Who Decides Whether Trump Is Unfit to Govern? (Unabridged version)

New York Times, August 29, 2017

By Peter D. Kramer and Sally Satel

The mental health of Donald Trump has been under scrutiny since he began running for president in 2015. Now, 28 Democratic Congress members have introduced a bill that could lead to a formal evaluation of his fitness.

Drafted by Representative Jamie Raskin, Democrat of Maryland, the Oversight Commission on Presidential Capacity Act sets in motion a part of the 25th amendment that empowers Congress to establish a permanent body to assess the president’s ability to govern. The proposed commission would consist of 11 members, at least eight of them doctors, including four psychiatrists. Without Republican (or even much Democratic) support, the bill will go nowhere. But it sets a template for a process that could — if discontent spreads — remove Mr. Trump from office on grounds of mental illness.

When directed by Congress, commission members would perform a medical examination to determine whether the president is fit to discharge his duties. If the commission found the president incompetent and the vice president agreed, he would immediately become acting president.

Since the 25th Amendment was written with temporary disability in mind, it allows the president to announce that he has recovered — presumably Mr. Trump would do so immediately — and force a Congressional vote to confirm or reject the finding of unfitness.

The key dynamic in this sequence is the medical assessment. It can sideline the president and set the context for a discussion of his fitness for office. The role of psychiatry in this process is likely to be problematic, for the profession and for the democratic process.

Much has been written lately about the Goldwater Rule, the American Psychiatric Association’s prohibition against members’ “offering opinions on someone they have not personally evaluated.” The profession adopted the rule in 1973, when diagnosis mainly arose from an understanding of patients’ unconscious processes. Today, diagnosis is often linked to observable traits (like arrogant demeanor and a tendency to exploit others, to name two that seem relevant), making evaluation at a distance more plausible.

Once a commission on competency was activated, if the president agreed to be examined, the Goldwater Rule would become moot. But even if Mr. Trump refused to cooperate, diagnosis might be the easy part — perhaps too easy.

For the sake of argument, assume that Mr. Trump has a narcissistic personality disorder. That’s what many experts clearly think, whether or not they can say so. He is grandiose, entitled, resentful, desperate for admiration, and so on. Once an assessment was set in motion, a diagnosis along the expected lines would be an all but foregone conclusion.

But mental disorders are not automatically disqualifying. Ronald Reagan’s son Ron has written that his father had early Alzheimer’s disease before and during his second term. Neurologists have found hints of the disorder in his speech. Any number of presidents — Franklin Pierce, Calvin Coolidge and Woodrow Wilson are on the list — have remained in office despite some level of mental impairment.

Historians believe that Abraham Lincoln suffered from clinical depression — a case that makes the point: A president can have a mental disorder and, overall, function admirably. Psychiatry as a profession would be alarmed if mental illness were considered an absolute bar to public service.

Of course, in the absence of any illness, it is possible to be incompetent. A president may be inexperienced, indecisive, or bad at judging character.

The disability anticipated in the 25th Amendment is not specified, but the intent is to cover impairment arising from illness. Once a president is diagnosed, the commission will need to determine whether he is incapacitated and whether the incapacity results from the disorder.

For grave and acute conditions, like psychotic episodes, dense dementia, or massive strokes, the connection is easy. A president who is comatose cannot govern. But what of less automatically disqualifying ailments?

The traits that might earn Mr. Trump a diagnosis of personality disorder were on display during the election campaign. Mr. Trump’s supporters chose him despite or because of them; they believed that egotism and combativeness were compatible with leadership. And he is governing as he campaigned. He is impulsive, erratic, belligerent, and vengeful. He ignores norms. He has scant regard for facts.

But is Mr. Trump unfit to govern in the meaning of the 25th Amendment? If so, its provisions might have been invoked the day he took office. If not, when did the incapacity arise? Will the commission follow a president’s behaviors, judging which one is the last straw?

In practical, if perhaps not in moral terms, these decisions might be less troubling if Mr. Trump were found to have an underlying neurological disorder — say, Alzheimer’s disease, with a resulting coarsening of longstanding personality traits. To the extent that the president’s supporters accepted expert opinion, they might be less resistant to the removal of a demented commander in chief than a narcissistic one.

The difficulty for psychiatrists is most apparent in the simplest case: personality disorder only. How does it relate to fitness? Can erratic behavior be strategic? Decisions at this level of refinement become ever less scientific.

Although flawed, the Goldwater Rule retains a function: to save psychiatrists from the temptation to misuse diagnosis for partisan purposes. The establishment of a standing oversight commission reintroduces this concern, in spades. Almost certainly, doctors will confirm what the whole world sees, that Mr. Trump is egotistic. Will they then declare the president unfit based on his established patterns of conduct — on Trump being Trump?

That result would strike those who elected him as elitist and anti-democratic. Don’t the people have the right to choose an exceedingly narcissistic leader?

For a president who is unfit but not impeachable and who still has the support of his cabinet, the Constitution offers Congress only this one way out, a declaration of impairment presented by a deliberative body of its choice. But that body need not be dominated by doctors. Senator Birch Bayh, who drafted the 25th Amendment, opposed overreliance on physicians. Bayh cited Dwight D. Eisenhower’s opinion that the “determination of Presidential disability is really a political question.”

Obviously, if a president’s health deteriorates dramatically, consultants should be called in. But when the problem is longstanding personality traits, a doctor-dominated commission simply provides cover for Congress to hide behind — allowing legislators, presumably including those in the majority, to arrange for the replacement of the president while avoiding responsibility for doing so.

However unlikely it is to be enacted, the Raskin bill sets a worrisome precedent, for the medicalization of what finally will most often be a political decision. If the time comes that Congress finds Mr. Trump unable to discharge his duties, its members should say so and then appoint a bipartisan commission dominated by respected leaders — perhaps elder statesmen and stateswomen — to set the removal process in motion.

One of us is a life-long Democrat, the other a Republican. But as psychiatrists and citizens, we are in agreement on this point: The medical profession and democracy would both be ill-served if a political determination at this level were ever disguised as clinical judgment.

Peter D. Kramer is an emeritus professor of psychiatry at Brown University and the author, most recently, of Ordinarily Well. Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute.