COMMENTARY

Would President Trump Pass the Air Force's Nuclear Evaluation?

Jeffrey A. Lieberman, MD

Disclosures

January 31, 2018

Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape. Just when you thought everything that needed to be said could be said about President Trump's behavior, mental health, and fitness for office, a new development occurs—hence, what I'm calling chapter 3 in "The POTUS's Mental Health."

Chapter 1 was when initial comments about his behavior and what might be causing it—and whether there was any potential underlying medical or psychiatric condition—involved the reaffirmation by responsible members of the medical community, psychiatry, and the American Psychiatric Association of the Goldwater Rule. This rule advises physicians (psychiatrists in particular) that it's not responsible or ethical to proffer diagnoses on public figures whom they haven't had the chance to examine and have thorough information about.

Chapter 2 dealt with the remedies for a sufficient level of concern about a president's fitness for office. These remedies were spelled out in the 25th Amendment, which allows for a mechanism to invoke an evaluation and potential transfer of power. The other remedy is in the context of what has become a tradition: the annual medical exam, which presidents routinely undergo but which almost never includes an extensive neuropsychiatric component.

What occasions chapter 3 is the comments that have been published in a New York Times editorial on January 19, 2018,[1] also presaged in a book authored by the same doctor, called A Clear and Present Danger: Narcissism in the Age of Donald Trump, initially published in 2016.[2] These come from a Dr Steven Buser, who [was] a psychiatrist in the military, specifically the Air Force. He [was] charged, as part of his responsibilities doing mental stability evaluations on personnel involved, with managing nuclear weapons.

To quote Buser:

As a psychiatrist in the United States Air Force, one of my responsibilities was evaluating the mental stability of airmen who handled nuclear weapons using the standards laid out in what is called the nuclear Personnel Reliability Program. There's no need to justify why our military would take every precaution necessary to ensure that the men and women in uniform handling nuclear weapons were fit to do so, whether they were in charge of the missile silo, or loading nuclear bombs into aircraft, or giving orders to them and up the chain of command. Strangely, the commander-in-chief, the one who would decide when and how to use these weapons, is the only individual in the chain who is not subject to the ongoing certification under the Program.

According to the program known as the PRP, personnel who handle nuclear weapons are held to higher standards of physical and mental readiness than other personnel, and rightfully so. The Department of Defense directive states: "Only those personnel who have demonstrated the highest degree of individual reliability for allegiance, trustworthiness, conduct, behavior, and responsibility shall be allowed to perform duties associated with nuclear weapons, and they shall continuously be evaluated for adherence to these standards."

Recently, the White House physician, Rear Admiral Ronny Jackson, gave the President a clean bill of health. And no doubt, by many standards, Mr Trump is in good shape. But the standards for a person's physical and mental health are different from his fitness to oversee our nuclear arsenal. What if President Trump were, indeed, Airman Trump and was to be assessed under the program's guidelines? Would I certify him as PRP-ready to work in the vicinity of nuclear weapons? That's a question. Would I?

To me, this raises a new perspective and level of consideration of the question of the President's behavior and fitness for office, and offers a pathway to remedy the ongoing concern and debate. First, before I get to that, let me just comment on what I view as a concern about Dr Buser's argument. His rationale for why there should be scrutiny and why there might be higher standards for individuals who control potentially lethal and life-ending weapons is understandable. The main comments about behavior, as they relate to diagnosis, are about narcissism and in the realm of character and personality disorder. As all psychiatrists know, this is an area of our nosology that is less firmly established in terms of scientific validity, and where the specific definition—and most logic boundaries—are less well defined. The exception to this might be sociopathy or antisocial personality, in which individuals have criminal records or past records of some deviant behavior, which, of course, the President does not.

Although I think the point that Dr Buser makes is correct, the potential diagnoses that it leads up to are not necessarily the strongest basis for removing the President from office. As he points out, the criteria for the nuclear weapon personnel evaluation are, for the most part, different from those used in making a medical diagnosis.

There is a saying, a rueful saying: Never miss an opportunity, even when it's the opportunity created through misfortune or something unwanted. I think the point that is being made by Dr Buser gives us a justification and offers a procedural approach for instituting a process by which sitting presidents are evaluated on when coming into office and during their term of office, to ensure their competence to fulfil their responsibilities. It's unfortunate that this is occurring [a year] into President Trump's presidency. It's a little bit like changing the goalposts in the middle of a game. Nevertheless, this is an opportunity to rectify a situation that really should have been addressed long ago.

If political candidates for the highest office in the land, the most powerful position on the earth, aspire to this, we need to be assured as to their fitness—their fitness in terms of their physical and mental well-being. This can only be done by having a direct evaluation by competent, nonpartisan experts who are physicians. There needs to be a mechanism in place to do so beyond what currently exists, which is an annual physical that doesn't include comprehensive testing of all organs of the body, and first and foremost in this case, the brain.

This debate, controversy, tawdry exchange of opinions in the public arena can come to some good purpose if a thoughtful policy is developed and enacted. This would include requiring comprehensive medical examinations of a president's health, which includes neuropsychiatric assessments in a comprehensive way, to ensure their health. If this were to be done, something good could come of this situation.

Thank you for listening. This is Dr Jeffrey Lieberman, Columbia University, speaking to you today for Medscape.

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