Heart: An American Medical Odyssey (17 page)

On July 25, 2000, the day that the Bush campaign announced that Dick Cheney was the governor’s pick for vice president, Dr. Cooley released a statement from Houston in which he said, “In a recent checkup by Dr. Jonathan Reiner, he declared that Mr. Cheney is in good health with
normal cardiac function.”

While I did believe that overall Dick Cheney was in good health and I thought his cardiac history would not interfere with the duties of vice president, I knew that his heart function hadn’t been normal in twenty-two years, and I had explained that to Dr. Cooley.

The newspapers and cable news outlets soon filled with uninvolved and uninformed medical pundits opining about Dick Cheney’s chances of surviving his time in office. Without either a physical exam or record review, the
New York Times’
s Lawrence K. Altman actually calculated the candidate’s odds:

Mr. Cheney’s statistical chances of survival for the next five years are 94 percent, slightly lower than for Americans without heart disease, according to figures that a Duke University cardiologist, Dr. Eric Peterson, calculated by comparing Mr. Cheney’s medical profile with those of other patients in a national registry of bypass operations kept at Duke.

USA Today
quoted Dr. Lawrence Cohn, of Brigham and Women’s Hospital in Boston, as saying that “if Cheney has scrupulously taken his medicine,
watched his diet and exercised,
‘he’s golden.’ ” Other experts offered less rosy pronouncements. In the
New York Daily News
, Dr. Stephen Siegel, a cardiologist at NYU Medical Center, said, “Atherosclerosis is like incurable cancer—it’s
a disease you control, not cure.” Craig Smith, chief of cardiothoracic surgery at New York-Presbyterian Medical Center in New York City, said, “The negatives are that he had early onset of coronary disease, which makes him more prone to have a recurrence.”

•  •  •

Sometimes the determination of whether a patient is medically fit for a job is easy. Consider the case of a commercial pilot who came to see me several years ago after he began to have chest pain. The patient was an experienced 747 captain who flew long-haul, trans-Pacific routes for a major airline and had flown as recently as a few days before his clinic appointment. Because pilots fear being grounded, they tend to be notorious doctor-phobes, a fact that made this patient’s visit all the more concerning. I ordered a stress test, which was grossly abnormal, and the cardiac catheterization that followed a few days later identified severe coronary disease. When we finished the procedure, I put a hand on the pilot’s shoulder and told him I thought he was a very lucky guy, having dodged a huge bullet. Imagine developing a heart attack while strapped into the cockpit of a jumbo jet traveling at 550 miles per hour 38,000 feet over the Pacific Ocean or, worse, losing consciousness on final approach with 450 souls in the seats behind you. The good news was that his heart could be fixed, and I was confident he would do very well. The bad news was that because he was going to need bypass surgery, his days as an airline pilot were over.
Federal aviation regulations disqualify pilots with angina, significant coronary disease, or a history of myocardial infarction and it would be difficult for him to regain his flight certificate. I told him that I was very sorry that he wasn’t going to be able to fly, projecting how I would feel if I could no longer practice medicine. He told me not to worry; he was close to retirement and he would be fine.

I’ve been asked to clear Secret Service and FBI agents before they return
to duty, foreign service officers prior to their overseas postings, as well as tour bus drivers, US marshals, and police officers; each of these occupations has well-codified health requirements. You can’t get a driver’s license if your vision is poor, enter the military if you fail the physical, or get security clearance without a background check. There are, however, no established medical fitness criteria for candidates for president or vice president of the United States.

•  •  •

On March 4, 1841, William Henry Harrison became the nation’s ninth president, but his time in office would be very brief, ending only thirty-two days after his inauguration when he died after developing pneumonia. Following Harrison’s death, Vice President John Tyler assumed the presidency, invoking for the first time in American history Article II, section 1 of the US Constitution, which states:

In Case of the Removal of the President from Office, or of his Death, Resignation, or Inability to discharge the Powers and Duties of the said Office, the same shall devolve on the vice president . . .

