This page is all editorialization, with only occasional use of highlight boxes like this one.
Contents of This Page
- General Remarks
The list of open questions below, compiled from other pages in this web mini-site, is provided only as a reminder. The list is not sorted in any particular order, and it mixes relatively less important questions with more important questions.
These questions are not discussed on this page. The remainder of this page discusses only the major factors that potentially impinge on Senator McCain's medical fitness to be President.
Medicine and the Presidency
Should an illness befall a President, or even threaten
to befall a President, the main concern will be its effects on job performance (1)
There are several major ways in which a medical condition could reduce job performance:
- Cognitive side effects, if the condition affects the brain directly.
- Cognitive side effects, if the condition affects the brain indirectly, e.g. when it causes metabolic abnormalities by damaging the liver.
- Cognitive side effects arising from treatments aimed at the condition, e.g. from medications.
- Reduced work time, caused by illness directly, or indirectly by time spent with physicians, time spent providing explanations to the public, and time spent briefing government officials.
- Decreased work performance (or energy) while recovering from diagnostic or therapeutic manuevers, e.g. surgery or chemotherapy.
- Decreased work ability imposed by the condition or its treatment, e.g. restrictions on travel overseas.
- Reduced attention to work because of worry and personal matters stemming from the condition.
- Unknown psychological effects on the President's judgement if confronting a life-threatening or career-threatening illness.
- Decreased governmental efficiency if Presidential power must be frequently passed from President to Vice President during periods when the President is compromised by medical matters.
- The potential for the Vice President and a Cabinet cabal to exploit Section 4 the 25th amendment to the Constitution to seize power from the President and plunge the nation into a Constitutional crisis.
The military's seemingly harsh intolerance of medical illness is often based on the above realizations, namely, that indirect effects of illness can interfere greatly with a person's availability for full duty even when direct effects of the illness are modest.
In the discussions that follow, it will be helpful to remember the indirect burdens that disease can bring -- even for a President, who has a medical staff at his beck and call.
Types of melanoma
The hazards to a McCain presidency from malignant melanoma arise from two possibilities:
Possibility of a new melanoma during a McCain Presidency
A medical reporter for CNN has calculated that Senator McCain has an "18% chance of having another skin cancer" (2)
This number is worthless, for two reasons. The reporter mentioned neither the type(s) of skin cancer included in the calculation, nor the period of time covered by the calculation. Despite these criticisms, it is quite clear that John McCain is at a much-higher-than-average risk for a new melanoma during the next four years.
A new melanoma would not necessarily be a threat to life, but it would interfere with the President's job: at the least, it would certainly trigger an intensive search to see if it had already spread. There would no doubt be long discussions on how to spin the news, and the press and the administration would certainly engage in essentially non-productive discussions of the President's treatment and prognosis (3)
The best known method to discover a new melanoma is frequent skin examinations by a dermatologist who knows his case well. This is the cornerstone of Senator McCain's melanoma care today.
Senator McCain and his campaign imply that he would continue his frequent skin checkups if he became President. There is actually reason to doubt this, as he deferred his skin checkups
while running for President in 2000 (4)
. The deferral is probably why the melanoma discovered on his temple in 2000 was so far advanced. Thus, if elected, a President McCain should have the results of his skin examinations disclosed publicly, at the time they occur (5)
. The public could then serve as a nagging parent should he fall behind in his check-ups.
Unfortunately, simple skin examinations are wholly inadequate for detecting a recurrence of the 2000 melanoma. If the 2000 melanoma returned, it would not likely return in the skin. It would more likely return in a deep organ, such as the brain or liver. Skin examinations would obviously not detect brain or liver tumors.
Thus, skin examinations will not detect an old melanoma that has spread to an internal organ, or a new melanoma that arises outside the skin, or a new skin melanoma that spreads to an internal organ before arousing suspicion.
The brain threat
Melanoma has a marked preference to spread to the brain (6)
. Thus, the public should not be satisfied that the Senator's skin examinations show no signs of melanoma. It is more important that his brain is free of melanoma.
