 I also want to introduce the audience to Mindy Schwartz. You may see Mindy's picture. Mindy is the co-director and co-organizer of this year's series on medical history and ethics. And it's wonderful to have Mindy with us. Let me welcome everybody to our session today as part of the 40th annual lecture series that we have done since 1981. Our speaker today is Thomas Jacques Murray, OC, which stands for Order of Canada, and MD. Dr. Murray is an accomplished Canadian neurologist, medical historian, author, researcher, and internationally renowned multiple sclerosis expert. He revitalized how medicine is taught at the Maritimes Medical School. He received his early education at Pictu Academy in Canada. Dr. Murray then studied pre-med at St. Francis Xavier University before graduating from Delhousie Medical School in 1963. After two years of general practice, followed by postgraduate studies in Halifax and in London and in Toronto, Dr. Murray joined Delhousie Medical School staff at the age of 31, jointly accepting an appointment as a neurology fellow at the Victoria General Hospital. In the decades that followed, Dr. Murray became a national and international leader in multiple sclerosis research. With more than 400 publications to his credit, he significantly increased our understanding and treatment of the autoimmune disease that affects more than 100,000 Canadians. He founded and directed Delhousie's multiple sclerosis research unit and became a founder and president of the International Consortium of MS Multiple Sclerosis Centers. His interest in MS also led to the development of Canada's first MS patient database. In 1985, after heading the Department of Neurology, Dr. Murray was named Delhousie's eighth dean of medicine. He transformed the school and medical education more broadly, leading the charge to replace traditional lectures with problem-based cases and introducing social accountability and affirmative action as key concepts in the curriculum. His most lasting accomplishment as dean of the school may be the creation of Delhousie's world-renowned Medical Humanities program. It allows students to participate in disciplines like music, dance, creative writing, history, and visual arts while completing their medical degrees. We need science, Dr. Murray once said, continuing, but science also needs the humanities to understand human values and the human questions and the human decisions that must guide our use of science. The end of the quote. Dr. Murray served, this is very important, as the first Canadian physician who was the chair of the American College of Physicians, and which in fact he was for two terms, and remains a member of the Order of Canada, the Order of Nova Scotia, an inductee in the Canadian Medical Hall of Fame. He's won five honorary degrees and many awards, recognizing his research achievements, but it's his vision for treating and training the whole person, body, mind, and spirit, that makes Dr. Murray one of Delhousie Medical School's most inspiring personalities. Today, Dr. Murray is going to present a paper to us entitled, it's a paper that attracts me enormously, entitled, what to do if the president is incapacitated, the history of the 25th Amendment. I suspect, Dr. Murray, that relates to the university, to the United States rather than to Canada. Yes. Please, it's all yours. Well, thank you very much. Now I'm going to start with this idea of what you do when a national leader such as a president becomes ill, but remains in power. And it's not just a US problem. It's a problem for every country, but the US is actually the only country that did anything to address this important question. It's not surprising that world leaders become ill while they're in power. Many of them achieve their positions later in their lives. And there are lots of examples of this occurring in most countries. These are national leaders, just as an example, who had strokes but stayed in power. I arranged a symposium in Washington some years ago on the issue of illness in national leaders. And one of the speakers that I invited was Leslie Payeson, who spent his career working for the CIA. And his job and his unit surveyed the health, mental health, and physical health of all the leaders in the world. And he indicated in a slide, it's interesting. It's the only time I've had a speaker who had to get his slides cleared by the CIA before the meeting. But what he indicated was on average, six leaders in the world will suffer an assassination each year or an attempt, and one will be successful. Two leaders per year will have a heart attack while they're in power. One to two leaders per year will be diagnosed with cancer. One leader per year will suffer a stroke. So you can see that illness in national leaders is a significant issue. It is a particular issue for the US. These are presidents who had periods of incapacitation while in power. Now, some of them were very short and some of them were, as we'll see, quite prolonged. So it is an important issue to look at. I'm going to be talking to the fellows at the center after this talk is over. And there are a few ethical issues that might be considered as we go along. One is, what is the right of the president to