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Book Review   |    
Steven S. Sharfstein
Psychiatric Services 2009; doi:
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by David Owen; Westport, Connecticut, Praeger Publishers, 2008, 420 pages, $44.95

Dr. Sharfstein is president and chief executive officer, Sheppard Pratt Health System, Baltimore.

The interface of medicine and politics is fascinating. The fate of nations is influenced by the health of their leaders, and when a leader becomes disabled by illness, the impact on millions can be considerable. I don't believe that these issues have ever received such a thorough discussion as in Lord David Owen's book, In Sickness and in Power. No one is more expert or able to address this problem than Lord Owen, a fully trained neurologist who, after completing his medical specialty training, became a member of Parliament, rising to the position of British Foreign Secretary, as well as cofounding the Social Democratic Party in Britain in the 1980s and leading it for close to a decade. The physician-politician is probably in the best position to assess and evaluate the medical and mental illnesses in leaders, which can then cast light on their decision making and the course of history. This book provides a broad, 100-year overview with a large cast of characters, including Woodrow Wilson, David Lloyd George, Warren Harding, Winston Churchill, and Adolf Hitler. The in-depth case histories on Prime Minister Eden and President Kennedy, the Shah of Iran, and President Mitterrand are particularly fascinating.

The last section of this book addresses the decisional capacity of leaders, how that should be assessed, and what should be done when an individual's leadership is compromised either by psychiatric or nonpsychiatric illness. Lord Owen believes strongly that selective disclosure of mental or medical illnesses is no longer acceptable, and politicians must educate public opinion about illness and disability and then trust their judgment. He calls for a more enlightened attitude among the public toward mental illness, but knowing the nature of the political process and concerns of the electorate, it is highly unlikely that this will happen soon. Lord Owen's call for an independent medical assessment before a leader takes office is an excellent idea, but what guarantee would we feel that this truly was independent and not politically biased. For example, the recent review of several hundred pages of John McCain's medical history, which was done within a very narrow time frame, without any copying, by a very small group of physicians did not allow an adequate assessment on the status of McCain's health and the likelihood of his ability to serve in office for four full years.

Lord Owen also calls for procedures to conduct a medical assessment after a leader takes office if there are concerns. His many examples of leaders who have had compromised judgment and made irrational decisions give one pause. The fine line between overt illness and what the author calls the "hubris syndrome" is one that is often difficult to ascertain. Whether a certain pattern of "hubristic" behavior constitutes a mental illness is often difficult to decide contemporaneously but often is quite clear in retrospect, as this interesting book describes. The author suggests procedures for "good government" in the context of the leader's becoming disabled and infirm. Being able to counter a leader's bad judgment that does not constitute an illness or disability is much more difficult to manage, and we must rely on the institutions of democracy to correct for these problems.

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