The Senator's continuing survival since 2000 reduces the odds of his old melanoma appearing in his brain. This is fortunate, because the absolute odds are quite high:
Metastatic spread of tumour cells detached from melanoma into the central nervous system (CNS) occurs ... in 10 to 40% of melanoma patients in clinical studies and up to 90% in autopsy studies. Headache is the most common presenting symptom, but brain metastases should be suspected in all melanoma patients with new neurologic findings. Magnetic resonance imaging is the best diagnostic technique for detecting CNS metastases. Median survival of melanoma patients with CNS metastases ranges between 2 and 8 months. (7)
For someone whose health is guarded so assiduously as the President's, it seems, at one extreme, as if he would need an MRI scan of the brain each time he had a headache!
Brain tumors present an insidious threat because of their potential to subtly warp thinking processes -- an obvious concern in a decision-maker.
Even if treated, residual effects -- from the tumor or its treatment -- might forever afterwards cast doubt on the President's decision-making. A canny politician would, therefore, realize that his political career would end the moment a brain tumor is discovered, no matter what the probability of successful treatment. Thus, to prolong his hold on power, it would be in the President's best interest to delay for as long as possible the recognition of such a tumor. The nation's interests are the opposite.
These realities are a conflict of interest. Like all conflicts of interest, this should be a red flag for voters. The Senator's physicians should outline what steps they plan to take, if any, to ensure they catch a brain tumor early. They should outline this before the election, so the voters can decide if it is adequate. It is too much to ask the voters to trust the President's physicians. Once their patient becomes President, patient-physician confidentiality means the President's physicians can say to the public only what the President asks them to. Public trust comes second to their obligations to their patient. And even if public trust did come first, the electorate does not know these physicians. They are not subject to Senate confirmation.
The medical surveillance plan for a President McCain should regularly include, at a minimum, a neurological examination conducted by a physician (preferably a neurologist) and imaging of the brain (e.g. by MRI). These studies should be performed now, especially because the Senator's drooping left upper eyelid
is a neurological finding compatible with a tumor in the brain; it warrants investigation.
The metabolic threat
Similarly, if an old melanoma were to spread to a metabolically active organ, such as the liver, and grow to significant size, then the organ could begin to malfunction. This can happen without the patient or an incurious physician being aware of it.
The liver is one of the most common organs to which malignant melanoma spreads.
If the metabolic malfunction is sufficiently far advanced, the brain can suffer. For example, a sick liver can allow ammonia levels in the blood to rise. The brain does not like ammonia. High ammonia interferes with thinking.
In most cases, non-cognitive symptoms would appear before cognitive ones. But this cannot be guaranteed, so a metabolic monitoring plan should be devised. It need not consist of anything more than periodic blood sampling. For the same reasons as screening for brain tumors, the metabolic monitoring plan should be made public.
The non-cutaneous threat
Most new melanomas arise in the skin, but sometimes they do not. For example, melanoma can occur in the eye. Although it is a rare tumor in the general population, in someone who has already had four primary melanomas (two on the head), and whose eyes are light
, and whose eyes probably had a great deal of sun exposure (see discussion of Senator McCain's cataracts
, it is reasonable to be vigilant for uveal and other ocular melanomas. It would be reassuring to know such a plan was being followed.
If caught early, the eye harboring a melanoma can be saved.
Melanoma risk estimates
In May 2008, Senator McCain's dermatologist told reporters that there was "no crystal ball to predict with certainty" if Mr. McCain's cancer would return, but she put the chance at less than 10 percent at this stage in his life (9)
If this is all the dermatologist said, it is insufficient. Are we to presume the risk is less than 10% but more than 5%? And what is the period of time covered by this 10%? The next year, the next decade? It is also puzzling that the dermatologist did not report the basis for her estimate. Is her estimate based on data from the medical literature, or her personal belief? The current age of evidence-based medicine demands the former, and anything less is unprofessional. And so, one is again left to wonder whether the Mayo Clinic's disclosures were intended to benefit its patient rather than inform the electorate. Hopefully, the missing information was, in fact, mentioned, but not reported by the press. If that is the case, then the press deserves opprobrium.
Regardless, the press deserves criticism for passively and uncomplainingly accepting such unsubstantiated pronouncements. The public relies on the press to ask questions that the public doesn't know should be asked. The press has clearly failed in this with respect to the Senator's medical history.