privacy? What is the public or the political right for them to know about the health of the president? And the president's physician, what is his duty? Is it only to the patient? Or does he have a role and a duty in relation to the country? And there are ethical issues that surround physicians who comment on the health of the president. And that's referred to as the Goldwater Rule. And we'll come back to that. Now, why bother to talk about the 25th Amendment? Well, periods of incapacitation, as I've shown, are common in US presidents. It's important to understand the process and the difficulty in applying it. And you should understand something about the 25th Amendment and its background, because it's constantly in the news and it's in a lot of TV plots. In the past year, these are just screenshots from the television showing that the 25th Amendment is repeatedly being discussed and applied. Now, there was a vote to use the 25th Amendment, but the vote did not come to fruition because Vice President Pence, who is responsible for evoking the 25th Amendment, refused to do so. If you watch television, all of these shows have had an episode, at least one episode, involving the 25th Amendment. Now, what I'm going to talk about is what the Constitution says about presidential disability, examples of the presidential incapacity, the history of the 25th Amendment and how it came about, a working group on presidential disability, which I sat on, and then we'll talk a little about the Goldwater Rule. Now, at the Constitutional Convention in 1787, they came together. They thought they were going to redraft the Articles of Confederation, but it became the drafting of the American Constitution and presidential disability was discussed at that meeting. But a very important question was raised by John Dickinson from Delaware. When they were discussing presidential disability, he stood up and said, what is the extent of the term disability and who's to be the judge of it? In other words, how do you define disability in a president and who makes that judgment? That will continue to be an unclear issue for 180 years. Now, what the Constitutional Convention said was on removal of the president, death, resignation or inability, power will pass to the vice president. Both president and vice president, or if both are removed, then the Congress will decide who is the president. But it was unclear from that who makes these decisions. It also was unclear what act means. If you act as a president, are you president? Are you an acting president or what? So let's look a little at some of the illnesses that have occurred and problems that have occurred and why in fact, presidents were not in fact, removed from power when they were ill or incapacitated. And this is the list that I showed earlier of all of the presidents who had periods of incapacitation while they were president. And some of them were somewhat difficult. William Harrison died when he was in office, but the vice president, John Tyler, got involved in the discussion of, is he an acting president or is he the president? He insisted before taking that job that he was the president. And so the others that followed that also insisted that they were not acting, they in fact were presidents. President Garfield's assassination were more complicated. He survived two and a half months after he was shot. The vice president Chester Arthur, however, refused to take power. And so the president remained in position of power although was unable to make any decisions or act responsibly. So who was in charge? It was not clear at the time. He would not take over the position of an acting president because he said that all his decisions would be questioned if the president recovered. Probably the best documented was Woodrow Wilson because in the last 17 months of his presidency, he was in an upstairs bedroom of the White House most of the time hemiplegic dysphasic and unable to really take the decisions that he should. The vice president was reluctant to act. And so the president remained in his position. Now, most of the decisions we now believe were made by his wife Edith. And my wife thinks that's the perfectly reasonable way to proceed. But this is not what the country expected. There was another question at the end of Ronald Reagan's presidency of whether or not he had Alzheimer's disease. Now his physicians denied that but recognized and diagnosed Alzheimer's after he left the presidency. But many people questioned at the time if Nancy Reagan was acting like Edith Wilson. But she said, no, she was giving them the answers to questions just because this hearing was not good. You may wonder if there were ever healthy presidents. Well, there were. Ford was, Carter was, Obama was, Clinton was. So let's talk about the 25th amendment because it tried to address all of these difficulties. The person who saw the problem was Eisenhower. Now he realized that during the time he was president, he had three times that he was ill. He had a heart attack in 1955. He had intestinal obstruction and surgery in 56 and 57. He had a stroke. Now at the time, the physicians not only tended to lie about the seriousness of his problems but they even lied to him. He saw the