The Real Question About Biden Is Not Medical (2024)

With President Joe Biden’s debate and subsequent interview with ABC’s George Stephanopoulos on everyone’s mind, some attention has shifted to a man who might have profound insight into his overall condition and whether he remains fit to serve: White House physician Kevin O’Connor.

O’Connor has implicitly cosigned the view that Biden is capable of the job. In February, he released a routine summary of Biden’s health, which noted that he has sleep apnea, a common and easily treated condition, as well as some other conditions, including atrial fibrillation and peripheral neuropathy (the latter of which probably affects his steadiness walking but is not particularly concerning). This week, O’Connor published a letter in response to murmurs that a “Parkinson’s expert” has been making extra visits to the White House. Biden, he wrote, meets with the neurology consultant and other specialists during his (again, routine) annual physicals. O’Connor revealed nothing alarming in the letter.

It should be said that all reports are that O’Connor is respected and admired for his integrity. I’ve heard several insiders say that if push came to shove, he’d do the “right thing.”

But what is that? What questions can the physician to the president really answer?

Can Biden lead the country in his current state? Sure. Could a replacement do better? That’s not his doctor’s call. The information we want to know about Biden may seem medical. But it’s mostly not.

Much comes down to prognostics, less to diagnostics. Were the president to undertake a fresh battery of neurologic and cognitive tests, the results themselves would provide only a snapshot of the present. Although I’ve long argued that older politicians—especially obviously ailing ones—should do this and make the results public, interpreting them is not as easy as many imagine. Lower scores on validated tests like the Montreal Cognitive Assessment correlate with higher risks for a variety of relevant conditions—but the results say nothing about the slope of things. A person scoring perfectly today may suffer a stroke and have a lower score tomorrow. That score could remain stable for years, with little effect on important daily tasks.

Meanwhile, a person with a progressive neurological condition might score 1 point lower on successive tests taken every six months. When precisely that decline inhibits crucial daily functions depends on the person and, importantly, the specific activities in question. Indeed, plenty of people with Parkinson’s disease should not drive. But many of them can still do math. At the hospital where I work, I’ve spoken to patients who are retired Nobel laureates who—I couldn’t help asking—keep up with their highly technical fields. Nevertheless, I wouldn’t want them operating heavy machinery around me.

At issue are the various and often unique responsibilities of the modern presidency. A president’s doctor can say his patient can take the proverbial 3a.m. phone call tonight. But he cannot usually predict, based on any test, whether that ability will still be there in a year. Likewise, cognitive tests provide very little context for how a person will function out in the world. As Biden suggested to Stephanopoulos, no test other than the presidency itself possesses the diagnostic information we covet.

Nor is it the purview of the president’s physician to determine whether his patient is performing his duties with sufficient independence—that is, without a team of advisers hovering over him. If the president needs a team to do a lot of extra meeting preparation for him but he nonetheless arrives prepared, what medical insight would override that? What’s the appropriate level of support in this job—regardless of age—anyway? This isn’t the Olympics, where a wind-aided time in the 100meters doesn’t count for the record books.

Some pundits have observed that Biden appears sharp enough to be a successful president but, paradoxically, not to run for reelection. But, in essence, his doctor implicitly clears him for the concrete campaign activities daily: traveling the country, giving speeches, shaking hands. This again becomes a question of effectiveness, not fitness—one that is political, not medical. Even if his doctor says “He will have bad days where he makes gaffes or has lapses,” why would a physician be responsible for assessing the resulting political optics?

Importantly, a physician cannot answer specific questions like how well his patient might perform in a very peculiar cognitive test indeed: another televised debate. Whether Biden has the mental sharpness to quickly and convincingly call out and refute a steady stream of lies that Donald Trump flings in the next debate isn’t something any cognitive test can determine. That’s what we’re really after and, perhaps, what makes the debate format uniquely interesting in this particular moment.

In fact, everything a president (or anyone) does can be viewed as its own kind of in situ test. I drove to work today. I passed that particular test. Will I be able to tomorrow? Probably. If not, and I need help getting there, can I still do my job? The answer to that is far more complicated, depending as much on the support systems available and the expectations of my employer as on whatever biological change or accident occurred to make operating a motor vehicle impossible.

This is not to say that physicians can’t help patients and their families navigate aging safely, based in part on neurocognitive test results placed into their specific contexts. Many of us have been involved in these conversations. Should Dad still drive? Does Mom need to retire? Do we need to hire help to come to the house? Specialists can add insights.

But it may surprise you that how these discussions go is often a reflection more of the stakeholders than of the patient. Important decisions—like whether a parent should undergo another round of chemotherapy—are heavily influenced by the emotions of their families. The adult daughter who has dutifully and daily attended to her ailing mother for years, who has seen the suffering caused by prior treatments up close, might say, “Enough is enough. The best treatment is to maximize quality, not quantity, of life.” Conversely, a usually absent brother who just flew across the country in a time of crisis may disagree, not realizing the role that guilt plays in forming opinions.

In the case of a president, even one who holds the opinions of his family in high esteem, people other than family also weigh in on and influence major choices. Crowded around the proverbial exam table are other politicians and people with power—people who will lose their status if Biden does not soldier on, people who may genuinely feel that the country will be better off if they continue to back their guy.

With the stakes as high as they are, I am warmed that many people still believe in the wisdom and insight that a trusted physician can offer. But my colleagues and I have our limits. We can’t just read test results and tell you whether the president can win the election or stave off another attack on democracy. Indeed, above all, there’s one question about Biden’s ability to continue that no doctor can answer: What’s the alternative?

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.