- His height
- His face
- His cancer
- His sons
- His feet
- Not depressed
- His smallpox
- His syphilis
- His gait
- His wife
- His life
- His shooting
If elected President, 72-year-old John McCain would be just the third person to become Commander-in-Chief past retirement age (1).
Naturally, this raises questions about his medical fitness to hold the four-year office.
This sub-section of DoctorZebra.com examines these questions, and the more fundamental concern: Is Senator McCain's medical history known in sufficient detail to allow a confident judgment of his medical fitness?
These web pages are written so that the facts (as reported by credible sources) are clearly separated from my speculations, questions, and editorials. Boxes such as this one contain the non-facts. I have tried to present the facts as clearly as possible, so the resulting debate can be as focussed as possible. It is best to think of these web pages as an annotated health history of Senator McCain.
The only political position espoused in these pages is one that supports open disclosure of candidates' medical information, with the goal of enabling the voters to make an informed decision. Expect to see instances identified where openness could be improved or where deliberate non-openness seems to be at work.
Do not expect to see a similar compilation for other 2008 presidential candidates. This one proved to be so much work that the prospect of doing more this year is impractical.
After a brief background on the law and Presidential health, we list Senator McCain's medical problems, as compiled from published reports.
The completeness of the available material is next assessed, leading to several open questions about Senator McCain's health.
Finally, Senator McCain's medical fitness for the Presidency is discussed.
For context, you may wish to consult the enumeration of the significant medical events that affected the oldest Presidents of the past.
The above quantitative calculations are crude. They show that the odds favor a President McCain surviving his term of office. Even so, it would not be surprising if he died in office.
- Senator McCain's medical record, as made available in May 2008, was inadequately disclosed. The limited time for inspection, plus the prohibition of opportunities for expert consultation, ensured that only a superficial analysis resulted.
- The less-than-adequate disclosure damaged the credibility of the McCain campaign in matters of the Senator's health. As a result, the campaign cannot be given, and is not given, the benefit of the doubt in the Senator's health matters.
- Although the McCain campaign stated that "every piece of paper" in the Senator's medical records was available for inspection in May 2008, no physician has confirmed this statement.
- Although the campaign allowed some of the Senator's physicians to speak, their candidness is unclear: (a) none of these physicians said they were authorized to speak freely, and (b) there was no disclosure of the ground rules, if any, governing what the physicians could and could not say.
- There is evidence, on two separate occasions (1993 and 2000), that Senator McCain delayed seeking medical evaluation of skin lesions that proved to be malignant melanomas. In 2000, this probably contributed to the cancer's advanced state when it finally was evaluated.
- The stage of the 2000 invasive melanoma has never been disclosed. It is unlikely that the stage was never recorded in his medical records.
- In the opinion of two pathologists from the Armed Forces Institute of Pathology who reviewed tissue from Senator McCain's invasive melanoma, the melanoma was not one tumor, but two tumors: a primary and a metastasis (i.e. the cancer had spread). It is unclear whether this concern was ever put to rest. The McCain campaign did not clarify this matter when specifically asked about it.
- In the best possible reading, the Senator's invasive melanoma of 2000 was a stage IIa tumor according to standard staging criteria, and a T3 tumor according to the criteria of the International Union Against Cancer.
- The risk that the Senator's invasive melanoma could recur is substantial. His dermatologist estimates less than 10%, and we read into this an implication of at least 5%. The dermatologist did not disclose the basis of her estimate. A back-of-the-envelope estimation, based on published studies and published in a major medical journal, put the risk at 6% per year (corresponding to 22% over a four-year presidency). Given that the Senator is eight years out from his tumor, this estimate seems high. To be conservative, we use a 2% per year figure.
- Should the invasive melanoma recur, it is most likely to recur in a deep organ. Skin examinations, which are currently the cornerstone of the Senator's melanoma care, would not detect such a recurrence.
- Melanoma has a propensity to spread to the brain. This would ordinarily be visible on scans. What signs and symptoms should prompt a brain scan? Given that the nation spends millions of dollars in Secret Service expenses to keep the President alive, it is reasonable to be extremely aggressive medically. However, there would certainly be calls for the President to resign if he had cancer in the brain, so there is a conflict of interest with regard to medical surveillance for cancers in the brain. The McCain campaign should publish the schedule of brain scans that would be followed during a McCain presidency.
- Based on his age and other cardiovascular risk factors, the Senator would face a not-insignificant risk of a fatal heart attack during his Presidency. There is not enough information to factor in his reportedly excellent performance during exercise stress testing. To be conservative, we adopt a 2% per year risk of fatal heart attack, somewhat less than the average risk for his age.
- Based on his age, the Senator faces a risk of non-melanoma, non-cardiovascular death. To be conservative again, we estimate it at 1% per year.
- There is insufficient knowledge to predict the Senator's risk of developing mild cognitive impairment over the period of a McCain presidency.
- Using the conservative estimates above, Senator McCain would appear to have a 2% (melanoma) + 2% (cardiovascular) + 1% (other) risk of dying each year while President. This 5% risk per year compounds to a 19% risk of death over four years. It does not include the possibility of non-fatal major illness.