The 25th Amendment provides a process to remove a president who is “unable to discharge the powers and duties of his office.” But there is no process to assess the abilities of candidates for the presidency.
The Federal Aviation Agency requires commercial airline pilots to regularly undergo an assessment of cognition and lists more than 200 neuropsychologists around the country certified to administer these assessments. Air traffic controllers are also required to undergo cognitive testing. For years, the Air Force, Navy, Marine Corps, and Coast Guard have required officers to undergo a battery of cognitive and personality tests for qualification and assignment. The Army now requires all personnel, including generals, to perform cognitive testing at least once every three years. A bipartisan bill introduced in 2024 would extend this to all military branches.
Increasingly, people entrusted with critical responsibilities in their occupations are screened and monitored for cognitive health. Shouldn’t this apply to the person with the most critical responsibilities — the commander in chief? A cognitive fitness evaluation is a necessary first step for people in positions of power who are responsible for the safety and well-being of others, though not sufficient on its own. A comprehensive assessment tailored to the unique demands of the role is essential.
The voters also think so. A remarkable 75 percent of likely voters surveyed in 2023 said, presidential candidates should be required to take a cognitive test. This demand was voiced by Republicans, Democrats, and independents alike. Such a large segment of the electorate rarely agrees on anything, but this is seen as common sense regardless of party affiliation.
Brain conditions that lead to cognitive decline can strike at any age, becoming increasingly common as people age. A 2020 analysis of 29,304 participants in the Health and Retirement Study concluded that “approximately two out of three Americans experience some level of cognitive impairment at an average age of approximately 70 years.”
Although changes in thinking abilities commonly occur as we age, some older people maintain high cognitive function and some younger people do not. Consequently, just as in the occupations mentioned, we recommend that all presidential candidates undergo a cognitive assessment with subsequent monitoring once elected. This should also apply to other governmental leaders, including federal judges.
Historically, simple cognitive screening tests such as the Montreal Cognitive Assessment or the Mini Mental State Exam have been discussed in this context. We believe this is inadequate. None of the occupational assessments for military leaders and the FAA rely on such simple screening tests. Instead, they employ assessments tailored to the demands of the occupation. Some of these assessments are computerized, and some are administered by a trained professional. At a minimum an assessment of presidential candidates and other high governmental officeholders should include an evaluation of complex attention, reasoning and problem-solving, learning and memory, language, and social cognition. It would be critical for a qualified professional to supervise this assessment.
With each presidential candidate questioning the mental capabilities of the other, there has never been a time when cognitive fitness assessments for governmental leaders has been so important and so urgent. The American public deserves leaders who are cognitively capable of performing the demands of office. Neither Republicans nor Democrats want cognitive impairment on the ballot.
Dr. Anahita Dua is an associate professor of surgery at the Massachusetts General Hospital and Harvard Medical School. Dr. Brad Dickerson is a practicing behavioral neurologist and professor of neurology at Massachusetts General Hospital and Harvard Medical School.