problem and he said, now through each of these instances, there was some gap that could have been significant in which I was a disabled individual. And you have to remember, this is the Cold War. I think there should always be someone at the helm that knows he has the right duty and responsibility of making a decision. Now after Kennedy was assassinated, Eisenhower of course was then in retirement. But he wrote to the junior senator, Birch Bayh, the chairman of the committee on constitutional amendments and said, there should be a clarifying amendment on presidential inability. Well, he did form, Bayh did form a committee. And in 1965, they presented this. It took 18 months to get it ratified by the states but in 1967, Johnson announced the approval of the 25th amendment. And the 25th amendment has a number of important sections. The section three says there can be a voluntary passage of power to an acting president. The president says then, when he's well again. Now that would be an example of something that would occur if the president was gonna have anesthesia for an operation, he could voluntary pass the power to a vice president. And then when he's recovered and feeling well again, he says that the 25th amendment is now over. But there's a section four. And this is the one that tends to vote most of the controversy. Section four says, well, if the president is unable to do that voluntarily, then involuntary passage of power to an acting president can occur when the president is incapacitated. The vice president and a majority of the cabinet, 15 of them or a body determined by Congress can inform the house and Senate that they agree on incapacity. The vice president then automatically becomes in charge. The president, if he disagrees and says, no, I'm not disabled or incapacitated. The vice president and the cabinet have four days to convince the house and Senate. And if they can't, then two thirds or two thirds of the house have to agree. And if they can't agree, then power goes back to the president. It's difficult. It's very difficult to evoke the 25th amendment. A lot of discussion in the past year about it, but I don't think people realize how difficult it is to enact. Couple of examples, 1981, Reagan was shot. He's more seriously ill than the public knew at the time. And that's been published since. He had immediate surgery, so article three couldn't be used. And article four should have been used, but vice president Bush was on an airplane. In 1985, there is some controversy about whether it was used when Reagan had colon cancer operation because there were apparently two letters. And Reagan later denied that the 25th amendment had been used. So up to this time, the 25th amendment had never been used. So a working group on presidential disability was then formed. In May 1994, President Carter invited the American Academy of Neurology to establish a working group on presidential disability. And I had been vice president of the American Academy of Neurology. And became involved with this. And this is the later report. And on the right, there is a very thick book of all of the discussions, committee meetings, and papers that were presented. Now, the working group was very interesting. I'm sure all of you have been on committees. And committees aren't always interesting, but this one was fascinating. On the committee were all presidential historians. All presidential physician back to Johnson. Those who had published on illness in presidents. And I had published on illness in other national leaders. And there were two senior representatives in the Washington press. And interestingly, two original committee members from the 25th amendment in 1965. And that's Birch Bay and John Freerich. And each meeting, we had a different president attend. Now, at that time, as the chairman mentioned, I was chairman of the American College of Physicians. And my office was just off to the right of this picture, looking down on Independence Mall, where the first discussions about presidential disability occurred. And also the American College of Physicians helped fund this working group. So as chairman, I was asked to be a member of it. So we were gonna look at section three about the voluntary passage, section four, the involuntary passage, and all of the difficulties in employing the process. Now, at one of the meetings at a coffee break, I talked to Birch Bay and said, you know, the 25th amendment that you and your committee drafted is very difficult to evoke. And he said, we did that on purpose. He said, it should be very difficult to remove a president. The 25th amendment protects the president and the will of the people who elected the president. So it's not a coincidence that the 25th amendment is very difficult to employ. In our committee, we had subcommittees. One was on balancing the issue of public disclosure with the president's presidential confidentiality. Also identifying criteria for disability and impairment. How do we determine what those really are? It was a subcommittee on advantages and disadvantages having a formalized contingency plan for the disability. We also looked at the position of the physician to the president and the White House medical unit and how