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Nationally recognized psychiatrist, internist, and addiction medicine specialist Muhamad Aly Rifai discusses his article, “How President Biden’s cognitive health shapes political and legal trust.” While carefully observing the ethical constraints of the Goldwater Rule, he analyzes the public discourse surrounding the cognitive health of former President Joseph Robinette Biden Jr. from a medico-legal standpoint. Muhamad explains how the former president’s known medical history, including surgeries for cerebral aneurysms, creates a clinical basis for concern about potential cognitive decline consistent with vascular dementia. He argues that public moments of cognitive lapse, combined with practices like the use of an autopen for official signatures, raise legitimate questions about a leader’s decision-making capacity and the validity of their actions. The core of his argument is an unequivocal call to establish clear, impartial, and publicly accountable protocols for cognitive health assessments for all national leaders, asserting that this is essential to uphold public trust and the integrity of the office.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai, internist and psychiatrist. Today’s KevinMD article is “How President Biden’s Cognitive Health Shapes Political and Legal Trust.” Muhamad, welcome back to the show.

Muhamad Aly Rifai: Thank you very much for having me to talk about this important topic on the mental health issues related to politicians, specifically to the former and sitting current president of the U.S.

Kevin Pho: All right, what’s your article about?

Muhamad Aly Rifai: In American politics, discussing the mental health and the fitness of a sitting president, a former president, or other politicians is a very delicate and important topic.

As a psychiatrist, I’m a member and a fellow of the American Psychiatric Association, and there’s an important historical event. In 1964, during the elections for the U.S. President, Senator Barry Goldwater, who was the Republican candidate, was in opposition to President Lyndon Johnson, who was a Democrat. At that time, Senator Goldwater had some conservative views that a lot of psychiatrists did not agree with. So, there was an article in a famous magazine that surveyed psychiatrists to ask them their opinion: What do you think about the psychological status or the mental health status of Senator Barry Goldwater? What is his psychological capacity to be in office?

Interestingly, about 12,000 psychiatrists chimed in and sent in answers, and the answers were quite revealing. One psychiatrist said, “I believe that Senator Goldwater is suffering from chronic psychosis.” Somebody said, “He’s a megalomaniac.” Somebody even said, “He is a paranoid schizophrenic who decompensates from time to time.” Even one person said, “I believe Goldwater has the same pathological makeup as Hitler, Castro, Stalin, and other known schizophrenic leaders.” But in reality, Senator Goldwater was a decorated Air Force pilot. He had been a senator for two terms and had very minimal to no mental health issues. But those comments are thought to have put their weight on the scale in that election, and Senator Goldwater ended up losing to Lyndon Johnson, who became the president.

In 1973, the American Psychiatric Association realized that ethical fault and adopted something called the Goldwater Rule, where psychiatrists are prohibited from making any comments about public figures without an examination and a consent of the subject. However, because this issue has exploded—the mental health of a former president, a sitting president—people can make public comments about what they’re seeing because these are things that we are seeing.

For example, the former President, President Biden, on public television in a debate to millions of audience members said, “We finally beat Medicare.” That was a significant comment that alerted people, even laypeople, that there was something going on psychiatrically and psychologically with the former president. So I made a comment about that while holding to the Goldwater Rule, but I just discussed and reviewed what we see with our own naked eyes about what’s going on with the former president.

Kevin Pho: So, tell me, in terms of what psychiatrists are seeing both with the former and current president, do you see the Goldwater Rule taking on more or less relevance today?

Muhamad Aly Rifai: I think the Goldwater Rule is still relevant. If you haven’t examined the person, you shouldn’t say, “Oh, I think this,” or “I think that.” But that doesn’t take away from the fact that what you are seeing now, with the proliferation of TV, YouTube, and reels, people can just create an impression that somebody is having significant psychiatric issues.

Now, in the case that I talk about with the former President Biden, I talk about the fact that he has documented and he himself had talked about having brain surgeries in the past. He’s had two brain surgeries for cerebral aneurysms, and we know, and there is documented evidence, that individuals who’ve had brain surgeries for vascular issues are at risk of developing cognitive issues later on in life. So that’s settled research.

We also know that he has some issues in terms of his heart. He has atrial fibrillation. He has other medical issues, and that raised a lot of worry, especially with his public performance. We also worry about the secretive nature of not talking about what’s going on with him. I think that really concerned physicians and the public. We were just recently informed that he has advanced prostate cancer, and we know that that may also contribute to some of the cognitive issues. We were not really sure whether this advanced cancer was something that was operative or something that was ongoing while he was a sitting president.

So, the fact that these issues were not shared with the public… and people talk, “Well, it’s the Health Information Privacy Act.” But the fact is that when somebody becomes the president of the U.S., most of these things are not applicable to them because they are a public figure. Everybody needs to be assured that they’re able to function.

The DSM-5 also talks about and was updated to talk about the major neurocognitive disorder and about the criteria for that. A layperson could actually match the criteria for a major neurocognitive disorder with what the former president was experiencing and can easily reach a conclusion that they may meet those publicly available criteria for a major neurocognitive disorder. So a lot of these things just need answers to allay the concerns of the public and U.S. physicians about what’s going on with our leaders.

