By Brad Segal
“If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency,” proclaimed Dr. Harold Bornstein. The gastroenterologist’s letter, released on the candidate’s website nine months ago, stumbles from the outset with a typo (“To Whom My Concern,”), then steamrolls over the most basic descriptions of health (medical school teaches us that vital signs are, well, vital), omits information pertinent to the public discourse (why does it fail to mention the medical reason exempting Trump from the Vietnam draft?), and strangely emphases non-medicalized traits (“His physical strength and stamina are extraordinary”). Most experts agree that this medical record, if we can even call it that, is at best hyperbole. It draws grandiose conclusions without medical justification. Even Dr. Bornstein conceded, “In the rush, I think some of those words didn’t come out exactly the way they were meant.”
Just this morning the Trump campaign released a second letter from Dr. Bornstein. But this time the doctor rather humbly concludes, “In summary, Mr. Trump is in excellent physical health.” These letters from Dr. Bornstein’s letter demonstrate a modern-day moral dilemma in providing care for a party nominee. At conflict is the physician’s professional duty to respect patient confidentiality, and his or her obligations to care for society more broadly.
First, patient-doctor confidentiality is not merely a byproduct of the law—it is a moral obligation grounded in the core tenants of the medical profession. To put it simply, if a patient comes to expect that his doctor will tell the entire community about the patient’s most embarrassing bodily defects, the patient may understandably deny his worsening symptoms of poor health at the next office visit. In the long run, erosion of trust in the medical system could endanger the public’s health–everyone is thus better off when doctors uniformly respect patient privacy. It is important to point out, however, that an informed and competent person can voluntarily waive one’s right to patient-doctor confidentiality, such as when a patient gives a physician the permission to provide updates to family members. Or when then-candidate John McCain instructed his physicians all 1,100 pages in his medical records.
At the same time, doctors are also under a moral obligation to promote overall well-being. Typically, these obligations are couched in the language of public health, like administering routine vaccines to decrease the burden of preventable disease. Nonetheless, it seems reasonable that if a sitting president undergoes surgery, the president’s doctor has a responsibility to the public to not prematurely announce complete recovery, lest the president unknowingly order a nuclear strike before the effects of anesthesia wear off.
When these two obligations conflict, from both an ethical and legal standpoint, there are certain situations where societal welfare trumps patient confidentiality (and yes, that pun was intended). For instance, diagnosing certain communicable infections obligates doctors to file a report with the CDC. Likewise, announcing that an individual was quarantined is morally palatable when the injustice of disclosing his or her health information is considered against an epidemic with massive human suffering.
With all of this in mind, the first letter signed by Trump’s gastroenterologist brings up two related questions. First, at what point does a doctor’s obligation to societal well-being justify breaking a candidate’s confidentiality? And second, when a person voluntarily runs for president, exactly how much health information is the public entitled to know?
As it currently stands, the extent to which an individual’s medical record is made available remains within the power of each candidate. The American Medical Association sanctions this policy in its code of ethics, which permits releasing at most, “only information specifically authorized.” A problem with this is the improbable scenario where a candidate is diagnosed with a disease that limits (or will limit) one’s capacity for decision-making, and the candidate declines to publicly share this information.
Unfortunately, calls for non-partisan solutions have gone unanswered. In 1994 Jimmy Carter published an article in JAMA urging creation of an independent panel of healthcare experts to help determine whether a sitting president is unable to fulfill his or her constitutional duties as a result of medical disability. Ethicist Arthur Caplan has long-argued that non-partisan health evaluation would help prevent candidates from self-censoring important medical details. Dan Diamond from Politico points out this would also quell the swirling health conspiracy theories.
In prior elections, presidential candidates have largely been more forthcoming about their health. Even though the nominees in the current race retain the prerogative to keep health information out of the public eye (which, actually, reminds me of tax returns…), their physicians should still categorically refuse to release statements about their candidate’s health when the medical facts are intentionally misleading or outright false. Complying with such a request is a straightforward conflict of interest, readily comparable to a doctor who gets paid for publishing a favorable drug review in a good journal. Scoring a gig as the president’s gastroenterologist is just not worth endangering public trust in the profession.