doi:10.1093/brain/awp039
Brain 2009: 132; 1407–1410
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BRAIN
A JOURNAL OF NEUROLOGY
BOOK REVIEW
Fit to decide?
The physician’s perspective
In 1966, a 28-year-old trainee neurologist crossed Westminster
Bridge from his research bench at St Thomas Hospital, where he
was working alongside David Marsden on the effects of adrenaline
on tremor, to enter parliament as an MP. He left medicine 2 years
later to become one of the youngest ever British Foreign
Secretaries, a founder and leader of the British Social Democratic
Party, and an international peace broker. He is David Owen.
Throughout his political career, he retained the title ‘Dr’, which
seems to have been more than a nostalgic reminder of his original
calling, since—in recent years—he has ventured a clinical interpretation of some of his observations on British and foreign political
leaders. The result is In sickness and power, in which Lord Owen
chronicles the effects of illness on heads of government, documents the complicities of their doctors, formulates statutory
mechanisms to deal with sick leaders and proposes a new clinical
syndrome, ‘the hubris syndrome’.
Much of the medical material has already been published.
But Owen has gleaned some new information about JF
Kennedy’s treatment from notes held by the Presidential Library,
and on the health of Anthony Eden from still-closed records at the
Birmingham University Special Collections Archives. Interviews
with the key doctors involved provide original data on the illnesses
of President Mitterrand and the Shah of Iran. These individuals
are Owen’s four principal case histories. To assist him, Owen
assembled an informal medical advisory team, including his son,
Gareth, a psychiatrist. Despite this, some errors have crept in:
considering Dr Owen’s neurological training, the reference to
levodopa as an anti-cholinergic drug is surprising (p. 35).
Sick leaders, their doctors and a
proposal
Owen’s history of illness in 20th-century leaders leaves no doubt
that the clinical care of our heads of government may be secretive,
chaotic and suboptimal. For instance, Anthony Eden ignored the
advice of his personal physician on the best surgeon to perform his
cholecystectomy, instead choosing a 60-year-old general surgeon
who had removed his appendix some years earlier. The result was
a botched operation: the bile duct and, possibly, a branch of the
hepatic artery were inadvertently ligated. Despite a biliary repair in
IN SICKNESS AND IN
POWER: ILLNESS IN
HEADS OF
GOVERNMENT
DURING THE LAST
100 YEARS
By David Owen 2008.
London: Methuen and
Santa Barbara: Praeger
Price: £25/$44.95
ISBN: 9780413776624/
9780313360053
Boston, Eden went on to have recurrent bouts of cholangitis.
Three years later, facing the Suez crisis, he may have been
taking excessive amounts of barbiturates, amphetmaines and
pethidine, some apparently administered by his bodyguard.
Kennedy had a similar problem. Whilst appropriately taking testostorerone and mineralo- and glucocorticosteroids for Addison’s
disease and analgesics for back pain, he also received undocumented quantities of ‘vitamin’ injections from Dr ‘Feelgood’ Jacobson.
From the proceedings that led to him being struck off the
physicians’ register in 1975, we now know that ‘Miracle Max’s
injections included amphetamines, multivitamins, corticosteroids,
solubilized placenta and ground bone marrow. Kennedy’s official
physicians seemed powerless to control Jacobson’s visits. But all
changed when Hans Kraus was brought in. This rehabilitationist
and sports physician said of Kennedy: ‘If I ever heard he took
another shot [of Jacobson’s injections], I’d make sure it was
known. No President with his finger on the red button has any
business taking stuff like that.’ Kraus was Kennedy’s sort of
man: an Olympic ski coach and elite rock climber, who demonstrated his skills by climbing the wall around the Presidential
pool. An advocate of stretching and exercise, his patients
included Katharine Hepburn, Eleanor Roosevelt, Yul Brynner and
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| Brain 2009: 132; 1407–1410
Rita Hayworth. He brought some coherence to Kennedy’s medical
care and effected an improvement in his condition.