their responsibilities play out in the 25th amendment. And I was on that subcommittee. And then we also even looked at the role of the president's spouse in all of this. So let's look a little at the physician to the president. One of the questions is how much does the public have a right to know about the president's health? Does he not just have all of the rights of privacy of any other citizen? Or does the public who always wants to know have a right? Does the media have a right? Because they demand answers to all these questions. And the other question is whether the president's physician has a duty to society as well as to his patient because it becomes a bit of a conflict of interest. So we know that politicians cover up their illness and they do so with good reason. And the reason is the public wants to know that there are good examples that show when they know they won't vote for the person who has any signs of weakness. So it's not surprising that politicians cover up and even lie about their health. Now Hula Tang, a British physician did a study some years ago and published a book on what the leaders to national leaders or the physicians to national leaders and how well they function. And he noticed that often they're untrained for their responsibilities because the president for instance can call anybody to be his physician. And that could be a friend from his hometown. But their responsibilities are major. They become in charge of the White House Medical Unit. And it's a very complex issue when the president moves because the White House Medical Unit is responsible for the health, not only of everybody in the White House when they're there but when the president travels. We also know that physicians to national leaders often lie. They'll often say the leader is healthy when he's not. We know that they often act because they wanna please the leader and they really like their job. They do not recognize that they have a duty to society. They feel they have a duty only to their patient who happens to be a leader. The advice they give, and this was a problem with the physicians to Eisenhower, their advice is often political, not the best medical advice. Now, one of the reasons that they don't act in any other way is that they have no guidelines. There's no guideline to say how the physician should act other than caring for his patient. We also know, and there are very good examples of this that the physician can be manipulated by the leader and one of the difficulties, of course, is that a president and other national leaders, they're used to giving orders, not taking them. And so they very often do not listen to their physicians. Now, here's an interesting example. When FDR died, his physician said it came out of a clear sky. He said, there was no indication of imminent danger. But others had noticed that in his last years, FDR looked very ill. At Yalta, for instance, both Churchill and Stalin commented on how unwell he looked. Now, when FDR was examined by consultants and physicians, they were told to keep no notes and no records. We know that he was admitted to Walter Reed over 30 times, often under other names, and all those records have disappeared. But one of the cardiologists, Dr. Brun, did keep a record of his blood pressure. And this shows, if you look down the lower part, during the time of World War II, his blood pressure was going from 226 over 118 in 1945, just before his death, his blood pressure was 300 over 190. Now, not many of us have ever seen a blood pressure like that. So what is clear is did not come out of a blue sky. So it's another example of a physician continually telling fibs to the public about the health of presidents. And the media made a big issue out of the recent discussions of the health of the president when Dr. Sean Connolly repeatedly went in front of the media, but evaded most of the questions, was very cheerful about how well President Trump was and later admitted that he was just trying to keep things on a positive light. Now, one way I said more presidents have died of assassination and diseases while in office. So the president's health is much more about the secret service than about the president's physician. So what did our committee say? Well, they said, we're not gonna change the 25th amendment, maintain the 25th amendment, no additional amendments, but there needs to be guidelines for how it's applied. The other important recommendation was that the 25th amendment should be used on every occasion. So it's not unusual and that people just get used to the idea that anytime the president is unable to make decisions for an hour or two or while under anesthesia or whatever, you just apply the 25th amendment and people get used to it and don't get upset about it. There should be a formal contingency plan agreed to before inauguration about how things would be carried out if that was necessary. Now this will turn out to be a bit controversial, but I thought it was a really important recommendation of the committee. People wondered, in the case of incapacity, why don't they just ask the doctors? Well, if you thought that the doctors were gonna say, well, the president is incapacity, nobody is ever gonna give the doctors