In the realm of American politics, discussing the mental fitness of a sitting president – or the performance of a former one – is as delicate as it is critical.

As a psychiatrist, I am profoundly aware of the ethical constraints outlined by the Goldwater Rule, adopted by the American Psychiatric Association (of which I am a Fellow). Psychiatrists’ ethical responsibility is to refrain from making specific clinical diagnoses without direct examination and consent. Yet, the cognitive abilities of former President Joseph Robinette Biden Jr. have become an undeniable public discourse, one I engage with not from a partisan stance but from medical and legal standpoints rooted in my extensive experience at the intersection of psychiatry, neurology, and law.

For full disclosure, I may peripherally gain benefit from this discussion by undermining the government’s illegal and invalid prosecutions of physicians during the era of the affected former president. Yet, I may also catch the fury of those supporting the former president. Supporters of the current sitting President Donald J. Trump may also feel a slight to his legacy from broaching this topic. Nonetheless, this is a pure medico-legal ethical discussion, without partisan politics.

Former President Biden’s documented medical history, notably his surgeries for cerebral aneurysms, inherently raises clinical concerns. Surgical interventions for brain aneurysms, as former President Biden underwent decades ago, carry significant risk factors for cognitive impairment later in life. Neurological literature robustly correlates vascular incidents, such as aneurysms and subsequent neurosurgical interventions, with potential cognitive decline, possibly manifesting as vascular dementia or a major neurocognitive disorder with vascular features according to the DSM-5-TR criteria.

Adding to concerns about transparency, recent revelations about former President Biden receiving care in a notably secretive manner for advanced prostate cancer, as reported by many media channels, underscore the importance of openness regarding the health of public officials. Such secrecy intensifies questions about potential undisclosed cognitive impairments, further complicating public confidence in leadership health disclosures. The public and the medical community are in a tailspin about whether the advanced prostate cancer diagnosis was an active one during his presidency.

A renowned neurologist, Russel Surasky, MD, publicly suggested that former President Biden exhibited symptoms consistent with vascular dementia as early as 2021. Surasky’s observations, disseminated through various media outlets, highlight visible signs he considers consistent with this diagnosis, including memory lapses, difficulty with language, and slowed cognitive processing speed. As a psychiatrist, my concern aligns less with definitive diagnosis—which ethically must be withheld absent direct examination—and more with the mechanisms of assessment and transparency needed for the American public. Several non-psychiatrist colleagues have written on this blog about the public observable symptoms of former President Biden and his decline.

The DSM-5-TR defines major neurocognitive disorder with vascular features as significant cognitive decline from a previous level of functioning, impairing independence in everyday activities. Symptoms can include executive dysfunction, processing speed decline, memory impairment, and fluctuating cognitive performance. These indicators, though non-specific and present across various neurocognitive disorders, must be thoroughly evaluated in individuals with known vascular brain events.

Given former President Biden’s known aneurysm history, assessing cognitive decline with a high degree of clinical accuracy demands comprehensive neuropsychological testing and neuroimaging studies. Standard cognitive screening tools such as the Montreal Cognitive Assessment (MoCA) or the Mini-Mental State Examination (MMSE), typically administered by White House physicians, while informative, may not fully capture subtle yet consequential deficits relevant to presidential decision-making. Moreover, such evaluations have remained confidential, complicating public trust and spurring conspiracy theories.

Significantly, public debate performance has provided observable contrasts in cognitive and physical agility between former President Biden and current sitting President Trump. While Biden has exhibited moments of noticeable cognitive lapses and diminished physical agility, President Trump himself faces ongoing allegations and concerns regarding his mental stability. These contrasting yet concerning indicators underscore the urgency of objective, transparent, and comprehensive mental health assessments for all presidential candidates, ensuring the American public’s confidence in their leaders’ cognitive and psychological fitness.