In medicine, odds on the order of 10 percent are considered high, and justify very aggressive medical surveillance.
Using references from the medical literature, Alam (10)
estimates the current risk of Senator McCain dying from his 2000 invasive melanoma as 6% per year. The method used is not rigorous, but it usefully highlights a fact missing from current discussions of the Senator's health, namely, the risk of his cancer returning is still significant.
Compounded over a four-year Presidency, an annual risk of 6% yields a 22% risk of death from melanoma sometime during a single presidential term. The risk of serious illness would be higher, as more people become ill than die. Even if the risk were 3%, the four-year risk would be 12%.
For someone of Senator McCain's age, the main threat to life is heart disease. Acutally, it is more relevant to speak of "cardiovascular" disease because vascular disease (i.e. disease of the arteries) is responsible for most strokes in the United States.
Physicians often speak of "risk factors" for a disease. These are elements form the patient's medical history or physical examination that increase the risk of the disease. The risk factors for heart disease and stroke are almost the same. Here is Senator McCain's list of cardiovascular risk factors:
- Risk factors present
- Male sex
- 50 pack-year smoking history
- High blood pressure, treated
- High LDL cholesterol, treated
- Low HDL cholesterol
- Risk factors absent
- Premature cardiovascular disease in family
- High blood sugar
- Risk factors unknown
- Left ventricular hypertrophy
The Senator's excellent exercise tolerance
should be viewed as a "negative risk factor." That is, it is a good prognostic sign.
Cardiologists have developed equations to calculate the risk of heart disease in individual patients. The Framingham equation
and the Duke treadmill score
are two of the most enduring.
According to the Framingham equation, Senator McCain has a 27% chance of having a fatal heart attack in the next 10 years (11)
. His Framingham worksheet
The total risk of a fatal heart attack over 10 years is 30% for the average man 70-74 years old, according to the Framingham worksheet. Thus, Senator McCain's cardiovascular risk is about average.
Use of the Duke treadmill score is problematic. It requires knowing which treadmill protocol was used during the Senator's stress tests (12)
. In the most optimistic case, if we assume the "Bruce" protocol was used, then Senator McCain has about a 10% chance of dying from heart disease in the next 10 years. If one of the less-strenuous treadmill protocols were used, his predicted risk of cardiovascular death would be higher. His Duke nomogram image
Because of the uncertainty about the treadmill protocol, it is premature to start hypothesizing about the difference between the Framingham and Duke risks in Senator McCain's case.
The identity of the treadmill protocol was almost certainly in the information that the McCain campaign made available in May 2008. This is a clear example of why a hurried examination of medical materials, by non-physician reporters
and non-specialist physicians, yields confusion.
A professor of medicine at Johns Hopkins used to teach (in the 1980s) that a person's occupational status was never a guarantee against dementia. He told the story of a Fortune 500 CEO who was found to have Alzheimer disease. The professor concluded "It doesn't take much brain power to run a large corporation."
Perhaps times have changed. Perhaps not.
Senator McCain is acquitting himself well, from a cognitive standpoint, in his campaign. His physician reports no evidence of short term memory loss
. His function today, however, is no guarantee of his function tomorrow.
He has several risk factors for dementia:
Remember, too, that vascular disease (disease of the arteries) can also lead to dementia. Senator McCain's vascular risk factors are discussed above.
(It would be nice to have a quantitave prediction of the risk of dementia over the next 4 years.)
Interestingly, it may soon be possible to perform brain scans to detect Alzheimer dementia before obvious symptoms occur. One could imagine future candidates of an advanced age undergoing such scans to forestall concerns about future declines in cognition.
Mild cognitive impairment
It is a mistake to think that dementia is the only threat to the thought processes of a future President McCain. "Dementia" is a carefully defined disease that encompasses only the most advanced part of the spectrum of impaired cognition.
Lesser, but still abnormal, degrees of cognitive loss could pose grave threats to the success of a Presidency. Neurologists have difficulty defining these lesser degrees of loss, which go by the name of "mild cognitive impairment" (MCI).
