- Sherwin B. Nuland
- Content Type
- Journal Article
- Foreign Affairs
- Issue Number
- Publication Date
- November/December 2008
- Council on Foreign Relations
- Pathological hubris is a disease that can plague leaders and threaten international security. Doctors must put transparency ahead of confidentiality and disclose leaders' sicknesses to the public.
- In Sickness and in Power: Illnesses in Heads of Government During the Last 100 Years . By David Owen. Praeger, 2008, 448 pp. $44.95. SHERWIN B. NULAND is Clinical Professor of Surgery at the Yale School of Medicine and the author of How We Die.
David Owen has been in the thick of British politics almost since he qualified as a physician in 1962. After just four years of practicing medicine and conducting research on brain chemistry, he was elected as the Labour member of Parliament for his home constituency, Plymouth Sutton, in the southwestern corner of England. For a time, Lord Owen attempted to attend to both parliamentary business and his own research, but in 1968 he left medicine, never to return. He has since served as minister of health, foreign secretary, and leader of the Social Democratic Party. He is currently chancellor of the University of Liverpool and a member of the House of Lords. In the six years that he practiced medicine, Owen came into close contact with doctors treating prominent politicians and observed firsthand the toll that political life takes on public figures. Thus began his interest in health and power, which culminated in The Hubris Syndrome. This book, published in 2007, argues that being in power brings about changes in one's mental state and leads to hubristic behavior, and that hubris is not merely a personality characteristic but a pathological state. Mental illness, Owen notes, "may need to be redefined to include a hubris syndrome." His latest book, In Sickness and in Power, examines how both specific diseases and intoxication with power have shaped major decisions by world leaders in the twentieth century. A HISTORY OF SILENCE In Sickness and in Power delves into the cases of four politicians whose judgment was impaired by disease in times of crisis: British Prime Minister Anthony Eden, who suffered from biliary tract disease during the 1956 Suez crisis; U.S. President John F. Kennedy, who was plagued by adrenal insufficiency during the 1961 Bay of Pigs invasion; the last shah of Iran, Mohammad Reza Shah Pahlavi, who had leukemia during the final years of his rule; and French President François Mitterand, who was battling prostate cancer from 1981 to 1995, during the Falklands War, the breakup of Yugoslavia, and the Rwandan genocide. Of all these cases, Eden's illness during the Suez crisis remains the single most striking historical example of a severe illness' impacting the conduct of a state.
As the United Kingdom, France, and Israel went to war against Egypt, Eden's behavior was volatile. The prime minister had temper tantrums, insomnia, and suffered from anxiety. According to Owen, Eden's inability to confront an increasingly complex situation -- involving the clashing interests of four warring nations, two superpowers, and the United Nations -- is traceable to the vicissitudes of the disease, which causes liver disturbances and high fevers. The medications Eden was taking played a role as well; the drug Drinamyl, for example, is known to produce restlessness, irritability, and overconfidence. Owen argues that Eden's judgment was "seriously impaired" when he made the crucial decisions "to collude with Israel, to mislead the American President and to lie to the House of Commons, even after the invasion." French and Israeli officials managed to convince the usually cautious Eden to join their plot -- a strategic misjudgment on Eden's part that was entirely the result of his disease and treatment, according to Owen. American readers will be most intrigued by Owen's detailed examination of Kennedy, who assumed the presidency with a long history of Addison's disease -- a chronic adrenal insufficiency that can cause muscle weakness, fatigue, and apathy -- and was beset with severe, disabling back pain during his three years in the White House. No single physician was in charge of Kennedy's care; it was "deliberately compartmentalized," leaving different doctors to treat different problems -- often incorrectly. The two doctors closest to Kennedy -- Janet Travell and Max Jacobson (also known as "Dr. Feelgood" due to his habit of treating everything with amphetamines) -- had neither the training nor the experience to see the entire clinical picture. Most of their treatments were inappropriate. Owen argues convincingly that the Bay of Pigs fiasco was the direct result of Kennedy's poor judgment, which in turn was the result of his ill health and inadequate treatment. Kennedy was suffering not only from severe back pain but also from stomach and colon problems, high fevers, sleeplessness, and occasional abscesses. By the time of the Cuban missile crisis, with his medical matters under much better control, a healthier Kennedy was able to make better decisions. This was largely because Travell and Jacobson were out of the picture and the president's Addison's disease was being treated by the highly respected endocrinologist Eugene Cohen. Compounding the problem of Kennedy's clouded judgment was the White House's insistence that the president was in good health -- even while he was being injected with steroids and taking hundreds of pills per week. Otherwise honorable men, such as Cardinal Richard Cushing, a close friend of the Kennedys, lied to keep the Kennedy family's secret, as did several doctors. Allowing Eden to govern while ravaged by disease and destabilized by drugs placed the