Why it’s hard to remove, or even diagnose, mentally ill or unstable presidents

In the wake of President John F. Kennedy’s assassination, members of Congress set out to update the procedures for handling an unable president. They soon realized that some situations would be far more challenging than others.

Famed political scientist Richard Neustadt emphasized one of the most ominous of those situations when he testified before the Senate. “Constitutions,” he warned, cannot “protect you against madmen. The people on the scene at the time have to do that.”

Congress’ reform effort culminated with the 25th Amendment. It provides essential improvements to the Constitution’s original presidential succession provisions. But a novel released in 1965, the same year Congress approved the amendment, makes a strong case that Neustadt’s insight was spot on.

The recently reissued “Night of Camp David” by veteran D.C. journalist Fletcher Knebel illuminates the daunting challenges that arise when the commander in chief is mentally unfit and unwilling to acknowledge it.

Flexibility an important part of 25th

The novel follows the fictional Senator Jim MacVeagh, who concludes that a paranoid President Mark Hollenbach is “insane” after he witnesses the president plot to abuse law enforcement powers and to establish a world government. Unbeknownst to MacVeagh, Defense Secretary Sidney Karper reaches the same conclusion. Karper remarks, “Congress did its best on the disability question, although there’s no real machinery to spot mental instability.”

The framers of the 25th Amendment did intend for it to cover cases of psychological inability. One of the principal authors, Rep. Richard Poff (R-Va.), envisioned a president who could not “make any rational decision.”

But the term “unable” in the amendment’s text was left vague to provide flexibility.

Additionally, the 25th Amendment is intentionally hard to use, with procedural hurdles to prevent usurpation of presidential power. Two-thirds of both houses of Congress must ratify an inability determination by the vice president and Cabinet when the president disagrees. Otherwise, the president returns to power.

Some believe these protections create their own challenges. As Harvard Law Professor Cass R. Sunstein observes in “Impeachment: A Citizen’s Guide,” “The real risk is not that the Twenty-Fifth Amendment will be invoked when it shouldn’t, but that it won’t be invoked when it should.”

This risk is heightened when the president may be psychologically unfit. Psychiatric assessment is descriptive and less evidence-based than other areas of medicine. In the novel, President Hollenbach’s doctor reports no evidence of a mental ailment. And there is a reason for that: Psychiatric illness is not beyond conscious manipulation.

LBJ at an American Legion gathering in New Orleans, Sept. 10, 1968. AP File/AP Photo
A deft politician, President Hollenbach knew enough to hide his paranoia. While he seems overtly paranoid in the solitude of Aspen Lodge at Camp David when he is sharing his delusions with MacVeagh, he appears completely sane, dare we say presidential, in public appearances. There is a long history of presidents hiding their ailments from the public, including Presidents Lyndon Johnson and Richard Nixon, who both grew paranoid in private.

Psychiatry can be objective

To further complicate assessment, the more subjective nature of psychiatric diagnoses introduces potential political biases among clinicians who might be asked to evaluate a president.

As critically, the American Psychiatric Association’s Goldwater Rule expressly prohibits armchair analysis by psychiatrists who have not directly examined the president. Those who had the opportunity would be equally constrained by patient confidentiality. This creates an ethical Catch-22.

Yale psychiatrist Bandy X. Lee and colleagues in “The Dangerous Case of Donald Trump” eschew this prohibition and feel it their ethical obligation to share their professional insights, invoking a duty to warn responsibility. One of us (Joseph) has suggested that while psychiatric diagnoses cannot be made from afar nor confidences breached, physicians have a supererogatory obligation to share specialized knowledge.