that he’s alive and well eight years later), much the same way that it has been Martin Shkreli and Jane Orient who have been driving the false narrative that somehow Hillary Clinton is “medically unfit to serve.”
This is all incredibly thin gruel that leads Orient to wildly speculate further:
Concussions often cause traumatic brain injury, which might not be visualized on standard CT or MRI. Many of our veterans who experienced blast injury from improvised explosive devices suffer from it. These are some symptoms: difficulty thinking, attention deficits, confusion, memory problems, frustration, mood swings, emotional outbursts, agitation, headaches, difficulties with balance and coordination, and seizures. Many veterans with such an injury cannot hold a job or interact normally with their families.
Obviously, it would be very dangerous for a person subject to symptoms like this to be dealing with foreign leaders or making critical decisions. The President of the United States may have to make world-changing decisions on a moment’s notice. For example, should we launch nuclear-armed missiles? And if the Commander in Chief is confused, who will make the call?
To be honest, I’d be much more worried about a perfectly healthy Donald Trump having access to the nuclear missile codes than even a Hillary Clinton with post-concussive syndrome. (Sorry, I couldn’t resist interjecting a little of my own politics there.) I’d also point out that when the President is incapacitated, the Vice President assumes the powers of the Presidency. Be that as it may, what do we have here? Again, nothing other than speculation.
Here’s some of what we do know about what happened. In December 2012 while she was still Secretary of State, Hillary Clinton, ill with a gastrointestinal virus and dehydrated, fainted and hit her head, suffering a mild concussion. After Christmas, she underwent an MRI for unclear reasons (there was a quote about this possibly being “follow-up MRI, that probably would not have happened for regular people” and the routine for a concussion in a patient who recovered rapidly after a few days and hadn’t suffered a skull fracture doesn’t generally include followup imaging). This found a blood clot known as a cerebral venous thrombosis. She was treated with anticoagulation and recovered. Neurosurgeons interviewed for the story agreed that this sort of clot was uncommon after a concussion with no associated skull fracture and was a potentially life-threatening condition for which treatment was indicated. Clinton was treated, and, by all accounts, made a complete recovery.
At this point it’s not inappropriate to note that Dr. Orient’s organization, the AAPS, is a an embarrassingly quacky physician organization that I first discussed ten years ago. (Has it really been that long?) Over the years, I’ve documented how the AAPS, through its house organ the Journal of American Physicians and Surgeons (commonly abbreveated JPANDS), has abused science with hilariously bad studies purporting to demonstrate that abortion causes breast cancer (it doesn’t); that administering multiple vaccines at one visit is not safe (it is) that with respect to DDT and the Zika virus the best strategy is to spray, baby, spray (it isn’t); that shaken baby syndrome is a “misdiagnosis” for vaccine injury (it isn’t); and that President Obama uses neurolinguistic programming to get Americans to do his bidding (he doesn’t). The AAPS is also all-in for a large number of antivaccine tropes.
It’s not too surprising that Jane Orient would like Donald Trump. After all the AAPS is explicitly opposed to any form of government regulation of health care; considers the FDA and Health Care Financing Administration to be unconstitutional; is utterly opposed to Medicare, viewing it as immoral; urges physicians not to participate in Medicare; describes public health programs as “tyranny“; and liberally quotes Ayn Rand. Basically, the AAPS believes that the free market will fix everything that’s wrong with health care. Well, not exactly. Rather, the AAPS believes that the free market, coupled with removing pretty much any restrictions on how doctors practice medicine, be it evidence-based guidelines, board certification, maintenance of certification, peer review, or even state licensure will return medicine to a golden age in which doctor knows best and can do whatever he thinks best for his patient. Of course, it doesn’t matter to the AAPS that such a golden age of medicine never existed.
The leadership of the AAPS, including Orient, and apparently many who publish in JPANDS seem to be a bit too enamored of their self-proclaimed “maverick” status and give the appearance of thinking that, like Ayn Rand’s hero, they’re “supermen” whose egoism and genius will inevitably prevail over timid traditionalism and social conformism. Reining them in with evidence only interferes with their autonomy and prevents them from exercising their genius for the good of their patients. If only the “herd” could appreciate that! No wonder JPANDS has published several articles with titles such as Evidence-based Guidelines: Not Recommended, The Effect of Peer Review on Progress: Looking Back on 50 Years in Science (featuring another scornful dismissal of the “herd instinct” and “conformity” and a fair amount of exaggeration of how much scientific progress is due to “violent confrontation” of old paradigms and how much is due to the slow accumulation of knowledge), and editorials attacking evidence-based medicine. To the AAPS, scientific consensus is evil, and evidence-based guidelines are unacceptable limits on the autonomy of physicians, as are any government regulations or third party payer systems.