Mild cognitive impairment is distressingly common in older Americans. Given the Senator's good performance during the campaign, it is unlikely that he has MCI today. Too little is known about MCI to determine his risk for MCI in the next few years.
Obstructive sleep apnea (OSA) is common: about 25% of North American adults have it (13)
. Senator McCain's thick neck would appear to place him at risk of the disease.
Untreated OSA has the potential to significantly influence a Presidency (14)
, as the example of William Howard Taft proves (15)
. Chronically unrefreshing sleep can influence judgment, temper, and cognition itself.
Snoring is a cardinal sign of obstructive sleep apnea. If Senator McCain snores, he should be tested for OSA.
Effects of captivity
The naval aviators who were imprisoned in Vietnam, now in their 60s and 70s, have been largely resistant to psychological damage from their captivity (16)
For Senator McCain, specifically, a Washington Post
physician-reporter gives this summary:
Sen. John McCain's 5 1/2 years as a prisoner of war in North Vietnam undoubtedly changed the course of his life. But now that he is 71 [72 at inauguration], that remote trauma seems unlikely to shorten his life span or to lead to mental or physical conditions that are not already apparent.
That is the implication of a body of research on the lifetime effects of captivity and war trauma and the anecdotal experience of the small group of naval aviators imprisoned with McCain at the notorious "Hanoi Hilton."
Even so, it is possible for effects of captivity to appear late in life, as part of a syndrome called LOSS (late onset stress symptomatology). Former POWs with LOSS re-experience past traumatic events plus physical hyperarousal. Fortunately, LOSS does not include some of the more distressing features of PTSD (post-traumatic stress disorder). (16)
There is little value, however, in trying to predict whether a President McCain would be at risk for LOSS. The psychological demands of the Presidency, and the pschological make-up of someone who is elected President, are sufficiently unique that such a person cannot be expected to fit into the groups of people in whom studies of LOSS have been conducted.
Myth of the strenuous campaign
Mark S. Litwin, a surgeon and "survivorship expert" at UCLA's Jonsson Comprehensive Cancer Center in Los Angeles, has observed: "The demands of the modern campaign [for President] are so significant that if one can get through them, one can assume they are as fit as need be" (16)
This belief is commonly held, but it is clearly false. Richard Nixon is the clearest counter-example. His three
modern Presidential campaigns (1960, 1968, 1972) subjected him to an extraordinary amount of public scrutiny. Yet, in the end he proved mentally unfit as President. It has recently been disclosed that he consulted a psychiatrist over a period of years in the 1950s (17)
Moreover, Litwin assumes a constancy of brain function. The brain of a 72 year old may not be the same brain two or three years hence.
Litwin should also have considered serious medical illnesses that can be completely asymptomatic, even in an active campaigner. The best example is a non-flow-limiting coronary plaque prone to rupture.
An "advance directive" is a person's written guideline for future medical treatment. It may, for example, specify that the person should not be resuscitated from a cardiac arrest, or not be connected to a ventilator (a machine that breathes for the person). An advance directive is best written at a time of mental competency, during sober reflection, without pressure of impending events.
Advance directives have proven to be extraordinarily helpful in clinical medicine. They could be similarly helpful in the case of a President who develops an illness that is somewhere between fatal and minor.
A Presidential Advanced Directive would differ from a medical one, as it would concern the retention or transfer of the office, not medical treatments. It has the potential to stabilize the country (and the government) in what would otherwise be a time of great uncertainty.
In the specific case of Senator McCain, a reasonable Presidential Advance Directive might reasonably include statements such as these:
- In the event I am diagnosed with cancer in the brain, I will, within three days, resign the office.
- In the event I am advised by physicians to undergo cancer chemotherapy, I will transfer power to the Vice President. In the event the treatment does not render me cancer-free, I shall not seek restoration to the Presidency.
- Should I suffer an illness or injury in which my physicians recommend oxygen therapy, I will transfer power to the Vice President until at least the time oxygen is no longer recommended.
- In all cases of illness, I will authorize my physicians to freely disclose any medical matters that would render me unfit for duty under US Air Force Instruction 48-123 volume 3 attachment 4 (18) or succssor.
Many other directives are possible. The 25th Amendment to the US Constitution offers a mechanism for transfer of power from President to Vice President, and back again.
