Beyond Biden and Trump: A Physician's Plea for Presidential Cognitive Accountability

Muhamad Aly Rifai, MD

Welcome back to The Virtual Psychiatrist. I'm Dr. Muhamad Aly Rifai, and as always, I'm joined by my Friend and fellow exonerated physician Dr. Chris Russo. Chris, how are you doing today?

Christopher Russo, MD

Hey Doctor Rifai, doing well. Excited for this one. Presidential cognition—it's a hot topic, and honestly, it's about time we dig into the science and the messiness around it. Auto Pen these weasels

Muhamad Aly Rifai, MD

Yeah, and it's gotten even messier with the recent updates to the DSM-5-TR. For folks who aren't glued to the coding changes, the supplement in 2022 brought a lot of new detail to how we diagnose neurocognitive disorders—delirium, major and mild NCDs, all that. But, you know, the real headline is that the criteria are still guidelines. They're not meant to be used like a checklist by someone without clinical training. It's all about context and clinical judgment.

Christopher Russo, MD

Exactly. I mean, the DSM-5-TR even says it—don't apply this stuff mechanically. You need experience, you need to know the patient, and you need to see the whole picture. I had a case not long ago, actually, where a patient came in with what looked like just a little forgetfulness. Nothing dramatic. But when I dug deeper—looked at their vascular history, did a nuanced assessment—it turned out to be a mild vascular neurocognitive disorder. If I'd just run through a checklist, I would've missed it. The coding is more detailed now, but the art of medicine is still in the interpretation.

Muhamad Aly Rifai, MD

Right, and the supplement even added new subtypes, like NCD due to unknown etiology, and clarified how to code for behavioral disturbances—agitation, anxiety, mood symptoms, psychosis. But again, you can't just tick boxes. You have to ask, is this a real change from baseline? Is it impacting daily life? And, is there a medical cause? The criteria are there to guide, not to replace, clinical expertise.

Christopher Russo, MD

And that's especially true when we're talking about high-stakes cases—like, say, the President of the United States. The context is everything. You can't just watch a debate and say, "Oh, that's dementia." There's a process, and it starts with a real, in-person assessment.

Muhamad Aly Rifai, MD

So let's talk about that—presidential health in the public eye. The medical and ethical complexities are huge. I mean, take Former President Biden. His medical history is public record—two brain aneurysms, a stroke, atrial fibrillation, sleep apnea. All of these are risk factors for cognitive decline, especially vascular neurocognitive disorder, according to DSM-5-TR. But the real controversy is, how do you assess a sitting president's cognition? And who gets to know the results?

Christopher Russo, MD

Yeah, and then you have the Goldwater Rule. For anyone who doesn't know, that's the ethical guideline that says psychiatrists shouldn't diagnose public figures without a direct exam and consent. It came out of the 1964 election, when a magazine published a poll of psychiatrists saying Barry Goldwater was unfit to be president. He sued, and won. The rule is still in place, but honestly, it's broken all the time, especially on cable news and social media.

Muhamad Aly Rifai, MD

And the media scrutiny just makes it worse. Every debate, every press conference—or lack of one—becomes a Rorschach test for the public. After Biden's debate performance in June 2024 where he said "we finally beat Medicare" , the speculation exploded. People were diagnosing him with everything from Alzheimer's to Parkinson's dementia, just from TV clips. But as we discussed in a previous episode about the dangers of armchair diagnosis, that's not how medicine works. You need a full assessment—history, neuropsych testing, sometimes imaging. And, you know, as someone who's been in the crosshairs of public and legal scrutiny myself, I can tell you, the tension between patient privacy and public accountability is real. I've had to defend those boundaries in court, and it's not easy.

Christopher Russo, MD

And the White House hasn't helped, honestly. The official medical reports for Biden in 2021, 2023, and 2024 all said he had "extremely detailed neurological exams," but they never included a mental status exam. We don't know if it was done and not reported, or just skipped. Either way, it leaves the public guessing, and that's a recipe for conspiracy theories and mistrust.

Muhamad Aly Rifai, MD

Exactly. And the stakes are so high. We're not just talking about one person's privacy—it's the legitimacy of executive actions, foreign policy, the whole democratic process. But at the same time, we can't just throw out medical ethics because the patient is famous. It's a real dilemma.