In contrast, the management of the Shah’s chronic lymphocytic
leukaemia from 1974 when in power to his death in exile in 1980
was a successful and discrete long-term collaboration between a
senior Iranian physician and two French haematologists, Georges
Flandrin and Jean Bernard. There was similar stability in the team
initially caring for President Mitterrand’s prostate cancer, but here
another issue arose: the conflicting responsibilities of stateappointed doctors to patient and public. For Mitterrand had
made it an election promise that the Presidential physician
would report publicly on the health of the premier every
6 months. Yet, when his illness was diagnosed, Mitterand insisted
that his doctor, Claude Gubler, omitted all mention of it in his
dispatches. Extraordinary measures were taken to ensure that no
one discovered Mitterand’s illness, to the extent that Gubler
drove him to secret appointments in an old car and administered
the chemotherapy himself, wherever the President happened to
be, hanging drips off picture hooks in the bedrooms of state residences. Gubler’s misleading public declarations and covert life
continued for 11 years, until Mitterand needed a prostatectomy
and the truth emerged. Sadly, in subsequent years, as Mitterand’s
despairing family sought less conventional treatments, the loyal
Gubler became increasingly side-lined. This may have precipitated
the release of his book about life as the Presidential doctor shortly
after Mitterand’s death. Although blocked by the French government, it quickly became available on the internet. And the debate
which Lord Moran’s book on Churchill’s medical problems
sparked, about medical confidentiality after the death of a public
figure, was ignited again.
During the life of their patient, the doctors chronicled in Owen’s
book acquiesced in their charges sometimes extreme demands for
secrecy, even to the exclusion of involving senior government
figures. None considered this inappropriate and very few seem
to have questioned the capacity of their patients as leaders.
Yet Owen contends that illness and its treatment may impair
the ability to lead and so influence international events
(of which more later). So, he argues, there should be a statutory
mechanism for assessing the health of leaders.
The diplomat’s perspective
In summary, David Owen recommends that democracies enact
legislation requiring a public, independent medical assessment for
all candidates for the post of head of government before they
submit themselves to direct elections nationwide or indirect
election through their political party. This, he believes, could
best be conducted by a general physician or neurologist, calling
in other specialists as necessary. Democracies should further legislate to make it mandatory for heads of government to have
an annual independent medical assessment, conducted this time
in private. The independent doctor would be required to report
any concerns over his findings to a designated senior political
figure, for example, in Britain, the Deputy Prime Minister.
If there were no grounds for concern, no report would be made
and there would be no publicity. But if the findings called into
Book Review
question the head of government’s capacity to discharge the
powers and duties of his office, the senior political figure would
decide whether to bring the matter to Cabinet who in turn would
consider involving Parliament or the comparable institution
in other countries. Finally, he favours limiting the number of
years any head of government can remain in office, in the case
of Britain 8 years of service, continuous or broken. Despotisms
present very different problems. Here, he would look to the
United Nations to intervene to remove a leader or bring about
regime change where it can be shown that there exists a threat
to the peace, defined more widely than at present to embrace
gross abuse of human rights.
The effect of sick leaders on politics:
an appraisal
These are important proposals which deserve debate and a considered response both from politicians and the medical profession.
I belong in neither category. But in 37 years of diplomatic service
(till 1997), I had the opportunity to see a good number of senior
office-holders, British and foreign, in action. I cannot say that we
spent much time worrying about their health. When working as
private secretary to Prime Minister Thatcher I accompanied her to
the funerals, in quick succession, of Brezhnev and Andropov in
Moscow and was left wondering how such an unfit and aged
leadership could possibly govern effectively the vast Soviet Union
or handle rationally and responsibly the nuclear and other issues
of the Cold War. President Reagan looked to my amateur eye
the model of good health in his several meetings with Margaret
Thatcher. And I do not recall coming away from summits with
President Mitterand or Chancellor Kohl with questions about
their fitness for office. When in 1983, negotiations were launched
in Beijing over the future of Hong Kong, the aged, chain-smoking,
spittoon-using Deng Xiaoping appeared more than capable of
conducting a complex dialogue and reaching decisions.
There were specific cases where a leader’s health was known
to be impaired, for example Yeltsin in Russia or King Hussein in
Jordan, which we followed as best we could. But the fact is, as
David Owen’s book shows, that with very few exceptions, leaders
the world over have been secretive about their health, successfully
concealing their illnesses from their public. My generation recall
the enormously attractive image of the young President Kennedy
taking office in 1960, bronzed, smiling and energetic, certainly
with a back complaint, said to derive from a wartime injury, but
otherwise appearing the very model of healthy vitality. How
wrong we were.
Nor in Britain did the issue seem at all pressing. I was surprised
when greeting one Foreign Secretary with ‘How are you?’ to get
the reply ‘In pain most of the time’. But there was no evidence
that his professional performance was affected and I thought little
more about it. Just before my retirement I worked for a few
months with the late Robin Cook but, unsurprisingly, detected
no signs that he would die prematurely from a heart attack a
few years later.