that kind of power. What they said was, let the doctors determine the presidential impairment. They can say, what is wrong with the president? It is the politicians who decide if the president is unable to carry out the duties and responsibilities of the presidency. So they separated the two. They said that the doctors can determine what impairments are there. They passed that information to the politicians, but the politicians then decide on whether he can continue to be president. They also suggested that the president should appoint a senior physician to the White House who's responsible for the president's health and for the White House military medical unit and is the principal source of information on any impairment in the president. The senior physician should make use, however, of the best consultants available at any time. They did discuss a great length, the difficulty of the patient's right, the president's right to privacy and the public's right to know. And then I can tell you that they did not make any firm decisions on these. It's just too complex for them to deal with. They did decide, however, that information about the president's health, it has to be determined by the president that the physician will talk, but if he does, he's the principal source of information about the president's health. Shouldn't come from other people. And they recommended that 25th Amendment is a remarkable, flexible mechanism for determining presidential disability and implementing the transfer of power. And this power should be widely known and destigmatized because you know, presidents didn't want to have a period in which they weren't president during their term. So they wanted to destigmatize the whole process and make it a normal action. Now, not always agreed. We had a minority opinion in our report on the two-stage process. Now I said that I rather like the idea of separating that, but John Freerick, Joel Goldstein and Birch Bay gave a minority opinion and we should listen to that because John Freerick and Birch Bay were members of the original drafting of the 25th Amendment. They said the constitution stipulates only one determination. It determines presidential ability as a political process. It doesn't recognize a medical process. Now, the politicians can get the best medical opinions, but the process is a political one. So that was the minority report there. And there was another minority report. And these are heavy hitters too, because these are all individuals who have written books about illness in presidents and the history of illness in presidents. They said that the president's physician is in the conflict of interest. So he should act for the president, but there should be a consulting commission on presidential health to provide advice to the president's physician. So this is an independent group established by Congress and free from presidential pressure. So Congress would appoint a group of outstanding individuals who would then act on oversight of the presidential health. Now, many of us don't like this idea, but it's been raised in other countries as well. I think, at least my personal opinion is that it puts this group in conflict with the president's physician and the president. That they would see this as a conflict to them and would attempt to cover up. We did present this report to President Clinton. Now, it has been used since, so it is working and it is being destigmatized. Twice it was used by George W. Bush. It was raised in the past year in discussion of President Trump. There are two ways to remove a sitting president. One is by the 25th Amendment and the other is by impeachment. And in January, after the riot on Capitol Hill, the issue was raised at that time and individuals at the time said that either they apply the 25th Amendment or apply impeachment. And that got into the conflicts that occurred in January of this past year. And these are some of the discussions that went on over television at the time, because it was a very heated period in political life in Washington. Now Nancy Pelosi, this is reflecting back on the concept that there should be an independent group overseeing the president's health, established a commission on presidential capacity to discharge the powers and duties of the office. So this is an independent oversight commission to assess inability. Now it didn't get anywhere, but it has not dead and it probably will be a continuing discussion. Now at that time in the past year, there were a lot of professional comments by physicians, psychologists and psychiatrists on the president's health. Now what we have to reflect on is what is called the Goldwater Rule. And the Goldwater Rule is in section seven of the American Psychiatric Association Principles of Ethics. And it says it's unethical to give a diagnosis for a public figure you have not examined. But there are a number of examples. And the one that got, I think the most publicity was his niece, Mary Trump, who is a psychologist. And she said he displays narcissistic personality behavior and that he's dangerous. And that's the whole tenor of the book. Now, does she have a right to do that even though she's part of the family? Well, she may be part of the family, but