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In the aftermath of President Biden’s debate with former President Trump last week, many of his supporters are offering various explanations for his shockingly poor performance and proposing several ways to squelch doubters and to regain voters’ confidence in his ability to win reelection to a four-year term.

But for that to happen, the public needs to be reassured that despite being physically feeble, there isn’t something medically wrong with Biden to explain the mental lapses, rambling, mid-sentence stumbles, apparent loss of concentration, open-mouth gaping, and flat facial expression that viewers saw during the debate.


Explanations for Biden’s debate failure range from jet lag from two quick overseas trips to senior moments to fatigue from over-preparation for the debate and the side effects of remedies he might have taken to offset a raspy voice from a cold. Biden himself has said he is not the debater he once was. Solutions to repair his image range from holding press conferences, granting interviews, and making many public appearances to show he is mentally vibrant and seeking a way forward.

Other solutions, including one from the editorial board of The New York Times, take a different tack: The day after the debate, it called on him to leave the race.

To be sure, Trump has also made statements that call his mental health and cognitive function into question, as his rant about sharks and electric boats and his relationship with MIT make clear.


The public needs to know if what ailed Biden during the debate, and Trump’s rambles and gaffes, are clues to whether something is wrong medically. If so, what treatments would doctors advise?

The White House and Biden’s personal doctor, Kevin C. O’Connor, have not said whether Biden took any over-the-counter or prescribed cold medications before the debate. In fact, O’Connor has said nothing publicly about Biden’s health since releasing a report of Biden’s last annual examination at Walter Reed National Military Medical Center in Bethesda, Md., in mid-February. At that time, a team of 20 specialists, including a neurologist, said they found no evidence of Parkinson’s disease (which can produce symptoms like Biden’s stiffness and facial expression), stroke, multiple sclerosis, Lou Gehrig’s disease (ALS), or other neurological disease. The doctors said they found he had mild peripheral neuropathy in both legs and its cause was unknown.

In summarizing his team’s extensive examinations, O’Connor used a military phrase to declare Biden “fit for duty” as president, head of state, and commander-in-chief.

Many neurological disorders can progress at paces varying with the individual. So a crucial issue for Biden and Americans now is this: What, if anything, should Biden’s doctors do, mid-campaign, beyond continued observation to further evaluate his cognitive and neurological status? How should they deal with the situation? Should some of the same specialists who examined Biden in February examine him again now to make sure nothing has progressed or appeared anew?

The February report did not mention a simple mini-mental screening test like the Montreal Cognitive Assessment. Many neurological experts say doctors should routinely administer such tests, particularly for older people, who have a higher risk for dementia than younger people, and for those with worrisome symptoms. But practicing primary care doctors say scheduling limitations imposed on them for examining patients leave little time to administer such tests and they are able to conduct a reasonable assessment from talking with their patients in repeated visits.

White House doctors usually have said that the tests they administer to presidents and vice presidents are the same as for ordinary people, based on evidence from studies and recommendations by expert professional groups.

An issue with the mini-screening tests is that the U. S. Preventive Services Task Force has concluded that “the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults.” Also, the talents for being an administrator like the president of the United States differ significantly from those needed to campaign and win an election to earn the right to occupy the Oval Office.

I believe it would have been wise for Biden to have taken such a test in February and that he should do so now, if for no other reason than to assure the public of his mental fitness. If he performs poorly, the doctors could recommend that he undergo more extensive cognitive testing. That can take a few hours. Undergoing repeat examinations mid-campaign may be difficult, but the president has around-the-clock care and the facilities at Walter Reed are always available.

Few question that Biden has shown signs of aging over the course of his presidency. He will be president until January 2025 and, if reelected, until 2029, at which time he will be 87 years old. His health is too important an issue for him and the country to not consider seeking a medical explanation for his performance during the CNN debate.

Biden last gave a full report of his health in February. Trump’s last full report was when he was president. The public deserves full reports of their most recent medical examinations.

Biden’s aides have vouched for the president’s good health and mental acuity and have long defended him against challenges from people who question whether his decline has been too great, and he is becoming unfit for duty. His aides’ observations are valuable, but they need facts and evidence to back up their judgments. Further, one must be cautious to evaluate the testimony aides offer because their jobs and careers are at stake. It is not clear that they always heed the government’s warning: “If you see something, say something.”

As a reporter, I’ve covered the health of presidents, and candidates for president, since talking with Ronald Reagan in 1980 about the then 69-year-old’s health, when he was poised to become the oldest person to be elected president in U.S. history. I cannot recall any other episode that has galvanized so much public attention on the physical and mental health of a presidential candidate as this one. That Biden is a sitting president who already holds the record as the oldest occupant of the Oval Office and wants to extend that record heightens the importance of knowing he is fit for that office.

Lawrence K. Altman is a physician, a clinical professor of medicine at New York University, and former reporter and “The Doctor’s World” columnist for the New York Times. He is researching and writing a book on the health of political leaders.

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