But what about the claim that Hillary Clinton has Parkinson’s disease? As Steve Novella points out, first of all, Shkreli is not a neurologist. He isn’t even a physician. Yet he thinks that because he’s been involved in drug development and clinical trials he can diagnose Parkinson’s on the basis of a video in which Clinton shows an exaggerated startle response that looks kind of goofy, which he calls dystonia. He also claims the video in which she trips is a “Parkinsonian freeze.” Dr. Novella, of course, is a real neurologist, and he tells us that none of these were dystonia, a seizure, or anything consistent with Parkinson’s. As he points out, Parkinson’s is an “across the room” diagnosis that is easy for a trained neurologist to recognize. He also notes that it’s impossible to hide for very long and that Clinton has been in the public eye constantly for thousands of hours over the course of the campaign.
This brings us to Donald Trump. Four days ago, the New York Times published an article by Benedict Carey entitled The Psychiatric Question: Is It Fair to Analyze Donald Trump From Afar? The story starts noting an incident from history:
In the midst of a deeply divisive presidential campaign, more than 1,000 psychiatrists declared the Republican candidate unfit for the office, citing severe personality defects, including paranoia, a grandiose manner and a Godlike self-image. One doctor called him “a dangerous lunatic.”
The year was 1964, and after losing in a landslide, the candidate, Senator Barry Goldwater of Arizona, sued the publisher of Fact magazine, which had published the survey, winning $75,000 in damages.
But doctors attacked the survey, too, for its unsupported clinical language and obvious partisanship. In 1973, the American Psychiatric Association adopted what became known as the Goldwater Rule, declaring it unethical for any psychiatrist to diagnose a public figure’s condition “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”
Supporters of the rule make the arguments that (1) most diagnoses made from a distance turn out to be wrong; (2) the labels themselves can cause real harm to the person and family members; and (3) the practice undermines the field’s credibility. All of these are very good arguments, every bit as good as arguments why physicians shouldn’t be “diagnosing” Hillary Clinton with a neurological disorder. The Goldwater rule is still a good rule, but unfortunately during the campaign there have been psychiatrists openly flouting the rule when it comes to Donald Trump.
What I find particularly troublesome is the disingenuous and downright slippery rationalizations made by some psychiatrists and psychologists making these “diagnoses.” For example:
Dr. Steven Buser, a psychiatrist who with his colleague, Dr. Leonard Cruz, coedited a new book, “A Clear and Present Danger: Narcissism in the Era of Donald Trump,” stressed, “We are careful not to make a clinical diagnosis here, to say that Donald Trump has narcissistic personality disorder.” The contributing writers include psychiatrists and psychologists, but Dr. Buser said, “We are focused on the image he projects, on TV, in tweets, in quotes.”
This is, to put it kindly, self-serving bullshit, and highly unethical bullshit at that. Dr. Buser should be ashamed of himself, but obviously isn’t. He should also take a goo, hard look at himself and ask himself how much of his “diagnosis” is due to his political dislike of Donald Trump, and I say this as someone who quite literally despises Donald Trump and opposes him more than any Presidential candidate who’s run in my lifetime.
In the end, as is often the case, my views tend to align with Steve Novella’s view. First, using psychiatric diagnoses as a form of political attack further stigmatizes mental illness. Arguably, this is going on both in the attacks on Hillary Clinton and Donald Trump. While the attacks on Donald Trump explicitly invoke mental illness, the attacks on Hillary Clinton imply that she is unfit due to “brain fog” or mental or psychological consequences of a concussion. I also agree that, if you’re a professional, you should be really, really cautious and circumspect about attributing diagnoses to people whom you have not personally examined and whose medical records and tests you have not personally reviewed. And, certainly, if you are not a professional, you should just stop with the armchair diagnoses altogether. That’s nothing more than embracing the Dunning-Kruger effect wholeheartedly.
The retort one will hear, of course, is that the President is the most powerful person in the world. He or she will have access to the nuclear codes and will command the most powerful military in the world. Surely, the voters have a right to know if a Presidential candidate has a medical condition that might seriously compromise his or her judgment. While this is a good argument, armchair diagnoses, be they from actual physicians with no clinical contact with the candidate or amateurs with no clinical expertise, do not actually address that argument, nor do they serve to prevent compromised candidates from acquiring power. That’s because diagnoses aren’t made that way. They’re still made through direct, hands on diagnosis by physicians who have the appropriate expertise. In the hands of amateurs like Shkreli, quacks like Dr. Orient, and disingenuous, self-justifying docs like Dr. Buser, they are political weapons, not diagnoses.
Hijacking medicine for political purposes serves neither medicine nor politics. It just becomes a tool for partisans to bring down their opponents. Skeptics should not succumb to the temptation to use medicine that way.