Trump is not her patient. John Gartner, a psychologist, advocated using the 25th Amendment because he said Trump had malignant narcissism which is a psychiatric condition that makes you evil. It combines narcissism, paranoia and psychopathy. And before the impeachment, more than 800 mental health professionals signed a letter to Congress, warning that ignoring the psychological aspects of humiliating Trump could lead to catastrophic outcomes. Again, here we have 800 mental health professionals commenting on the health of the president who is not their patient. They also use this outline which you can download from the internet which is the definition of malignant narcissism and you can just check off the boxes. And you might, for a matter of interest, download it sometime and see if it actually applies. Now, the psychiatrist also wrote a book. 27 psychiatrists gave papers in a book called The Dangerous Case of Donald Trump. Now, the question is, are they breaking the Goldwater Rule? Trump is not their patient, but they argue they're assessing dangerousness, not making a diagnosis. Now look, the Goldwater Rule, just as a matter of historic interest, goes back to the time that Goldwater was running for president. And there was a button that every Goldwater supporter had which said, in your heart, you know he's right. And so a contrary one was put up which said, in your guts, you know he's nuts. And Fact Magazine did a survey of 1189 psychiatrists in the United States and asked if Goldwater was psychologically capable of being president. And they said, no. Now, Fact Magazine, you have to understand that those psychiatrists weren't coming forward and saying that Goldwater was not competent. Fact Magazine did it as a poll. So they were asking if the president, or if Goldwater was capable of being president. So it's a different kind of answer. And Goldwater sued the magazine and he was successful. And it was after that that the American Psychiatric Association, very upset about all of that, put section seven in their Principles of Ethics, saying it's unethical to give a diagnosis of a public figure you have not examined. So that's now the Goldwater Rule. Now the Goldwater Rule has some critics. Some oppose the Goldwater Rules arguing that psychiatrists have a social responsibility. And diagnosis is also about observed behavior, not just interview. And they apply what they say is the Tarasoff Rule, which says a therapist has a responsibility to warn of serious danger to another. They'd have to make the argument though that they're a therapist, but the person they're talking about isn't their patient. So the working group, we published this booklet and we presented this to President Clinton. And the recommendations, as I mentioned, maintain the 25th Amendment, evoke 25th Amendment every time it's appropriate, have an agreed consignancy plan, have impairment as a medical decision, inability as a political decision, and the physician can talk about the president's health, but he can't lie. Well, I hope this little overview of whether it has been an interesting period explains why the application of the 25th Amendment is very complex and why, as Senator Beye said, it's supposed to be difficult. So the discussion is not over. The discussion of the 25th Amendment oversight the presidential's health, the right to information about the health of the president. These discussions are going to continue. So the story is not over, but my talk is. Thank you very much. These are a couple of my Christmas tree decorations from the time at the White House. Thank you so much. That was wonderful talk. Mindy, are you there? You bet, right here. Do you want to handle the questions? I'll be happy to handle the questions and also say a few words. I would love questions here because one of the things, and Jack, I'm sure you know this, I'm a Sherlock Holmes fan, and Conan Doyle said when physicians go wrong, they're the worst of criminals. They have nerve in all the knowledge. And so one of the interesting, you talked a little bit about extreme narcissism, but I'm also interested in a further talk about what's going on. And the other interesting over thing is there's a bunch of political leaders who are physicians. Isn't the head of Syria an ophthalmologist? I think so, and I think there was one person in Congo or something who was also a doctor. So there's been a bunch of political leaders who have also been physicians, so that's an interesting overlap. Another historian commented once that physicians often get involved in politics, but they seldom rise to leadership. And he said, and it's a good thing they do. Absolutely. Anybody have any questions or want to continue this conversation? I think, first of all, I want to thank you. I think it's terrific. And I'm glad you highlighted, I had no idea that you were on that commission and that was just fortuitous here that you would give a good talk on an interesting topic. So I'm showing all my cards, but I just think it's really fascinating how, and the previous histories of the presidents, like I'm very fascinated by, do we know if Reagan had Alzheimer's during his presidency? Is there more data? What I can tell you is that his physicians were on our