The politics of medicine

Twelve days ago, I was contacted by a social scientist who I’ve known for twenty years.  She’s a professor at the University of Michigan, and she wanted to tell me how concerned she was about the possibility that Joe Biden has Parkinson’s disease.  Her concerns were based on her experiences with a close relative, the experiences of her colleagues with their relatives, and, more troublingly, her conversations with a leading Parkinson’s expert at UM’s medical school, which is home to some of the nation’s and the world’s top researchers into parkinsonism, the cluster of related diseases of which Parkinson’s is the most common and best known.

Until that moment, I hadn’t really thought about Biden and parkinsonism at all.  The only fleeting thoughts I’d had on the subject were when I read some comments posted on LGM by a self-identified doctor, who said they had had a lot of experience with Parkinson’s patients, and Biden had a lot of publicly observable symptoms suggesting he was in the early stages of the disease.  I thought that was interesting, but really didn’t think more about it until I was contacted by my long-time colleague.  I asked her to put me in contact with the top Parkinson’s researcher who shared her concerns, and she did.  This researcher put me in contact with other parkinsonism researchers.  I also got in contact with the LGM commenter.

After a few days of interviews, conversations, and looking into the background of this situation, I learned the following:

Many neurologists and movement disorder specialists are saying, both on and off the record, that Biden currently has many symptoms associated with parkinsonism.

Biden has never been tested for parkinsonism.  He has received three general neurological examinations as president, the most recent by Dr. Kevin Cannard nearly six months ago, on January 17.

Per Biden’s personal physician Kevin O’Connor’s letter of February 28, Dr. Cannard’s examination found no symptoms consistent with Parkinson’s disease.

Biden has not been examined in any detail by a doctor since then, although he’s had quick check-ins for things like colds.

Per the White House, Dr. O’Connor was saying as of last week that, based on the January 17 examination by Dr. Cannard, Biden currently has no symptoms consistent with parkinsonism, and therefore is not going to be tested for parkinsonism.

Based on the information I’ve been able to gather, I’ve learned:

Leading experts on parkinsonism are certain that, based on his publicly observable behavior, Biden has a number of symptoms consistent with parkinsonism.

All these experts agree that Biden should be examined for parkinsonism.  Here I want to emphasize that none of this is my opinion.  I have, obviously, no professional expertise in this matter.  What I’m doing is reporting the views of various people who do have such expertise. I have yet to encounter any expert who has expressed the slightest disagreement with the views I’m reporting.

Turning again to the experts:  The diagnosis of parkinsonism remains fundamentally clinical.  No blood test or MRI scan or the like is going to produce a definitive biological marker for the diseases in question, although there have been recent advances in scanning that make a final diagnosis easier to reach.

Diagnosing Parkinson’s disease involves a several-hour exam for that purpose, in which the patient’s medical history, and current reaction to various physical tests, are compared to a formal rubric, to determine whether treatment is warranted.  Note that the conclusion that treatment is warranted is not a final diagnosis: it’s a step on the road to a final diagnosis, which can often take many months to reach after an initial diagnosis.

Treatment consists primarily of dopamine replenishment therapy via drugs.  The patient is put on a course of medication, and then is often given a DaT scan, to gather direct physical evidence regarding whether the treatment is working, along with ongoing observations of whether the patient’s symptoms are being ameliorated by the drugs.  Again, it can often take several months, or in some cases even more than a year, to reach a final diagnosis, although the initial reaction to treatment tends to be highly suggestive, if not definitively so.

Despite his current symptoms, Biden has not been tested for Parkinson’s and parkinsonism, and it’s almost certain that, for what appear to be purely political rather than medical reasons, he won’t be before November.