Yet, if specific cases of illness did not weigh heavily with me,
I did develop a more general area of concern. David Owen
Book Review
contends that the people best placed to observe a head of
government’s behaviour in office are members of the Cabinet.
I believe that there is a better-placed group, namely the private
secretaries of that head of government. They are in much more
continuous contact, see the leader with guard down as well as up
and are inevitably more conscious of changes of mood and behaviour. My own experience suggested to me that not only did
members of the public not begin to appreciate the real strains
upon the incumbent but that they could not do so, because so
much has to remain private if government is to be effectively
conducted. The demands on the British Prime Minister are extraordinary: the bewildering variety of complex domestic and international issues, the requirements of the political party and
Parliament, the incessant media barrage, the public appearances
and speeches and the huge amount of foreign travel. And all that
is routine. Bring in major crises such as, in my time, the Falklands
War or family problems such as the temporary loss of a son in the
Sahara, and only an exceptional person will be able to handle
the strains over any length of time, particularly when he/she has
few ways of relaxing and will at best take only a short holiday,
and even then with some repugnance. There is a serious question
of how long, as a matter of good governance, the same person
should continue to hold the post, which is why I respond positively
to Owen’s suggestion of limiting the period of office, despite all
the difficulty there will be in persuading the political class that it is
practicable. I doubt if the strains are any less now than then.
Indeed, after what Owen describes as Prime Minister Blair’s
‘hubristic vandalism’ in downgrading the Cabinet and erecting
new structures to bring foreign affairs, defence and intelligence
directly under Downing Street’s control, they may well be greater.
If, when I began reading this book, I wondered how serious the
problem of illness in heads of government is, I was convinced by
the case. Owen’s survey of their illnesses over the past 100 years,
and his detailed case studies of Eden, Kennedy, the Shah of Iran
and Mitterand clearly demonstrate that it has been relatively
common for leaders to conduct government and manage crises
at times when, we now know, their illnesses should have raised
questions about their capacity to do so. Lord Owen judges that
Eden was seriously ill when he took key decisions in the Suez affair
(1956–57). And there seems little doubt that Kennedy’s misjudgements over the Bay of Pigs were related to being unwell: suffering
diarrhoea from colitis as well as non-gonococcal urethritis, no
doubt compounded by Addison’s disease and the effects of
‘Miracle Max’s ministrations. The Shah of Iran was a very sick
man by 1973, 6 years before the Iranian Revolution, with a
form of chronic lymphatic leukaemia. Mitterand was told when
he took office that he had advanced cancer of the prostate.
It does not by any means follow that illnesses always reduce
capacity to take sound decisions but Owen, who is well placed to
judge, believes for example that Eden’s key decisions about Suez
and Kennedy’s errors of judgement over the Bay of Pigs fiasco and
his summit that year with Khrushchev were attributable to their
state of health and that, by any rational medical assessment,
Mitterand should never have been re-elected for a second term.
His detailed research also shows that with few exceptions, notably Eisenhower and Reagan, heads of government have deliberately concealed their illnesses from their public. Kennedy, the Shah
Brain 2009: 132; 1407–1410
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and Mitterand are prominent examples but the practice is so
entrenched that we can be sure that it is still widespread.
Politicians, understandably, never wish to display weakness
of any sort, and are mercilessly hounded by the media if they
do so. It will be an uphill struggle to persuade them of the
merits of the proposed reforms. But the case is strong on democratic grounds alone, especially given the homage paid today by
all political parties to transparency in government.
The hubris syndrome
Two years ago, Lord Owen published what was in effect an
advance extract from the present book, under the title ‘The
Hubris Syndrome: Blair, Bush and the Intoxication of Power’
(London: Politico’s, 2007). His treatment of the syndrome is in
part tentative because it is not yet medically recognized. He proposes a provisional list of symptoms, of which, he suggests, three
or four would need to be present before a diagnosis should be
contemplated, namely, in attenuated form: a narcissistic propensity to see the world as an arena for power and glory; a predilection for image-enhancing action; a disproportionate concern with
presentation; a messianic manner and a tendency to exaltation;
identification of self with the state; use of the royal ‘we’; excessive
confidence in one’s own judgement; belief that one is accountable
to History or God; restlessness and recklessness; loss of contact
with reality; tendency to allow a broad vision of an action to
outweigh practicality, cost etc.; and incompetence because detail
has been ignored.
