A reader asks:

I’m struck by your insight back in 1984 when you suggested that Reagan might be developing Alzheimer’s disease. Would you feel comfortable making such a suggestion again if you thought it were warranted?

I ask because I believe you’ve cautioned against long-distance diagnoses (unless I’m confusing stuff you’ve written from other things I’ve read online and off). You’ve gained 18 years of experience and wisdom since 1984, and I wonder whether you still think it was a good idea to make your long-distance diagnosis about Reagan.

It’s a tricky question because you were correct back then. But, generally speaking, do you think it’s a good idea for a doctor to say of a presidential candidate, “I think he should be checked out because, from what I see on TV, he exhibits signs of X disease or Y malfunction.”? That’s much different from saying, “I believe he should be checked out mentally and physically as a matter of policy.”

Thanks for the question. It is at times like these that I wish I were satisfied by any of the online comment systems for blogs [having flirted with a few, as readers will recall, and uninstalling each for one reason or another…]

In any case, I do indeed have qualms about diagnosing without doing a face-to-face history and examination of a patient. Probably, the public comments I’ve made (on FmH) have been cavils about the ‘parlor games’ of explaining the behavior of long-dead historical personages by a brilliant stroke of diagnosis without any medical evidence, as well as the worrisome proliferation of web-based psychotherapeutic treatment and medication prescribing sight unseen by physicians and allied health professionals I consider unscrupulous and unethical for doing so. Since I’m ‘out’ as a psychiatrist on the web, I have also — not very frequently, it turns out — received emails privately requesting medical or psychiatric advice and have demurred on those same grounds. In essence, my position is that it is (a) unethical to diagnose outside the confines of the doctor-patient treatment contract; (b) more likely to be inaccurate without the iterative process a face-to-face presence allows; and, finally, (c) it may interfere significantly with some existing treatment relationship the patient already has. [This is for a different discussion altogether, but this last point follows from my conviction that much diagnosis is not the delivery of an incontrovertible medical fact to the patient, but rather the weaving of a web of consensus with them. A diagnosis is one, shared, way of making sense of the data the patient has brought you about their current suffering, and its value depends on its explanatory power, which involves not only its scientific plausibility but the interpersonal context in which it is embedded.]

While I turned out to be correct in worrying in 1984 that Reagan had Alzheimer’s Disease, I don’t think I was prescient — now that I know more (much more!) about the diagnosis of dementia — so much as lucky. So much for accuracy, although I was pretty certain he was having some nature of cognitive difficulties by that time. Of course, the public exposure of a political candidate or leader, also, gives a great deal more opportunity for observation and ongoing refinement of diagnostic hypotheses than either a deceased historical personage or a private individual without public visibility.

As for the ethical concerns, I think we have to have a different, a lower, threshold for worrying about the intellectual wherewithal of any man with his finger on the nuclear trigger (or, for that matter, senior officials around him). For purposes of raising public concern, influencing people’s comfort electing someone President and Commander-in-Chief, or provoking interest in further formal examination of his mental status, I would continue today to be far more comfortable suggesting he might have a troubling medical condition than I would with a private individual where the concern was merely the treatment implications of the diagnostic hypothesis.