From all this, I draw the following conclusions:

• The probability that Biden has parkinsonism is significant.  By “significant,” I mean it’s high enough that any specialist would recommend that he be tested for it now.  Untreated Parkinson’s disease can advance quickly, especially at Biden’s age, and the treatments have gotten very effective (They are less effective for some of the other varieties of parkinsonism, and at least a couple of experts believe that his symptoms are most closely related to those seen in the early states of Progressive Supranuclear Palsy, which unfortunately is much harder to treat than Parkinson’s).  The testing is not dangerous or painful, so, given the consequences of failure to treat the disease early in its course, it makes absolutely no sense from a purely medical perspective not to test for it, when a patient has symptoms associated with it. Obviously the purely medical perspective is not the only consideration here.
• The fact that, per Dr. O’Connor, Dr. Cannard found no symptoms of Parkinson’s in January is not very significant at the moment.  Imagine defending against a medical malpractice lawsuit in which a patient had Parkinson’s symptoms in July, that then went untreated for many months later, by noting that he had a general neurological exam in January, and had had no symptoms at that point. There is nothing in the slightest degree unusual about a patient, specifically an 81-year-old man (age and sex are both strong risk factors for Parkinson’s, especially age), not having Parkinson’s symptoms in January and then having symptoms six months later.  As one doctor who is also a medical malpractice attorney put it to me, six months is an eternity is this sort of context, featuring a geriatric patient with current symptoms of the disease.
• That Biden has several symptoms of parkinsonism doesn’t mean he has parkinsonism.  Parkinsonism, human beings, and medicine are all complicated phenomena.  Sometimes what looks like a classic presentation at initial diagnosis turns out to be something else.  Sometimes something that doesn’t fit the classic paradigm in various ways turns out to be the disease anyway.  Again, the initial diagnosis is clinical, followed by a course of treatment to see if the symptoms are ameliorated.  Only then can a diagnosis, eventually, become final. Another way of putting this is that even if Biden were tested for Parkinson’s today, there’s a very good chance he wouldn’t have a truly final diagnosis before the election.
• Dr. O’Connor is, for many of the same reasons that, historically speaking, have often made the president’s personal physician a poor source of public information about presidential health, in a very difficult position here.  He is a long-time friend of Joe Biden and various members of the Biden family.  He has had business dealings with Biden’s brother.  He is an at-will employee of his famous patient.  He is probably not a fool, so he no doubt recognizes that recommending that Biden be tested for parkinsonism now would effectively end Biden’s re-election campaign.
• The political and medical ethics of this situation are inherently complex.  If Joe Biden were an average 81-year-old man displaying the symptoms he’s been displaying over the past few months, there can really be no doubt whatsoever that he would have already been tested for parkinsonism.  Every expert I spoke to about this was unequivocal on this point.  But he’s not, so he hasn’t been, and he won’t be before November.
• If you believe Joe Biden has the best chance of defeating Donald Trump, it’s a perfectly defensible position, in my view, to accept everything in this post and still argue that he ought to remain in the race.   If Biden has parkinsonism, then waiting several months to diagnose and then treat it is clearly bad for Biden’s health, but Biden’s health is less important than the health of the republic.
• It’s important to keep in mind that Parkinson’s itself is not a form of dementia, although most Parkinson’s patients eventually develop dementia in the late stages of the disease.  But this can be forestalled for many years, and often permanently, by appropriate treatment.  Obviously it’s suboptimal for a president to have Parkinson’s, but “optimal” left the station quite awhile ago now.  There’s no reason, for example, that a Parkinson’s diagnosis in a sitting president would necessarily be a 25^th amendment-triggering event.
• Which brings me to the following thought experiment. Suppose all of the facts above were the same, except we were in January of 2027 instead of July of 2024.  I’m going to hazard the following:  Not a single one of the LGM commenters who have worked themselves into an indignant frenzy of outrage about my posts regarding this matter would support the idea that Biden shouldn’t be tested for parkinsonism, given the known facts.  Why? Because, under those circumstances, it would make absolutely perfect sense – indeed it would be morally and politically, as well as medically, imperative – to test Biden for parkinsonism immediately, so that, should he be found to have the disease, he could resign from office, be replaced by Kamala Harris, and get the appropriate medical treatment for his condition.

But it’s not January of 2027, so things are little more complicated than that.