His main candidates for the label are Lloyd George (‘mesmerised
by the world stage’), Hitler (‘all the key factors’), Mussolini,
Margaret Thatcher and, especially, President Bush and Prime
Minister Blair.
It soon became a feature of the way Bush and Blair spoke after
9/11 that the world they lived in had, almost by definition,
to be different from the world past leaders had lived in. Their
problems had to be somehow greater and more challenging
than those of other leaders – a ludicrous claim when one considers the challenges that the Second World War and the ensuing nuclear weapons stand-off in the Cold War posed for the
post-war generation of leaders. The language and rhetoric of
both men began to take on the ring of zealotry: nuance and
qualification became rarer, certainty and simplicity became ever
more dominant (p. 261).
Owen reveals the details of two private dinners with Blair, at
both of which Iraq was discussed. In 1998, Blair was prepared
to engage in complex discussions but by July 2002 he seemed a
different man, restlessly hyperactive and totally confident in himself and unprepared to discuss detail. On the way home, Lord
Owen’s wife described Blair as ‘messianic’. Owen suggests that
Blair’s hubris started to develop after the Kosovo crisis of 1999
and that these characteristics and inattention to detail, plus
an obsession with presentation, significantly contributed to his
incompetence in failing to plan for the aftermath of the invasion
of Iraq, in his hopeless pursuit of a second UN resolution and in
his manipulation of international law and intelligence.
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Bush’s hubris syndrome, he thinks, probably developed quickly
after the terrorist attacks of 9/11. He, like Blair, then developed
the ‘ring of zealotry’; certainty and simplicity replaced nuance; and
he worked in a climate which disregarded the possibility that
his approach could actually worsen the problem. For both men,
‘God is the force which drives them to challenge reality’.
I have no special insights on Bush or Blair. But I would contend,
and I think David Owen would agree, that during my time with
Margaret Thatcher, she displayed few of the qualities in his list
though some of them do appear to have become prominent later.
Owen accepts that the kind of loss of capacity involved in hubris is
very familiar in the careers of political leaders. And he believes
that, where it exists, it is a characteristic of high office and
becomes more dominant the longer the office is held.
The physician’s perspective
At best, Owen’s description of the hubris syndrome as set out in
‘In sickness and power’ is an hypothesis. Long on description of
the syndrome, but short on validation, Owen seems prepared to
compromise on the discipline of scientific argument that saw his
early work with David Marsden published in the Lancet and
Journal of Physiology. For instance, the possibility that political
preferment selects for the characteristics that later manifest as
the hubris syndrome is not fully explored. That said, this is partially
corrected by Owen and Davidson’s ‘occasional paper’ in this issue
of Brain, where some evidence is presented and the syndrome is
characterized as an acquired personality disorder—itself a contentious concept.
There is a more fundamental concern. To categorize something
as an illness, it is not enough to say that a particular environment
Book Review
(prolonged political power) induces unusual human behaviour (the
hubris syndrome) which is potentially harmful (impaired political
judgement) and can be treated (by removal from office). For, if so,
we could equally pathologize the ‘love-sick’ teenager who cannot
concentrate on his schoolwork. When the Greeks recognized
the U$ bri& of pride or arrogance in those mortals who aspired to
be Gods, they did not feel the need to call it a disease. The
dangers of defining the hubris syndrome as a psychiatric condition
are that it undermines the ability of ‘non-professional’ politicians
and civil servants closest to the ‘sufferer’ to make the ‘diagnosis’;
and it burdens ill-equipped doctors with the responsibility
of recognizing such features as ‘incompetence in carrying out a
policy [due to] . . . inattention to detail . . . to be distinguished from
ordinary incompetence’. Might it not be preferable rather to
recognize the hubris syndrome as an occupational hazard, not
dissimilar to the rambling self-congratulatory speeches of retired
professors of neurology, from which the institution has to protect
itself?
The diplomatic medical perspective
Both of us believe that whatever reservations one might have
about David Owen’s analysis of the hubris syndrome, it would
be a pity if these qualifications obscured the merits of the rest
of the book. His account of sickness in heads of government
shows that the problem is real and his prescriptions for dealing
with it deserve serious consideration. Whether they will get it from
the political class is another matter.
AJ Coles and AJ Coles
Beaulieu and Cambridge, UK