Because eight of the thirty-seven vice presidents who followed Tyler were eventually elevated to the presidency, the essential medical qualification of a vice president is undoubtedly fitness to be president. How medical fitness is defined, who gets to define it, and how much the public has a right to know are more difficult questions.

•  •  •

During the 1960 presidential primaries, rumors began to circulate that Senator John F. Kennedy had Addison’s disease, a serious and potentially life-threatening illness involving the adrenal glands, prompting the candidate’s brother Robert F. Kennedy to declare:

The Senator does not now nor has he ever had an ailment described classically as Addison’s Disease, which is a tubercular destruction of the adrenal gland. Any statement to the contrary is malicious and false.

While tuberculosis was not the cause of Senator Kennedy’s adrenal insufficiency, he clearly did have Addison’s disease, which was diagnosed in England in 1947 after Kennedy, then a Massachusetts congressman, collapsed during a visit to London.
Senator Kennedy told the historian Arthur Schlesinger, “No one who has the real Addison’s disease should run for the presidency, but I do not have it.” Kennedy adviser Theodore Sorensen said, “He is not on cortisone. . . . I don’t know that he is on anything—anymore than you and I are on.”
The candidate was, in fact, taking cortisone daily and had a steroid pellet surgically inserted under his skin every few months to replace hormones his adrenal glands could no longer sufficiently produce.

In 1992, the
Journal of the American Medical Association
published an interview with two of the pathologists who performed President Kennedy’s autopsy after his assassination on November 22, 1963. While the Warren Commission report of the autopsy findings did not describe the adrenal glands, in the journal interview, Dr. J. T. Boswell, one of the principal Kennedy pathologists, stated that they could find
no gross evidence of adrenal tissue and only scant cells on microscopic examination, consistent with the diagnosis of severe Addison’s disease. In a follow-up editorial, the journal’s editor in chief, Dr. George Lundberg, noted that in the 1960 general election, only 114,673 (0.17 percent) votes separated Kennedy from Nixon. Lundberg writes:

The mental and physical health of a presidential candidate . . . is of great political concern to the electorate. But had the American people been told that one candidate had suffered for more than 13 years from an incurable, potentially fatal, although fully treatable disease and that there were potential serious adverse effects of treatment, would the election results have been different?

Herbert Abrams, professor emeritus of radiology at Stanford University and a member of Stanford’s Center for International Security and
Cooperation, has written extensively about presidential health and public disclosure. He notes that when the public votes,
“it expresses its consent and endorsement at the ballot box. Such consent can only be informed if it is based on full disclosure.” How much does the public have a right to know? Abrams likens the threshold for candidate disclosure to the informed consent process prior to medical procedures:

When the public chooses a president, the risk that must be disclosed is any illness that may impede the candidate’s capacity for decision-making for the nation, or render him disabled during the course of his tenure as president and thereby unable to serve.

Lawrence Altman, now a senior scholar at the Woodrow Wilson International Center in Washington, DC, who has spent much of his career relentlessly advocating for greater access to the medical records of political candidates, states:

In my view, the public uses elections to hire its officials, expecting these employees to be able to serve their full terms without being inconvenienced except for minor ailments. Nevertheless, no ailment should disqualify anyone, even if ill or dying, from holding office. The choice is the electorate’s.

Although in recent elections it has become increasingly common for the candidates” physicians to release statements outlining their patient’s pertinent medical issues, cooperation, transparency, and veracity have varied over the years.

