This introduction to the special issue on presidential disability and succession focuses on the distinctly positive contributions that invocations of the Twenty-Fifth Amendment have made to American political life since the Amendment's ratification in 1967. It also underlines the importance for Presidents, their family members and aides to understand the necessity for putting the welfare of the country first, above all else—even at times above the wishes of a disabled Chief Executive. As the articles in this special issue make clear, the Twenty-Fifth Amendment provides an effective constitutional mechanism by which the country's well-being can be maintained while simultaneously showing compassion and respect for a disabled leader. The idea for this issue emerged from a conference organized by Professor Robert E. Gilbert focusing on presidential disability and succession held on the campus of Northeastern University in April 2014. Papers from the conference assembled here clarify and add to the historical record about presidential inability while illuminating the many political, legal, and constitutional contingencies that future presidential administrators may face. Contributors to this issue have varied disciplinary and professional backgrounds, including expertise in American politics, constitutional law, the presidency and vice presidency, presidential impairment, and, of course, the Twenty-Fifth Amendment to the Constitution.

This article focuses on potential gaps caused by the absence from the Twenty-Fifth Amendment of provisions to deal with the disability of a Vice President and the omission from the statutory line of succession law of provisions comparable to Sections 3 and 4 of the Twenty-Fifth Amendment for when there is an able Vice President. The analysis offers a critical review of the latent ambiguities in the succession provision to the United States Constitution, noting problems that have arisen from the time of the Constitutional Convention, to John Tyler's accession to office, to numerous disability crises that presented themselves throughout the twentieth century, to the present day. As the world becomes more complex and threats to the presidency more common, continued examination of our succession structure and its adequacy for establishing clear and effective presidential succession provisions under a broad range of circumstances is of paramount concern. This article embraces this robust discussion by offering some suggestions for improving the system in a way that does not require a constitutional amendment. The first part of the analysis traces the events that have driven the development of the nation's succession procedures. The second part examines the inadequacies, or “gaps,” that remain in the area of presidential inability, and the third part sets forth recommendations for resolving these gaps.

Vice President Thomas R. Marshall has been criticized for not acting more aggressively to exercise presidential powers and duties after President Woodrow Wilson suffered a stroke in October 1919 which compromised his ability to discharge his office for much of the remainder of his term. Yet Marshall faced formidable constraints in the constitutional, political, institutional, and factual context in which he operated. This paper examines these constraints on Marshall's political behavior. His conduct becomes understandable when viewed in the context of those inhibiting factors. The paper also considers the impact of the presidential inability provisions of the subsequently ratified Twenty-Fifth Amendment which renowned Wilson scholar Arthur Link suggested would have made no difference. While questioning the practicality of that counter-factual, the paper argues that the Amendment would have been helpful but suggests that a Wilson-like situation, if one could be imagined in modern times, could present a relatively taxing challenge to our constitutional system.

This paper assesses the likelihood that the Iran-Contra scandal was shaped heavily by the effects of Ronald Reagan's cancer surgery in summer, 1985. During the President's hospitalization and in the period soon after, he took several actions—which he apparently did not remember—that launched a policy that was unwise, counterproductive, and a failure. These damaged both his Administration and his standing in history. The 25th Amendment afforded Reagan the means by which his involvement in these events could easily have been avoided. However, the President and his aides determined that he would resume the powers and duties of the presidency only hours after undergoing extensive cancer surgery. This decision contributed materially to the most damaging episode of Reagan's eight-year presidency.

Political concerns often compromise the delivery of high quality medical care in ways that can be both problematic and dangerous for political leaders. President John F. Kennedy's medical care offers a particularly rich exposition of the many ways in which these dynamics can play out and how additional factors can complicate matters, such as when the patient is himself duplicitous, when family members try to intervene in care, and when public exposure risks political future. This article examines the politics and management of Kennedy's medical conditions by the various physicians involved in his care and explores how these considerations may have compromised not only the quality of his care but, in turn, exerted an influence on his behavior. This happened not only through the downstream effect of his treatment on his thoughts and behavior but also through the tremendous allocation of time and attention that his care required—attention a healthier man would have been able to direct toward problems of greater national concern.

Decision-making is an essential component of executive function, and a critical skill of political leadership. Neuroanatomic localization studies have established the prefrontal cortex as the critical brain site for executive function. In addition to the prefrontal cortex, white matter tracts as well as subcortical brain structures are crucial for optimal executive function. Executive function shows a significant decline beginning at age 60, and this is associated with age-related atrophy of prefrontal cortex, cerebral white matter disease, and cerebral microbleeds. Notably, age-related decline in executive function appears to be a relatively selective cognitive deterioration, generally sparing language and memory function. While an individual may appear to be functioning normally with regard to relatively obvious cognitive functions such as language and memory, that same individual may lack the capacity to integrate these cognitive functions to achieve normal decision-making. From a historical perspective, global decline in cognitive function of political leaders has been alternatively described as a catastrophic event, a slowly progressive deterioration, or a relatively episodic phenomenon. Selective loss of executive function in political leaders is less appreciated, but increased utilization of highly sensitive brain imaging techniques will likely bring greater appreciation to this phenomenon. Former Israeli Prime Minister Ariel Sharon was an example of a political leader with a well-described neurodegenerative condition (cerebral amyloid angiopathy) that creates a neuropathological substrate for executive dysfunction. Based on the known neuroanatomical and neuropathological changes that occur with aging, we should probably assume that a significant proportion of political leaders over the age of 65 have impairment of executive function.