For example, a practicing physician exhibiting just a small portion of the cognitive decline and lapses exhibited by former President Biden would quickly be referred to the state medical boards for an assessment and would lose his license in short order. From a medico-legal perspective, significant cognitive impairment in a sitting president has profound implications. The 25th Amendment clearly stipulates processes to address presidential incapacity. However, activating this constitutional safeguard requires incontrovertible medical evidence, transparent clinical evaluations, and a consensus of qualified medical professionals. Historical precedence underscores the gravity of this measure and the rigorous standard it demands.

The stakes are extraordinarily high. Former President Biden’s cognitive health impacts not only his personal legacy but also the validity of executive actions, legislation endorsements, judicial appointments, and foreign policy decisions made during his tenure. Cognitive lapses displayed publicly, such as his infamous debate statement, “we finally beat Medicare,” further fuel legitimate public and medical concern. Such moments raise critical questions about decision-making capacities, from daily governance to pivotal policy decisions.

During former President Biden’s tenure, the White House occasionally turned to an autopen—a mechanical device replicating signatures—to execute official documents. This practice sparked controversy and fueled passionate debate about Biden’s cognitive health, prompting the Senate to openly question his mental fitness. Critics seized upon the autopen as symbolic proof of what they perceived as Biden’s undeniable cognitive decline, raising critical concerns about authenticity, transparency, and legacy.

My personal and professional journey, marked by profound encounters with governmental scrutiny intersecting medical and legal realms, reinforces my advocacy for transparency and rigorous evaluation standards. Public trust hinges on the assurance that the nation’s highest officeholder maintains cognitive fitness to fulfill the demanding responsibilities of the presidency. Thus, my call is unequivocal: Establish clear, impartial protocols for cognitive health assessments of our leaders, respecting their dignity yet upholding the essential tenets of transparency and accountability. Only through rigorous, standardized, and publicly accountable cognitive evaluations can we effectively balance respect for personal medical privacy with our imperative civic duty.

Former President Biden deserves compassionate care and dignified treatment, free from undue stigma or partisan exploitation. Yet, equally, the American people deserve assurance, supported by robust medical evaluation, that their sitting president, or a prospective candidate, can meet the demands of his office fully and capably. The stakes, ethically, legally, and nationally, could not be higher. Transparency, medical integrity, and constitutional clarity must guide us. In confronting this challenging discourse around former President Joseph Robinette Biden Jr.’s cognitive health, we navigate not merely the medical intricacies of dementia or neurocognitive disorder but the foundational trust upon which our democracy stands.

Muhamad Aly Rifai is a nationally recognized psychiatrist, internist, and addiction medicine specialist based in the Greater Lehigh Valley, Pennsylvania. He is the founder, CEO, and chief medical officer of Blue Mountain Psychiatry, a leading multidisciplinary practice known for innovative approaches to mental health, addiction treatment, and integrated care. Dr. Rifai currently holds the prestigious Lehigh Valley Endowed Chair of Addiction Medicine, reflecting his leadership in advancing evidence-based treatments for substance use disorders.

Board-certified in psychiatry, internal medicine, addiction medicine, and consultation-liaison (psychosomatic) psychiatry, Dr. Rifai is a fellow of the American College of Physicians (FACP), the American Psychiatric Association (FAPA), and the Academy of Consultation-Liaison Psychiatry (FACLP). He is also a former president of the Lehigh Valley Psychiatric Society, where he championed access to community-based psychiatric care and physician advocacy.

A thought leader in telepsychiatry, ketamine treatment, and the intersection of medicine and mental health, Dr. Rifai frequently writes and speaks on physician justice, federal health care policy, and the ethical use of digital psychiatry.

You can learn more about Dr. Rifai through his Wikipedia page, connect with him on LinkedIn, X (formerly Twitter), Facebook, or subscribe to his YouTube channel. His podcast, The Virtual Psychiatrist, offers deeper insights into topics at the intersection of mental health and medicine. Explore all of Dr. RRifai’splatforms and resources via his Linktree.