First published on on Sept. 25, 2016

Let us put aside for a moment specific questions about the health of this year’s two major Presidential candidates, and ask how candidate health should be treated in the next election cycle. The difficulties attending the current candidates’ health disclosures are by no means unique to these individuals, and so will surely arise again.

There can be little doubt that formal guidelines, or perhaps laws, are needed. This year’s experience shows that the electorate is deeply interested in candidate health, and that lurching from one grudging, partial information disclosure to another serves no one’s interests, including the candidates’.

The traditional approach used in recent election cycles – relying on a candidate’s private physician to decide what information should be disclosed – is obviously maladaptive. It would be the exceptional candidate who could refrain from trying to influence the physician: “After all, doctor, I think I know better the demands of the presidency than you do… with all due respect.” And it would be the exceptional physician who could shed the traditional role of advocating for his or her patients and instead act purely in the nation’s best interests.

But remember that there is an American healthcare system in which physicians explicitly do put national interests before individual interests: the military. Furthermore, this system focusses largely on determining when someone is medically fit to perform a specific job: pilot, cook, parachutist, whatever.

For 31 years I have been part of this medical system, and believe its processes can be a model for fair, clear, and transparent methods to determine what goes into a disclosure about a presidential candidate’s health. Let me explain how, by first explaining how the system works.

Consider an airplane mechanic who wants to become a pilot in the Air Force. Air Force regulations dictate that a local military physician give the mechanic a “class I flight physical examination” – its details are also spelled out in regulations – and that the results of this examination be submitted to a higher headquarters for review. The exam includes a comprehensive medical history.

At the higher headquarters, military physicians compare the mechanic’s medical data with the medical standards for the class I exam, then approve or disapprove the exam as warranted. For example, if the mechanic has a heart murmur, the exam will be disapproved because the class I standards forbid it. Air Force standards are extensive, addressing almost any imaginable medical condition, for every job, and have evolved over decades, so they now tend to change little.

Importantly, our disqualified mechanic still has hope – he can apply for a waiver, because murmurs are not always a sign of disease. His local military physician will send him to a cardiologist, who will listen to the murmur and order an echocardiogram test. The results of the echo, plus the cardiologist’s opinion will be sent to higher headquarters. The headquarters physicians will consider these new, more detailed data, and approve the mechanic’s exam if the new data show nothing structurally wrong with the mechanic’s heart and that this is an “innocent murmur.”

For presidential candidates, the voters are the higher headquarters. They set the medical standards, and they are the only ones who decide if a condition is waiverable or not. But to do this, they must know about the condition.

So, our guidelines (or law) would tell physicians that any medical condition in a presidential candidate that is disqualifying for, say, air traffic controller duties in the Air Force, should be (must be) disclosed to the voters. Everything else could be kept private. Happily, aside from being fanatical about eyes, Air Force standards generally disqualify only significant conditions. Syphilis in the past is not disqualifying, so long as no lasting complications exist. But cancer now or in the past is disqualifying – unless waived.

Next, when a disqualifying condition is present, how much information about it should be publicly disclosed? A sensible initial answer is: as much information as the Air Force requires in waiver applications for the condition. This is sensible because the voters are essentially deciding whether to grant the candidate a waiver. The Air Force has policies on waiver data requirements.

Crucially, no matter what standard is chosen (experts can debate air traffic controller vs. another), military medical standards are time-tested across a very large population of active individuals of both sexes, and are as immune to external influence as any human endeavor could reasonably be. To reduce the chances of one physician secretly warping data, we could require that two physicians, from different states, sign disclosures – akin to peer review.

The most important feature, however, is that the standard will be clear and consistent. The old political truism about a candidate for office applies to whatever standard is chosen: It doesn’t have to be better than the Almighty, just better than the alternative – which today is chaos.


(Disclaimer: The views here are my own, and are not necessarily those of the Department of Defense or the California Military Department.)

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