Abstract
DEAR SIR
I read with great interest Kaplan's sketch of Radovan Karadzic. 1 It is timely and important. However, it is an untenable position when in referring to the American Psychiatric Association's The Principles of Medical Ethics 2 Kaplan sees fit to state that ‘the perils of retrospectively pinning convenient labels on leaders who are not available to be examined are well known, and should be avoided at all costs’. In fact, the American Psychiatric Association advises that ‘it is unethical for a psychiatrist to offer a professional opinion unless he/she has conducted an examination and has been granted proper authorization for such a statement’.
Kaplan expresses reservation about considering ‘diagnoses such as manic depression or paranoia’. Likewise, with reference to Redlich's work Hitler: Diagnosis of a Psychopathic Prophet, 3 he emphasizes that the term psychopath is ‘unsuitable, and ultimately untenable, for describing political leaders’. However, it is heartening that, although apparently cautious about endorsing the discipline of pathography, in his equally important paper on Hitler and his physician, Dr Morell, Kaplan expressed the view that ‘pathography — the study of disease [!] in the famous — has its critics, but the advantages cannot be ignored’. 4
History is replete with examples of leaders for whom personality or illness, physical or mental, has impaired their decision-making and judgement, at times with far-reaching consequences for nations. 5– 8 Kaplan talks about ‘the effect of illness [!] on the famous and infamous, the consequences of which resonate through history’. 4 Thus, historians are particularly eager to know whether the genesis of a leader's incomprehensible or aberrant behaviour is likely to have been the product of individual and/ or non-individual factors. 9 Paraphrasing P. Bagge, an eminent Danish historian, one cannot escape the fact that man as a volitional being everywhere constitutes the dominant link in historical causality, thereby rendering the historical phenomena so complex that in order to understand and disentangle them historians must always search for the individual factors. 10
Pathography, which is applicable to any personality, sick or sound, provided that sufficient biographical material is available, is a valid retrospective method for historians in their quest(s). 11 The pathographical result is a facet, of course, but often an indispensable one.
The primary aim of leadership pathography is not to retrospectively pin convenient labels on leaders who are not available to be examined — be it subjects with possible manic-depressive disorder, paranoia or psychopathy — but first and foremost to examine whether or not the person's decision-making and judgement were impaired and, if possible, by what factors. 5 , 6 Second, sober pathography can add new and, at times, rich dimensions to psychopathology per se. As Jaspers advised, psychiatrists should read good pathographies. 12
The ethical issues surrounding the publication of medical reports and/ or expert opinions about leaders are eminently illustrated by the case of Winston Churchill. 8 His doctor, Lord Moran, was widely condemned, virtually ostracized, for his writing publicly about the medical and psychological condition of his famous patient, just 1 year after his death in 1965. 13 It had been impressed upon him that it was ‘[his] duty to make [“some facts about Winston which were not known to others”] available to posterity’ because ‘it is inevitable that everything about this man will be known in time. Let us have the truth’. Eventually Moran himself, who initially did not believe that Churchill's place in history needed ‘a footnote by his doctor’, ‘came to see that it is not possible to follow the last 25 years of Winston's life without a knowledge of his medical background’. 13 Among the many critical voices, 14 in an ‘annotation’ in The Lancet in 1966 it was argued that although ‘historians can rightly claim that Lord Moran's contribution may throw useful light on the events which Churchill helped shape… [he] would have done better to avoid clinical details’. 15 Thus, the annotation concluded that Moran, ‘by writing publicly about the medical condition of an identified patient, is creating a modern precedent. It is a bad precedent which none should follow’.
Almost 40 years later no one would or could question that Lord Moran's diaries on Churchill are invaluable, indispensable documents towards a pathographical and historical evaluation of this great statesman. The only mistake Moran made, if any, was the premature timing of the publication. 8
Historians' research into leadership without access to medical documents and expert opinion would often remain incomplete. Finally, it can be argued that the general public has a right to know about the leaders who helped shape or, for that matter, at times, ruin their destinies. Juvenal saw it clearly all those years ago when asking the forever essential question: sed quis custodiet ipsos Custodes? [But who guards over the guardians (i.e. our leaders) themselves?]