It should always be remembered that the occupant of the office is of secondary importance. The integrity of the office is primary. No human is irreplaceable. The advance directives would be aimed at preserving the integrity of the office, not at preserving a dying President's hold on power.
What are the odds that something medically bad would happen to a President McCain during his four year term of office?
First, there is the possibility that his invasive melanoma
could recur, either killing him, making him severely ill, or requiring treatment that would make him ill. We will conservatively estimate the odds of this at 2% per year.
Second, there is the possibility of a heart attack or a stroke. The risk predictions vary for Senator McCain's specific history. We will put him at a lower than average risk
for a man of his age, and say the risk of cardiovascular death is 2% per year.
Third, there is the normal risk of death that anyone faces at a given age. Normally, cardiovascular deaths account for about half of all deaths in older persons. We will be generous to the Senator again, and put his risk of non-cardiovascular, non-melanoma death at only 1% per year. (19)
Fourth, there is the possibility that mild cognitive impairment
may begin to occur. There is not enough information, however, to predict the odds of this, so we will call it zero.
Overall, therefore, the annual numerical risk appears to be at least
2% (melanoma) + 2% (cardiovascular) + 1% (general) = 5%. Quantitatively inclined readers should note that it is fair to consider these as independent causes, and simply sum them (20)
When compounded over 4 years, a 5% annual risk works out to a 19% chance of something medically bad occurring during a McCain presidency. This is a very conservative estimate.
This section could be dramatically improved. Logistical constraints have prevented more exhaustive research. Because it would not have been possible to conduct that research before the election, it seemed more important to publish this site as you see it. To be fair to the Senator, I have put in the most favorable numbers to him at every point.
Senator McCain has said that Ronald Reagan is one of his heroes (21)
. He should, therefore, be familiar with one of Reagan's most famous borrowed lines, "Trust, but verify" (22)
As it stands today, the McCain campaign offers too much trust, and not enough verify.
The Senator should be applauded for making his medical records available for inspection, especially if they are his complete medical records. But he should be vigorously condemned for his tactic of forcing the inspection to be cursory and hurried.
Senator McCain forces us to place a great deal of trust in his physicians. They are perhaps fine people, but let us not forget that, at the Mayo Clinic, by their own sanctimonious admission, "the needs of the patient come first" (23)
. In this situation, the Mayo Clinic should put the nation first
All physicians are aware of their dual responsibility to the public health and to their patients' health. Thus, there is no ethical conflict for the Mayo Clinic to speak freely and completely about the Senator's health, should the Senator allow it. In fact, the Mayo Clinic should have insisted on such liberty before agreeing to make any statement on McCain's behalf.
No statement from the Mayo physicians shows that they were allowed to speak freely. In fact, it is clear they were not. There was no discussion of the AFIP report. There has been no clarification on the staging of the 2000 invasive melanoma
. If the Mayo Clinic assembled members from all three of its centers to discuss McCain's case in 2000, then it was clearly not as straightforward a case as the public disclosure would have us believe.
The Mayo Clinic has essentially operated as an arm of Senator McCain's campaign, wrapping itself in a misleading cloak of high-sounding moral principle. Mayo should have told the McCain campaign they would say nothing at all, unless they were allowed to speak freely. Most importantly, the Mayo Clinic should have disclosed the ground rules under which its disclosures were made
. Only by knowing the ground rules could the public be assured that Mayo was not being complicit in a cover-up.