committee and they say no. Okay. But he was diagnosed after, however, there was a lot of comment during his presidency. And so that we, whether you feel that it's another example of physicians, perhaps giving a better light on their patient or not is still up for discussion. Yeah, you mentioned another thing I want to bring, that was interesting. I read a little bit about the history of FDR, which is fascinating on many levels. And his, just like you said, you didn't really need an expert. I think his early physician was an ENT doc before he got broomed. That's right. Famous article on him. But the other thing is as hard in modern times to appreciate the level of censorship that has been gone on in previous generations at different times. I mean, I remember learning that Wilson never mentioned influenza. He never talked about it. I mean, pandemic of worldwide catastrophe. We hear, we're watching CNN and we're watching the numbers day by day. It is hard for us to fathom the leader of the free world and such an important person, never mentioning the disease that we use as kind of the benchmark of all subsequent pandemics. I just think it's absolutely fascinating. That's right. Anybody else have any interesting either comments or ideas? Hey, Jack, Tony reader from Neurology. Yeah. Do you think that leaders should take a test online, artificial intelligence or something every day or week to prove their fit? Well, you know, people have suggested that, but most of the discussion has been, we don't require that of anybody else except pilots. Right, right. And there's always been an objection to that kind of intrusion. But people have repeatedly raised this idea that leaders should have regular assessments. Now, one of the things you'll notice is that presidents do that. In other words, they'll have a battery of tests every so often, but you will only hear about it if the tests are normal. And so, and you may remember, there was a competing Dole and Clinton, I think, were competing with their cholesterol levels and blood pressure and that sort of thing. That's because they were normal. They're not gonna reveal anything if their tests aren't normal. The other thing about that is just a minor thing. And that is that often they get over tested. They don't follow the recommendations that we would have for anyone else who was 60 or whatever. Can I just take another thread since nobody seems to be volunteering and I have a million questions. You raised the issue of presidential wives kind of surreptitiously. And one of my friends emailed me about, don't you think other wives would have done what Edith Wilson did? It is interesting the role of wives, presidential wives both for good and for bad and for controversy. And I don't know, there's famous presidential wives like Lincoln's wife who suffered terribly and was also vilified. So I just think it's very interesting because a lot of politicians may have been successful because they had smart, motivated, accomplished, you know, efficacious women at their side and sometimes leading them. Well, I think that's right. And it's interesting that our first meeting, we had our first meeting was at the Carter Center. And Jimmy Carter actually discussed this issue. He was asked about, you know, do you think other wives would act like Edith Wilson? And he said, of course they would, you know, because they're all strong women and they're all intelligent and they're all very knowledgeable about the political process because they're part of that life. So he thought, yeah, that wouldn't be unusual at all. That's great. Anybody else wanna take advantage of one of the most interesting lectures we've had in a long time? I mean, I could go all afternoon. I think this is terrific. The other thing is that, Okay, wait a second. We gotta get Jay next, okay? Okay. No, Jack, you wanted to say something, but we're sorry. I'm just gonna say that the US is, you should be complimented because it's the only country that takes this seriously. And it's the only country that's really addressed it. But every country, I mean, there are lots of examples in Britain, Australia and Canada and elsewhere. None of them have really given any thought to it because they think that the parliamentary system that they use can easily deal with it. But actually it never deals with it well. So there are lots of other examples that are worth looking at as well. And Churchill was a real study about not only about his health, but about his attitude and treatment of his physicians. He would argue the president of the Royal College of Physicians out of his diagnosis. Yes, and my question was actually very similar. I was curious about other countries having this, having anything sort of similar and you're probably exactly right in countries that are not so executive centric as ours is, that's not so, this is, they might feel that's not so, not so similar. I'm curious if there's any, been any sort of development at sort of state levels for like say similar like equivalence for governors have there been any states that have thought about this kind of question? I don't know that, someone else may know. I was just curious about that. I don't know, it's a great question. We should see if we