Is it fair to question a presidential candidate’s mental fitness?

"My heart sank as he floundered his way through his responses, fumbling with his notes, uncharacteristically lost for words. He looked tired and bewildered," Ron Reagan, the son of President Ronald Reagan, wrote of his father's performance during the first 1984 presidential debate.

This article first appeared in Salon.

At the time, there had long been rumors that Reagan was suffering from cognitive impairment — perhaps Alzheimer's Disease — and as he struggled during the first debate against his Democratic opponent, former Vice President Walter Mondale, those concerns threatened his reelection campaign. He recovered during the second debate with a memorable quip, joking that he would not allow age to become an issue in the campaign because "I am not going to exploit, for political purposes, my opponent's youth and inexperience." The audience laughed, the nation moved on… and, a decade later, Reagan announced to the world that he had been diagnosed with Alzheimer's.

We will never know whether he had the condition during the 1984 election, and whether Mondale could have become president if it was revealed that Reagan had the debilitating disease. What we do know is that, almost forty years later, a similar controversy has arisen in the current election.

Diagnosing a political leader from afar is a famously fraught affair. In the 1960s Sen. Barry Goldwater of Arizona, who had lost in a resounding landslide when he ran for president as the Republican nominee in 1964, sued Fact magazine for running an article in which 1,189 psychiatrists said he was unfit for office. Goldwater won the suit, and ever since the media has followed what is known as the "Goldwater rule," which says that psychiatrists should not offer professional opinions on public figures unless they have personally examined them.

Generally, doctors and mental health professionals shy away from even speculating over the health of someone that they cannot examine directly. Trump, in particular, has led to a renewed debate over the medical ethics of diagnosing from afar: some psychologists believe that, as a public figure who wields so much power, experts have a moral imperative to raise red flags when they see them; while other medical professionals believe such behavior is unethical and paints their profession in a bad light.

Still, bizarre behavior in a public setting can feel alarming to those who are paying attention. And indeed, as the likely Democratic nominee, Joe Biden's public behavior is broadcast widely and is, even to a layperson, frequently bizarre. He has confused his wife for his sister, failed to remember the most iconic words of the Declaration of Independence, told a baffling and somewhat creepy story about little kids touching his hairy legs and claimed at one point that he was running for the Senate and urged people who dislike him to "vote for the other Biden." Listening to his post-caucus speech after being defeated in Nevada — an address that came before his comeback in the South Carolina primary — it is shockingly difficult to comprehend what, exactly, he is trying to say.

Some of these gaffes can be explained away by Biden's history struggling with stuttering, something he has been open about. Yet there are aspects of his medical history that hint that his gaffes could go beyond a mere stuttering problem. Biden had two brain aneurysms in 1988 — the same year he ran his first presidential campaign — which establishes a medical history for him of brain-related trauma. (I reached out to Biden campaign officials for comment; none responded.)

Biden's tics go beyond the inarticulateness of President George W. Bush or even the mild gaffes to which Biden himself was famously prone during his vice presidency. There is a lack of lucidity, a difficulty in comprehending what the man is trying to say or whether even he knows exactly what he is trying to say. There is an important difference between candidates who say things that are stupid, wrong or ridiculous and someone who seemingly struggles to put together coherent thoughts; one indicates an unhealthy mind, the other a mind that may be outright wilting away. It is difficult to listen to Biden speak without fearing that he falls into the latter category.

Among experts with whom I spoke — including those who know Biden personally and mental health professionals — some agreed that Biden should proactively take steps to put public fears over his mental fitness to rest. Others expressed unease at raising the question.

"The so-called 'concerns' that Trump, his family, and his acolytes are raising about the former Vice President aren't worthy of response," Laurence Tribe, a professor at Harvard Law School, told Salon by email. "I've known Biden for years and detect no loss of intellectual acumen. His slips of the tongue are legendary and, even if slightly more frequent these days, are nothing compared to the constant truly idiotic slips of the brain that characterize Trump. Had we not grown sadly accustomed to Trump's mangling of language, logic, syntax, and sense, we'd all be running for the exits."

Former political consultant Bob Shrum, whose firm has worked with Biden, expressed disgust with the accusations about Biden's mental fitness when speaking to Salon.

"I think they're preposterous and I think they're even more preposterous coming from the place they're coming from," Shrum told Salon. "I mean, Donald Trump proves his mental disability every time he opens his mouth."

Tribe and Shrum are certainly correct that Trump's mental fitness also needs to be a question. As Dr. Bandy X. Lee, a Yale psychiatrist, told Salon last month, Trump is "anti-human" in his psychology, displaying narcissistic and sociopathic traits that lead him to make decisions which deliberately hurt thousands of people and grossly overestimate his own expertise. The president also has a gnat-like attention span, as the man who ghostwrote his most famous book once observed, and lies so often that as of last month it averages out to about 15 untruths every day.