|1. ||If the President had a communicable disease, the safety of the people around him would become a concern. Because that is not an issue with Senator McCain, it will not be further discussed here. Abraham Lincoln, however, contracted smallpox while President. The White House was semi-quarantined for weeks, and members of Lincoln's staff were immunized against the disease (Sotos, John G. The Physical Lincoln Sourcebook. Mt. Vernon, VA: Mt. Vernon Book Systems, 2008, printing 1.1.).|
|2. ||Gupta, Sanjay. "McCain in 'excellent health,' doctor says." (Video report.) CNN.com. 2008 May 23. [Note: to see the video, click on the VIDEO tab, located next to the READ tab.]|
|3. ||These discussions would be non-productive in the sense that they would not be advancing the interests of the United States on the world stage. They would be productive in the sense of fostering an open government.|
|4. ||The Senator's recent decision to suspend temporarily his campaign, in order to attend to upheavals in the US financial system, add to concern that he might impulsively suspend medical follow-up to attend to apparently more pressing issues.|
|5. ||Disclosing the results of his skin examinations would also allow the public to ensure his examinations were occurring -- rather like a hovering parent!|
|6. ||There is increasing evidence that President Franklin Roosevelt had a melanoma that spread from above his left eye into his brain, where it grew into a large-sized tumor mass that ultimately bled and killed him.|
|7. ||Chiarion-Sileni V, Murr R, Pigozzo J, Sarti S, Tomassi O, Romanini A. Brain metastases from malignant melanoma. Forum (Genova). 2003;13(2):170-182.|
|8. ||For many years it was uncertain whether sun exposure increased the chances of developing a melanoma in the eye. Recent cautions from Australian authorities suggest that sunlight is indeed a risk factor.|
|9. ||Altman, Lawrence K.; Bumiller E. "McCain's Health Is Called Robust by His Doctors." New York Times. 2008 May 24.|
|10. ||Alam, John. "US Senator Johnn McCain and risk of melanoma-associated mortality." Lancet. 2008; 38: 1388-1394.|
|11. ||The input values were: age 72, LDL 139, HDL 35, blood pressure 145 systolic, diabetes no, smoking no. The blood pressure is a guess, based on statements from the Senator's internist, and the fact that the Senator is taking anti-hypertensive medication. This guess may be too high, but, in a crude sense, it is balanced by omitting the Senator's 50 pack-year smoking history.|
|12. ||The "treadmill protocol" refers to the speed and up-angle of the treadmill, and when they are increased.|
|13. ||Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002; 165: 1217-1239.|
|14. ||Think how you feel after one night without sufficient sleep. Magnify that by a factor of several-fold, and you begin to understand how someone with untreated sleep apnea feels every day, no matter how much time they spend in bed.|
|15. ||Sotos, John G. Taft and Pickwick: sleep apnea in the White House. Chest. 2003; 124: 1133-1142.|
|16. ||Brown, David. "POW Aftereffects in McCain Unlikely: Research Shows Past Trauma Probably Won't Affect Candidate's Life Span." Washington Post. 2008 May 23, page A06.|
|17. ||Gupta, Sanjay. "Fit to Lead." CNN. Special Investigations Unit. Broadcast 2008 October 11. Note: I have some questions about bias in this source. They claimed that Senator McCain's temple melanoma was the size of a dime and the thickness of a nickel. It was actually larger then a penny (which is larger than a dime) and thicker than a nickel. In addition, they devoted much air time to Senator Obama's smoking history, without once mentioning that Senator McCain smoked two packs of cigarettes per day for about 25 years.|
|18. ||A different standard, no less rigorous than that applied to air traffic controllers, may be chosen. The choice of standard requires study, and should ultimately be enacted into law.|
|19. ||Regarding Senator McCain's time as a prisoner of war, it is not known how the longevity of ex-POWs compares with that of other veterans or non-veterans (Brown, David. "POW Aftereffects in McCain Unlikely: Research Shows Past Trauma Probably Won't Affect Candidate's Life Span." Washington Post. 2008 May 23, page A06.).|
|20. ||Because melanoma is an uncommon cancer in the general population, it does sigificantly not affect the numbers for overall death. The cardiovascular and general risks are defined as independent.|
|21. ||Presidential Debate #2 of 2008. October 7, 2008.|
|22. ||This was an old Russian proverb that Reagan appropriated. See: Sagdeev, Roald Z. The Making of a Soviet Scientist. New York: Wiley, 1994. page 302. (ISBN 0-471-02031-1 @ Amazon.com).|
|23. ||The full quotation, from Mayo's CEO, is: "...patient privacy is integral to Mayo's core value that the needs of the patient come first, and we are releasing this information at the request of Senator McCain" (Trastek VF; Eckstein JD; Hinni ML; Connolly SM. Statement Of Health Status, Prepared By Mayo Clinic At The Request Of Senator John McCain. 2008 May 23.).|