Christopher Russo, MD

And then there's the stigma. Social media and political discourse have turned "dementia" into a weapon. Every slip of the tongue, every moment of confusion, gets labeled as "senile" or "demented." It's not just inaccurate—it's harmful. It stigmatizes people living with dementia, and it muddies the waters for real diagnosis. As the Alzheimer's Society pointed out, you can't diagnose from a distance. There are so many reasons someone might look confused—fatigue, stress, even just not knowing the topic. But the language gets thrown around so carelessly.

Muhamad Aly Rifai, MD

Yeah, and it normalizes really unhelpful language. Terms like "senile" or "addled" are outdated and demeaning. They're not used by professionals anymore, but the media keeps repeating them. It makes it harder for people to seek help, and it turns a medical issue into a political insult. And, you know, the public's reaction to Biden's debate performance and his withdrawal from the 2024 race is a perfect example. There was a rush to judgment—people saying, "See, that's dementia." But without a formal assessment, that's just speculation. The real risk is that we miss the nuance, and we perpetuate stigma for everyone living with cognitive disorders.

Christopher Russo, MD

And let's not forget, armchair diagnosis is dangerous. Even experts like Dr. Surasky, who went on TV to say Biden had vascular dementia, admitted he hadn't examined him. That's not how this works. You need a full workup—history, neuropsych testing, sometimes imaging. Otherwise, you're just guessing. And that guesswork can have real consequences, both for the individual and for public trust. But remember his staff was covering for him and they were using the Auto Penn these weasels

Muhamad Aly Rifai, MD

Absolutely. And, you know, as we saw with the autopen controversy—where the White House used a mechanical signature for official documents—every little thing gets interpreted as evidence of decline. But sometimes, it's just a practical solution, or a sign of a busy schedule. We have to be careful not to read too much into isolated incidents. The real danger is that we start to see every mistake as proof of disease, and we lose sight of the person behind the headlines. But also consider the legal implication like the use of Auto Penn to appoint Judges, like the auto penn appointment of Assistant United States Attorney Brandy McMillion as a federal judge after she lost the Bothra case what a doozy

Christopher Russo, MD

Can't Agree more Dr. Rifai should call those Judges Auto Penn Judges Like Judge McMillion, ... So let's talk about the legal and ethical frameworks. Diagnosing public figures without a formal assessment isn't just bad medicine—it's potentially defamatory. The Goldwater Rule is there for a reason. Clinicians have a responsibility to maintain confidentiality, avoid bias, and stay neutral, even when the pressure is on. If you get approached for an opinion about a political leader, you have to be really careful. It's easy to get swept up in the moment, but the consequences can be huge.

Muhamad Aly Rifai, MD

And the legal implications are real. The 25th Amendment lays out a process for addressing presidential incapacity, but it requires clear, incontrovertible medical evidence. That means transparent, standardized assessments, not just rumors or TV analysis. And the White House physician has a dual duty—to the patient and to the public. But that doesn't mean you can just release private medical info without consent. It's a tightrope walk.

Christopher Russo, MD

There's also the question of best practices. Should we have formal guidelines for assessing the cognitive health of political leaders? Some people are calling for mandatory cognitive testing for all candidates. I get the logic, but it raises questions about privacy, fairness, and who gets to interpret the results. It's a slippery slope.

Muhamad Aly Rifai, MD

Yeah, and as someone who's been through government scrutiny myself, I can say—transparency is important, but so is dignity. We need clear, impartial protocols that respect both. Maybe it's time for the medical community to develop best practices for navigating these situations—balancing public accountability with medical integrity. It's not easy, but it's necessary if we're going to maintain trust in our leaders and our profession.

Christopher Russo, MD

Couldn't agree more. And, you know, this isn't the last time we'll be talking about this. The intersection of medicine, law, and politics is only getting more complicated. Like I think Biden Auto Penn Appointment of the prosecutor in our case who became a Judge whether that appointment is valid who knows but this is constitutional crisis if the rulings and appointments go out the window.

Muhamad Aly Rifai, MD

Yeah, and that's why we're here. Thanks for joining us on The Virtual Psychiatrist. Chris, always a pleasure.

Christopher Russo, MD

Thanks Aly. Looking forward to next time.

Muhamad Aly Rifai, MD

Take care, everyone. We'll see you soon. and in the Words of our Friend Norm Clement you are within the norms