Kevin Pho: To your knowledge, how stringent are neurocognitive tests done on sitting presidents and prominent political figures?

Muhamad Aly Rifai: A lot of public figures hide their mental health issues. Mental health issues are perceived as a weakness. Now, we have some public figures that have advocated or publicized their mental health struggles—their addiction struggles—and have carried them as a shield of solidarity with the American public and with patients. We know the Secretary of Health and Human Services has struggled with addictions in the past, has struggled with depression in the past, and he’s been public about it. So the fact that some politicians and some public officials will talk about these things publicly creates the impression for those who are secretive about them that there’s something going on. There’s something more than meets the eye, and that creates the difficulty with that issue.

But these tests, when politicians are running, they need to have a full battery of tests that become public with neuropsychological testing, especially for individuals who are older than age 65 or age 70: a full Mini-Mental State Examination, a MoCA test, and more stringent, formalized neuropsychological testing for speed, comprehension, mathematics, and things like that that would give hints for any declining cognitive issues.

I also bring up the example of a practicing physician. If a practicing physician exhibited just a fraction of what the sitting president exhibited, a patient would quickly be calling the board of medicine, and the physician would lose their license very quickly and would be referred to the physician’s health program. They would not be able to practice. So it is very timely that we talk about these issues in a former president and be able to develop rules for the future for further assessments.

Kevin Pho: As you know, we live in a highly polarized society, and everything will get politicized. So, how can we as a society have a necessary conversation about cognitive fitness without it being immediately dismissed as a partisan attack?

Muhamad Aly Rifai: I think we can borrow from the field of medicine. We do it all the time. We have colleagues who voluntarily relinquish, for example, the ability to do surgery because they think they’re not sharp enough. We have colleagues that will, for example, restrict their practice to only outpatient practice when they realize that their manual dexterity skills as surgeons decline with age. So the field of politics should borrow a little bit from medicine in terms of politicians self-censoring their ability to participate in high-stress jobs, like the job of the President of the U.S., that requires a lot of cognitive capacity and the ability to do these things. We also have colleagues that will alert each other when we see another colleague who’s struggling in a collegial and positive way rather than in a punitive way.

Now, I understand that there are politics involved, and that’s why I brought in the Goldwater Rule, which happened in the sixties. That was a Republican candidate that was accused of having mental health issues versus a Democratic candidate. Now the shoe is on the other foot, and we’re having a Democrat being accused by the Republican establishment. We’ve seen it both ways. So I think in terms of this being politicized, we need to draw the distinction that we are talking just about humans who may be suffering from conditions and that the public needs to be notified about that.

Kevin Pho: So, I’m hearing what you’re saying: that politicians, perhaps over a certain age like 65, should undergo mandatory MoCA, Mini-Mental State Exams, and neuropsychological testing on a routine basis, and those results should be made public. Is that what I’m hearing from you?

Muhamad Aly Rifai: I think that is accurate. Like U.S. physicians, we have to take maintenance of certifications. We have to take tests. We have to demonstrate our competency and our ability to do the job. Similarly, for politicians, their job is cognitive decisions, high-level decisions; they should be able to demonstrate publicly that they’re able to perform these tasks.

I watched a press release from the White House yesterday and a public showing where something happened. People started questioning that the current sitting President, President Trump, was experiencing swelling in his lower extremities, and people put pictures on that, that his legs were swollen. Then the press secretary talked about the fact that he was tested. They did a lower extremity Doppler. They did lower extremity ultrasounds. They did a lower extremity venogram. They did echocardiograms of the heart. They did full testing to figure out that he had venous insufficiency of the lower extremity. That’s a condition associated with individuals who are above the age of 70. And it was benign. They said he did an echocardiogram of his heart, and his ejection fraction was normal. There are no issues.

People noticed blotching on his hands. So I think being proactive and public about it—if people had heard about that or, with the former president, “Yes, he’s experiencing this, this is what’s going on”—that would have allayed a lot of concerns. Public information, I think, would be able to allay some of these concerns.

But standards, I think, are very important. We know a colleague physician was interviewed by Congress to talk about the mental health issues of the president, and unfortunately, he invoked his Fifth Amendment rights and didn’t want to talk about it, invoking the privacy of the president. So these issues should be formalized. As a medical community, we need to come up with standards and say, “This is what needs to be done for us to be confident that our leaders have the mental health as well as the physical health abilities to lead this country.”

Kevin Pho: We’re talking to Muhamad Aly Rifai, psychiatrist and internist. Today’s KevinMD article is “How President Biden’s Cognitive Health Shapes Political and Legal Trust.” Muhamad, let’s end with your take-home messages that you want to leave with the KevinMD audience.

Muhamad Aly Rifai: Sure. The stakes—ethically, legally, and nationally—could not be higher. Transparency, medical integrity, and constitutional clarity really must guide us. In confronting these challenges and the discourse about former President Biden’s cognitive health, as well as the health issues of the current sitting president, we navigate not merely the medical intricacies of dementia, cognitive issues, or medical issues, but also the foundational trust upon which our democracy stands. So I think we need to have standards, and we need to advocate for those standards.

Kevin Pho: Thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Muhamad Aly Rifai: Thank you.