•  •  •

In spring 1944, as US and Allied forces were readying for the invasion of Europe, President Franklin Delano Roosevelt’s health was declining. The president had developed influenza in December 1943 and had not rallied after that illness. On March 27, 1944,
Dr. Howard Bruenn, a cardiologist from the National Naval Medical Center, examined
the president. He found that the president appeared tired and gray, coughed frequently, and was significantly short of breath when he moved. The president’s blood pressure was 186/108, and examination of the chest revealed rales (derived from the French
râle
, meaning “rattle,” indicating the presence of fluid in the lungs). Dr. Bruenn diagnosed congestive heart failure and recommended one to two weeks of bed rest, codeine to suppress the cough, digitalis to strengthen the heart, and sedation. Admiral Ross McIntire, the president’s physician, rejected the recommendations, citing in Bruenn’s words the “exigencies and demands on the President.” The president’s condition remained unchanged over the next few days, and civilian consultants were brought in, one of whom was the prominent surgeon Frank Lahey, founder of Boston’s Lahey Clinic. On April 4, the president felt better, but his blood pressure was now 226/118. In response to growing rumors about the health of the president, Admiral McIntire held a press conference and declared:

When we got through, we decided that for a man of 62-plus we had very little to argue about, with the exception that we have had to combat the influenza plus the respiratory complications that came along after.

The public was never told that the president was struggling with congestive heart failure.

In a letter dated July 10, 1944, ten days before FDR accepted the nomination of the Democratic Party for a fourth term, Dr. Lahey wrote:

On Saturday, July 8, I talked with Admiral McIntire in my capacity as one of the group of three, Admiral McIntire, Dr. James Paullin of Atlanta, Georgia, and myself, who saw President Roosevelt in consultation and who have been over his physical examination, x-rays, and laboratory findings concerning his physical condition. . . . I am recording these opinions in the light of having informed Admiral
McIntire Saturday afternoon July 8, 1944 that I did not believe that, if Mr. Roosevelt was elected President again, he had the physical capacity to complete a term. I told him that, as a result of activities in his trip to Russia he had been in a state which was, if not in heart failure, at least on the verge of it, that this was the result of high blood pressure he has had now for a long time, plus a question of a coronary damage. With this in mind it was my opinion that over the four years of another term with its burdens, he would again have heart failure and be unable to complete it. Admiral McIntire was in agreement with this.

In November, President Roosevelt defeated New York’s governor, Thomas E. Dewey, in an Electoral College landslide. Only a few months into his fourth term, on April 12, 1945, President Roosevelt died from an apparent cerebral hemorrhage, likely precipitated by his uncontrolled hypertension.

•  •  •

Mr. Cheney asked Gary Malakoff and me to provide our own reports, which the campaign released the same day as Dr. Cooley’s. I intended the statement to be a succinct and accurate description of Mr. Cheney’s medical history and his current status, not an exhaustive case presentation. No one from the Bush-Cheney campaign proffered any guidance or guidelines for the documents, which were released to the public unedited. I wrote:

Mr. Cheney has a remote history of an inferior wall myocardial infarction that occurred in the late 1970’s. Cardiac catheterization following that episode revealed moderate coronary artery disease and he was managed medically for the next several years. A small, second, myocardial infarction occurred in 1984 and again in June 1988. Cardiac catheterization during that hospitalization demonstrated an increase in the extent of his coronary disease and he subsequently underwent successful coronary artery bypass graft
surgery at George Washington University by Dr. Benjamin Aaron. Following surgery, Mr. Cheney returned to his vigorous lifestyle and has been essentially asymptomatic for more than a decade. Recent nuclear stress tests have been stable, and unchanged, for the past several years. Recent echocardiography shows some left ventricular dysfunction consistent with the history and distribution of his remote myocardial infarctions.

Clinically, Mr. Cheney continues to lead an asymptomatic and extraordinarily vigorous lifestyle. He travels extensively for work, exercises 30 minutes per day several days per week on a treadmill, and engages in vigorous recreational activities such as hunting.

I knew that my statement would be carefully scrutinized, and for that reason, the 173 words took me most of an afternoon to write. Cheney had a complicated medical history, and the task of distilling twenty-two years of cardiac events into a few paragraphs of text intended for the general public was challenging. Ultimately I decided to simply summarize Cheney’s salient history and his current status.

Presidential campaigns are about electing presidents. Rarely does a vice-presidential candidate matter to the outcome. There are two times, however, when he or she can make a real difference—for better or worse. The first is the acceptance speech at the party’s national convention. The second is the nationally televised debate.