Physician or publicist? What’s a doctor to do when the president wants to be Superman?

Before deciding to take a photogenic, early-evening helicopter ride from Walter Reed National Military Medical Center back to the White House, President Trump toyed with an even more dramatic idea. He discussed wearing a Superman T-shirt under his dress clothes, coming out of the hospital looking exhausted, and then tearing off his outer shirt to reveal himself as the ever-strong Superman.

Made-for-tweeting publicity stunts that are rejected can still teach us something: In this case, it is about the power of costumes and the narratives they bring with them.

From the time the president left the White House for Walter Reed on the evening of Friday, Oct. 2, until he helicoptered back to 1600 Pennsylvania Avenue the following Monday, he was in the sick role. This is a role the president wanted to shed as soon as possible — as we all would — and he seems to have enlisted his personal physician, Sean Conley, also known as the White House physician to the president, to help him.

Conley caused great consternation in the press corps when he gave incomplete, misleading, and downright wrong medical information to the press.

The debate about what medical information a president owes to the public, and the role of the White House physician in supplying it, is an old one. This president’s ongoing Covid-19 saga has done little to settle it in large part because, even more so than his predecessors, Trump wants to share all medical information he thinks is good for his image and withhold all medical information he thinks might compromise his superman image of himself.

The president’s physicians

During the 2016 presidential campaign, then private citizen Donald Trump’s physician of almost 40 years, Harold Bornstein, wrote a letter for the press summarizing his patient’s health. He ended it with an almost ridiculous line dictated by Trump: “If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency.”

Trump thought about keeping Bornstein on as his personal physician in the White House. But soon after the inauguration, he decided to use the official White House physician, Ronny Jackson, a rear admiral in the U.S. Navy who had served as President Obama’s personal physician since 2013. In his report on the first annual physical on the president, Jackson described Trump as “absolutely … fit for duty,” saying, “I think he will remain fit for duty for the remainder of this term and even for the remainder of another term, if he’s elected … he has incredible genes … he might live to be 200 years old ” (although he probably won’t). As to the rest of Trump’s condition, Jackson assured the press, “I can promise you there’s absolutely nothing that I’m withholding from [you].”

Trump later nominated Jackson to be secretary of Veterans Affairs (Jackson later withdrew from the process) and chose his next in line at the White House Medical Unit, Sean Conley, who, it seems fair to say, modeled himself after Jackson in the role of the president’s  physician.

The president’s infection with Covid-19, and his transfer to Walter Reed, brought into stark relief the question of the role of the president’s White House physician in supplying contemporary medical information to the press in a possible crisis.

The role of the military

One fact that helps resolve that question is that while the president’s physician is in the military, the president is not — his secondary title of commander in chief is a civilian post that comes with being president. The use of military physicians in the role of White House physician is, as others have noted, mostly for convenience of the physicians who do not have to disrupt their practices to attend to the president in this role.

And it is here where the costumes matter.

Conley wears his Navy uniform on occasion, but when discussing the president’s health with the press, he usually wears the physician’s traditional white coat. (Jackson did the same.) This is appropriate, since the role of the White House physician is to safeguard the health of his or her primary patient, the president. With the president, this physician’s role is rightfully seen as that of doctor and patient. The centrality of this role answers the question of patient privacy, or what the president’s physician can (or should) tell the press.

The president’s right to privacy

The president has a right to medical privacy as a patient. This is both for his sake and for ours. If he was not certain his physician would respect his privacy, he might not see him to determine the cause of a symptom, and risk it getting worse. Perhaps more importantly, no president would ever consult a psychiatrist to pursue mental health symptoms because of the extreme stigma mental health treatment has in some segments of the population unless privacy was assured. For the president’s sake and for ours, we want to keep those treatment doors open.

The press, of course, will continue to ask about the president’s health, and there is no limit to the public’s curiosity. It is up to the president to set limits on disclosure with his physician — and if the president doesn’t set any limits, the president’s physician should. Some information, like mental health or treatment for a sexually transmitted disease, should be out of bounds because of its extremely (irrational) prejudicial impact. Abortion information should always be off limits as, I think, should probabilistic genetic information.

That said, the president’s physician cannot lie or mislead the public by providing partial information. The role is physician, not publicist.

The obligations of the president’s physician

Does the president’s physician have any special obligations under the Constitution? The short answer is no. There is no role for the president’s physician set out in the 25th Amendment, which covers presidential disability and succession. On the other hand, if the vice president or a group of cabinet members, having observed what they consider troubling and perhaps disabling behavior by the president, seek out the opinion of the president’s physician, I think the physician has an obligation to respond honestly to that inquiry.

In the absence of an inquiry, the president’s physician has an obligation to make what disclosures are necessary to protect the president and those around him if the president is a danger to himself or others. This could include anything from not wearing a mask while sick with Covid-19 (and not taking steps to inform anyone exposed to him of the danger and how to avoid it) to informing the secretary of defense of any condition that might affect the president’s ability to make a rational decision about launching a nuclear attack. Some commentators, for example, were worried about Trump’s reaction to the steroid dexamethasone. One side effect of the drug is mood enhancement, including inflated self-esteem, which could help explain the desire to play Superman, although it is difficult to imagine that the president’s self-esteem could be any higher than it usually is.

There is nothing quite like the president-physician relationship. In general, we are all better off if the president has a physician he can trust to maintain privacy. The public does, however, have a right when making a decision to elect or reelect a president to be informed if there is a reasonable medical probability that the candidate is not likely to survive for four years, or is more likely than not to become mentally incapacitated in that time.

Other than this, the president has a right to medical privacy.

George J. Annas is the director of the Center for Health Law, Ethics & Human Rights at Boston University School of Public Health.