"When someone points out faults or defects in others, it says more about the person pointing them out then the person who they're designating," Lee told Salon for this article. "Especially in Donald Trump's case, it's partly because we know about his psychological structure, we've been observing it in real time and experiencing effects of it for a while. And the pattern has been that whatever he accuses of others, he exhibits himself. "It's kind of a subconscious confession, if you will."

At the same time, opponents of Trump must avoid the perils of whataboutism. The fact that Trump is mentally unfit for the office, and that millions have suffered as a result of said unfitness, does not invalidate concerns about Biden and his apparent unfitness. Americans should not have to choose between a president with toxic narcissism and one who may be teetering toward senility. Trump supporters are hypocritical when they point to Biden's issues and ignore those in their own man; that doesn't excuse Biden supporters from committing an analogous error.

That said, there is a solution to this problem. As Lee told Salon, "there probably is reason for concern" about Biden's mental fitness, even though she feels Trump's issues deserve more attention. Lee said that she "would still recommend that Joe Biden consider a mental fitness for duty exam, and we have established a nongovernmental independent expert panel to be able to do that."

Another psychiatrist, Dr. David M. Reiss, had a similar observation.

"Obviously he's old and anyone over 70 should have an evaluation," Reiss told Salon. "And I wrote that about Trump. I'd say that about him in general. In terms of what we're seeing... I've met him personally. I haven't evaluated him, but it has to be put in perspective of the documentation that he's always had a stutter, he's always had some problems with malapropisms, etc. And personally from what I see, you know, in public and from the brief time I met him, I don't see anything striking. Now would it be reasonable for him to have fully evaluated at 78? Of course. But is there anything striking about his presentation? Not that I've seen."

This is one point of view, and given that it comes from experts, it should not be taken lightly. If people who spend their lives studying the human mind feel that reactions to Biden's seeming slippage are exaggerated, that should heavily factor into how we evaluate his mental fitness for the presidency. The same, of course, is also true of the fact that they believe he should undergo cognitive testing.

At the same time, most Americans are not experts in mental illness. They believe what appears in front of their eyes and what they hear with their own two ears. A presidential candidate who tends to ramble, to digress, to struggle to focus on the same subject during his speeches will be perceived as mentally unfit, especially if his opponents are already making that charge.

This, in turn, could cost Democrats the 2020 presidential election, regardless of whether it is fair or unfair.

I must add that I am not trying to add to the stigma that surrounds mental health issues. I have written before about how mental illness is stigmatized in dangerous and unjust ways, how as an autistic person I am especially sensitive to mental health-based discrimination and how I have been personally impacted by it.

At the same time: Whether one likes it or not, there is a difference between a president simply having a mental health issue like anxiety, depression, bipolar disorder or alcoholism (one 2006 study found that just under half of America's presidents had at least one of those conditions, including our greatest president — Abraham Lincoln) and a president being incapable of doing the job because of mental health issues.

We're already seeing that with Trump's self-absorption caused him to waste precious time America needed to prepare for the coronavirus pandemic, and one recent study estimates that 36,000 people died because of delays in lockdowns that Trump could have taken the initiative to implement. As Lee pointed out, there is an apt analogy to be found in how President Woodrow Wilson suffered a debilitating stroke with a year-and-a-half left in his second term, rendering him unable to fulfill his duties during an influenza epidemic, the delicate peacemaking tasks after World War I and America's mission to give women the right to vote and prohibit alcohol.

"Descriptions of Woodrow Wilson's incapacities in 1920 almost mirror exactly the incapacities described of Donald Trump, and were some of the primary reasons the 25th Amendment was added to the U.S. Constitution," Lee told Salon by email, referring to the constitutional amendment that attempts to put mechanisms in place for replacing a mentally incompetent president. "Instead of relying on the extraordinarily difficult process of applying the Amendment's 4th Section after an error was made, it seems to me that mental capacity evaluations, or fitness tests, would be valuable to do ahead of time. They are usually mandatory for jobs that deal with life-and-death situations, and now commonly even for less consequential positions.  The people deserve to have this information when deciding whom to hire for the most consequential job in the world, so that they may make an informed choice."

Of course, whereas Wilson was able to hide from the media for nearly 18 months and thus avoid widespread exposure for his mental unfitness, Biden does not have this luxury. The nightmare scenario for Democrats is that, at a pivotal moment during the campaign, Biden will struggle to put together a coherent thought, to maintain his lucidity, to convince the voting public that he is able to spar with Trump and the Republicans on the issues. Should that happen, Democrats will squander a prime opportunity to retake the White House.