United Kingdom in grave danger during the Suez crisis. Similarly, compartmentalizing Kennedy's care and withholding information about his health endangered the United States during the Bay of Pigs crisis. DIAGNOSIS: HUBRIS Conventional diseases are not the only maladies that plague leaders. For many heads of state, the experience of being in power brings about psychological changes that can lead to grandiosity, narcissism, and irresponsible behavior. Leaders suffering from this political hubris syndrome believe that they are capable of great deeds, that great deeds are expected of them, that they know what is best under all circumstances, and that they operate beyond the bounds of ordinary morality. Such leaders often insist that their nations are forces for good in the world and can do no wrong. And the longer they stay in office, the stronger these tendencies seem to become -- as the cases of Mao Zedong, Fidel Castro, and Robert Mugabe have made clear. The result, observes Owen, is absolute "incompetence in carrying out policy." To illustrate the symptoms of the hubris syndrome, Owen focuses on one leader he knows well and another whom he has met: former British Prime Minister Tony Blair and U.S. President George W. Bush. Of Blair, who once considered going into professional acting, Owen writes, "Politics offered him a very large stage on which to perform," adding that "actor-politicians tend to be especially narcissistic." According to Owen, as prime minister, Blair also possessed an absolute moral certainty -- a conviction that his motives were always supremely honorable. This certainty drew the British prime minister to Bush, who also seems to believe that he functions for a higher purpose. According to Nabil Shaath, who was then the Palestinian foreign minister, in 2002 Bush told him and other assembled Palestinian officials, "I'm driven with a mission from God. . . . God would tell me, 'George, go and end the tyranny in Iraq.' And I did." Such religiosity and missionary zeal bound Blair and Bush together in their effort to oust Saddam Hussein. To a hubristic leader, lying, cutting corners, and even invading foreign countries are justified in the interest of accomplishing a supremely moral mission. As time passes, such a leader's inherent overconfidence is bolstered by his or her unchallenged and increasing power. Once it reaches this stage, the hubris syndrome becomes full-blown and its victim delusional in his or her tendency toward grandiosity. It is a common error of physicians to overestimate the decision-making capacities of their patients. But this everyday phenomenon becomes far more dangerous when the patients are heads of state.
Owen is not the first to observe that hubris sometimes overtakes leaders, but he is the first to argue that it is a pathological condition that requires serious study, especially of the ways in which it affects decision-making. Looking back on the eight years of the Bush presidency, this seems sensible. Owen's book should be read by all practicing physicians responsible for the health of political leaders -- and by the leaders themselves. After all, the hubris syndrome is probably not only a preventable disease; it may be a reversible one as well. Having brought the disease of hubris to the world's attention, Owen offers only one possible remedy for it: "strengthening national democratic checks and balances." It is weak tea, but it may help. The U.S. Constitution already provides one such check: the Twenty-fifth Amendment allows the vice president and a majority of cabinet officials or of Congress to declare the president unfit to serve if they feel that he or she is unable to discharge the responsibilities of the office. In such a situation, accurate, unadulterated information from a presidential physician would be vital for decision-makers. But there are stronger safeguards that should be considered. In cases involving physical illnesses, such as Eden's or Kennedy's, a single physician should be placed in charge of both overseeing the patient's treatment and issuing medical reports to political advisers and the public. This would commit the doctor to transparency in cases in which the national interest is concerned, guarantee that the public is informed, and result in better care for the leader. A doctor treating a leader must also be on the alert for hubristic behavior and inform the head of state and his or her closest advisers when the symptoms arise. After all, by its very nature, the hubris syndrome makes it unlikely that someone afflicted with it will recognize it in him- or herself. But early warnings from doctors and top advisers could ward off its full-blown expression. Finally, heads of state should, on taking office, agree to forego medical privacy. And the doctors treating them should waive their commitment to doctor-patient confidentiality for the greater good of the country. Too often, confidentiality is confused with secrecy, transforming physicians into willing accomplices in a conspiracy to mislead the public. But deliberately distorted medical reports that paint a rosy picture can endanger national and international security. Rather than hiding the truth when a head of state is severely ill, doctors should not hesitate to disclose important health information. Some might argue that public discussion of leaders' ailments and official recognition of the hubris syndrome would lead to more secretiveness, defensiveness, or even paranoia. But in democratic societies, discussion of leaders' and potential leaders' medical problems should become the norm. And if a defensive or paranoid head of state ever dismisses a doctor for sharing medical information with the public, such conduct should constitute grounds for impeachment.