Are medical incapacity and ‘fitness to govern’ in politics questions of clinical judgement?

Editor,

Kapur and Begam highlighted timely debates about medical incapacity in high office, which have spanned medieval monarchies to modern democracies. ¹ Nevertheless, calls for routine medical examinations of governmental leaders invoke broader questions that may prove prohibitively complex within a single democratic polity, let alone across disparate cultures and political systems.

A primary difficulty lies in the assumption that ‘fitness to govern’ can be determined solely through clinical judgements. ² Illness, functional impairment and poor governance are neither synonymous nor mutually exclusive concepts. Individuals may exhibit pathology but still function effectively in demanding professional environments, whereas dysfunctional leadership can materialise in the absence of any discernible disorder. ²

Although cognitive decline amongst governmental leaders warrants serious reflection, screening instruments provide no normative cut-off for determining medical incapacity in politics. This notion itself remains nebulous, with constitutional mechanisms for adjudicating ‘fitness to govern’ often ill-defined (or non-existent).^1,2 Equally, chronological age-based criteria risks contravening anti-discrimination legislation and may be an imperfect proxy for cognitive functioning.

More fundamentally, any screening regime in high office would require agreement on which actors may initiate evaluations and when, who conducts them, how results are interpreted, what public disclosure is justified and what authority the findings would carry. ² Such protocols would inevitably occur within polarised political environments, rendering medical neutrality precarious to uphold, and would require sufficient and sustainable financing, which may be difficult to guarantee in certain jurisdictions.

Kapur and Begam’s proposal also omits whether assessments would be voluntary or compulsory. ¹ If optional, leaders may refuse; if legally enforced, tensions could arise around autonomy and privacy. Following presidential tradition, Donald Trump’s 2026 medical release conveyed little beyond a declaration of ‘excellent health’, illustrating gaps between theoretical intent and real-world practices. ³

Of course, Kapur and Begam’s arguments are legitimate, yet technical solutions to socio-political problems rarely survive contact with the conditions they seek to address. Any viable screening framework would necessitate sustained cross-cultural and socio-political consensus building before meaningful implementation could conceivably begin (if at all). Ultimately, however, we concur that these conversations are long overdue, and in an unstable world, are becoming harder to ignore.