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The patient's blood pressure averaged 209/100 mm Hg, a level now considered to be a medical emergency. His heart was enlarged, his skin was gray due to lack of oxygen in the blood, and an ECG showed signs of terminal cardiac disease. His cardiologist later described his condition as "godawful."

But the public knew none of this. Eight decades ago, President Franklin D. Roosevelt's personal doctor misled the world about his health, allowing a deeply sick man to accept the Democratic party's nomination and win an unprecedented fourth term. He would drop dead of a brain hemorrhage in April 1945, leaving a vice president who'd been left in the dark to manage the last days of a world war.

Now, the health of presidential candidates is in the spotlight as President Joe Biden, 81, faces questions about his frailty and former President Donald Trump, 78, recovers from a gunshot injury. What obligations do White House physicians have -- if any -- to be honest with the public about a president's health?

"It's not the role of a physician to be a snitch," argued neurologist Steven Lomazow, MD, of Belleville, New Jersey, who's written about FDR's health. "If they know the president wants them to lie, it's OK for them to lie."

The President's Health Is 'Satisfactory'

On Christmas Eve 1943, an international leader was recovering after a nasty bout of severe pneumonia and atrial fibrillation -- but it was not the U.S. president. FDR, just 7 days after returning from a grueling 5-week international trip to Cairo and Tehran, wished the ill man -- British Prime Minister Winston Churchill -- all the best in a radio speech.

At this time, Roosevelt was "still buoyant" after his meetings with Churchill and Joseph Stalin, where he'd looked like "an animated, alert public man," wrote the late Joseph Lelyveld, a former New York Times executive editor, in his 2016 book, His Final Battle: The Last Months of Franklin Roosevelt.

Then FDR caught the flu and was too sick to give the State of the Union address. Next came tremors, weakness, weight loss, "queer" chest sensations, stomach cramps, headaches -- and falsehoods galore. He was in "robust health," declared White House physician Ross T. McIntire, MD, an otolaryngologist. McIntire, a navy admiral, "would cheerfully go on offering such roseate prognoses and testimonials, without qualifications or the slightest suggestion of concern, until the votes were counted the following November, indeed until the president died," Lelyveld wrote. "Then he'd put his name to a ghostwritten book claiming he'd always spoken the truth."

Roosevelt's cardiologist, Howard Bruenn, MD, later said his condition was "shocking" and "godawful." The president was diagnosed with hypertension and congestive heart failure. The recommended treatments: take naps, take it easy, no pack-and-a-half of Camel cigarettes per day, "no irritation." Maybe take a few months off work. Never mind that there was a war going on.

McIntire was "appalled" by the suggestions, Bruenn noted later, reportedly saying "you can't simply say to him, 'Do this or do that.' This is the president of the United States." (Bruenn's notes said McIntire's reaction was "somewhat unprintable.")

McIntire told the press that a presidential physical was "satisfactory."

A low-salt diet and digitalis helped the president to breathe better, but his condition remained poor. On April 12, 1945, just 3 months after Roosevelt had been inaugurated for his fourth term, he died of a brain hemorrhage in Warm Springs, Georgia, at the age of 63. Bruenn estimated his blood pressure was 350/195 mm Hg.

Physician-Patient Confidentiality Rules the Roost

White House physicians have long massaged the truth about several presidential medical crises, including Woodrow Wilson's , James Garfield's , and Donald Trump's . Grover Cleveland underwent a that wasn't disclosed for decades.

FDR's situation stands out because he was commander in chief during a world war and he was running for another term. What obligations do White House clinicians have to their patients, the public, and the truth?

In their 1993 book, When Illness Strikes the Leader, political scientist Robert Robins and psychiatrist Jerrold Post, MD, accused cardiologist Bruenn of taking part in a "conspiracy to misrepresent the president's health status to the president, his family, and the nation."

But Joel T. Wu, JD, MPH, a University of Minnesota bioethicist, said physician-patient confidentiality is iron-clad, with rare exceptions, such as "if we think the patient is going to cause a specific serious kind of harm to someone else, and we can prevent the harm with the disclosure. If patients know that their doctors can disclose information about them that might hurt them without their permission, that could undermine the trust of all patients in physicians and the medical system and result in ineffective or inappropriate care."

Clinicians can refuse to answer questions about a patient's care, he said, but it's unethical to lie about a patient's care or selectively omit information in order to create a false impression.

Will Presidents Ever Be Transparent?

Psychiatrist Jacob Appel, MD, JD, MPH, a bioethicist at the Icahn School of Medicine at Mount Sinai in New York City, said White House physicians "ideally" should not lie to the public. However, the president calls the shots, and "the result may be omissions that mislead the public."

Appel noted that "some of our sickest presidents, such as FDR, John F. Kennedy, and Ronald Reagan, are viewed by many as our most successful," compared with healthy ones like Millard Fillmore and Rutherford B. Hayes.

He added that "predicting medical outcomes is extremely difficult." In 1940, Roosevelt ran against Republican Wendell Willkie, a lawyer and corporate executive who was a decade younger and seemingly healthier. But, as Appel noted, Willkie died 4 years later of a heart attack at age 52.

John G. Sotos, MD, a , has that clinicians be required to disclose to the vice president and cabinet when a president has a "disqualifying medical condition," such as those that would keep an Air Force controller off the job.

But the University of Minnesota's Wu cautioned about imposing external mandates on any physician "because then there will be a competing interest beyond the rights and interests of the patient alone."

Of course, the president can ask physicians to be open with the public, as Roosevelt apparently didn't. Keeping his health secret, Lelyveld wrote, would have been "absolutely consistent with his character and methods, his customary slyness, his chronic desire to keep his political options open to the last possible moment."

Theodore N. Pappas, MD, a surgeon at Duke University in Durham, North Carolina, who's studied the illnesses of multiple presidents, doesn't expect full disclosure at the top.

Dwight D. "Eisenhower was the only one that was very open as far as I could tell," he said. (After Eisenhower suffered a heart attack in 1955 while in office, a physician helpfully to his "good bowel movement" a couple days later.) "The rest were not transparent. That's just what they do, and I don't think it's going to change."

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