could find out. One of the things I should point out about this whole process that we didn't discuss very much. And that is that many of the examples, if you read about illness and national leaders are in lots of books and papers about this, they mostly talk about individuals who developed, who had strokes or heart attacks or whatever. The most difficult issue is mental problems. For instance, the most dangerous examples are leaders who are paranoid. And there are lots of examples of paranoid leaders who kill a large percentage of their own people. And so it's not the stroke or the heart attack or whatever, that's really the big issue. Cause they're quite obvious. The problem is when you have people like Stalin or EDMN or Hitler, even though some of them, particularly Hitler developed physical illness, but their problems were paranoia and other aspects that made them dangerous. And they're the most difficult to address and to judge. Take the floor. Yeah, it's not so much a question, but just based on what you just said, the observation that kind of had been sticking with me through this talk is that it's a particular and almost a different scenario when it's a question of mental incapacity. And with the 25th amendment because at the end of the day, the physicians who are examining and advising the president and the vice president and the cabinet and everybody who's making these decisions all have their own political biases and agendas. And so whereas if you're saying, okay, the president's had a stroke, you can look at a CT scan, you can look at an MRI, you can do a physical exam and look at their objective findings. If you think the president has cancer, you can get a biopsy and look for cell atypia, but we don't have any sort of objective criteria for, I mean, in psychiatry there are criteria, but a lot of it is so much, I think more related to the interpretation of the examiner. And so I almost wonder if there needs to be a different system for the assessment of incapacity. Just like, I believe it was, Dr. Reeder spoke up and said like an AI assessment. I think it's just a really unique and difficult thing to assess. Yes, that is the most difficult aspect. And in fact, at the present time, there's no answer. And one of the things about politicians is not in their interest to be examined. And then there's a whole nother issue about having more women leaders in office and raising the issue of people who develop postpartum illnesses, postpartum depression, postpartum psychosis. It just, there's a lot of other spinoffs on this conversation. Yes. Another issue that almost never gets discussed, but there are a number of examples in national leaders in alcoholism. Also in the post-war period, a number of national leaders, including in the US, were heavy users of amphetamines. Now, some of us are old enough to remember when amphetamines were not regarded as being dangerous. I mean, university students took it to stay up all night for studying for exams and truck drivers took it to stay on the road. And a lot of people were taking it for weight loss. And so amphetamines were not regarded as being that dangerous in the 50s and 60s. And a lot of national leaders to keep up with their schedule, we're taking heavy doses of amphetamines. The only one who admitted it, although we have records on some others, was Anthony Eden. And Anthony Eden later addressed the issue of why he mismanaged the Suez crisis as being the heavy doses of amphetamines that he was taking at the time. Yeah, and there's some interesting literature on the fact that the Germans used it. There's a book, Karla Kearns reminded me of this, but my husband read a book on the use of amphetamines as part of the whole, you know, Nazi program to really keep people up and, you know, do kind of terrible things they did. Hitler was getting a lot of amphetamines from his physicians, the ones he didn't shoot. Both, talking about difficulties of a national leader with his physician, both Stalin and Hitler often shot their physicians. Anyway, anybody else, or anybody? They're dramatic form of feedback. Yeah, all right. Anyway, this was terrific, Jack. I think it was a really engaging and high level discussion and so much food for thought. And I'll just check in with Mark, but I have a feeling you have a hand power before you meet with the fellows, but I wanna thank you on behalf of the McLean Center and Mark and myself and everybody who listened. That was terrific. And I'm so glad that you were able to come and share both your experience with us and also make us think in a way that I think few of us really thought before. So thank you so much. Thank you, it was a pleasure. Jack, thank you so much. I agree with everything that Mindy has just said. And it was quite an inspirational talk. I had heard of the 25th Amendment, but I never knew that it had come out in 1965 and that it had been analyzed and pursued for many years since then and that it had been approached, if not invoked, not infrequently. Quite amazing. But yeah, let's gather with the fellows at 1.30 and I hope the fellows will come on board with if possible with a few questions. We look forward to it. Thank you again so much. Thank you, bye-bye. Thanks Mindy, bye-bye.