As one of the physicians who recently expressed concern about President Joe Biden’s health and his likelihood of significant decline over the next four and a half years, I was relieved when he ended his reelection campaign—and also overwhelmingly sad. In essence, as people keep saying, he had his car keys and driver’s license taken away with the whole world watching. This evening as he gave a short speech from the White House about his accomplishments, his voice was weak, he stumbled occasionally over his prepared remarks, and his physical presence was diminished from what it once was.
For months, I have wished that I could have Biden in my exam room, not as the president of the United States, but as a patient in my geriatrics clinic. Instead, watching from afar as he insisted on running, I wondered if his doctors were talking to him honestly about his concerning symptoms, and his disappointing odds of fulfilling the requirements of the office for another term. I hoped that if they were discussing his future, they were pointing out the advantages of taking charge in this situation, even when no available option was Biden’s ideal. But, given what they and the president said in public before he ended his campaign, I worried that little of this was happening. Despite the aging U.S. population, few clinicians are trained to care for aging bodies, much less to discuss the developmental stages of elderhood and identity-threatening realities of later life.
In medicine, we use the term difficult conversations to refer to discussions of existential issues, particularly those with inherent uncertainty and ambiguity. They work best when the patient, perhaps in the presence of family or friends, shares their view of their own health and their hopes or concerns for their future, before—if they’re open to it—hearing a physician’s view and having a chance to explore the possibilities of the coming years in more depth. I might have asked the president what worries or scares him and what brings him joy and meaning, and worked to identify what his best- and worst-case scenarios would look like.
Part of what was so excruciating about watching Biden hold on to his hope of winning a second term was seeing someone struggle to accept that their best-case scenario might be impossible. Variations of this situation play out daily in clinics and hospitals, and if you have a shred of empathy, it’s always heartbreaking. Yet few such difficult conversations—or the loud silences that too often take the place of these conversations—happen so publicly. Watching this one reminded me how unwelcome they are in American life, even in the offices of physicians delivering bad news.
Admittedly, in denying the evident changes in how he walked, spoke, and looked, Biden contributed to the painful and public way that questions about his next four or five years of life were discussed. But his actions were of a piece with common age-denying choices and behaviors: Think of the gray hair diligently covered by many people over 50, the carefully cultivated older gym body, the graduation date dropped off a résumé, and the popular falsehood that “age is just a number.” These choices and statements are a response to a culture that views the diminishment of advanced age not as the natural progression for living organisms but as a personal failure. And people in this country do have reason to dread advanced old age. It can be deeply isolating, and many people end up warehoused and treated in ways that make little sense in a health-care system that hasn’t kept up with the numbers or needs of older adults.
This election cycle in particular has inundated Americans with signals that “old” and “disabled” are categories no one should want to join. Magazine covers have shorthanded politicians’ old age and questions about their competence with images of walkers. In the past, Donald Trump has ridiculed a disabled reporter and refused to be seen in the company of wounded veterans. In March, he mocked Biden’s stutter, and his nephew claimed today in Time magazine that Trump said people with disabilities “should just die.” (Trump has not yet responded to this.) Pundits and politicians alike have simplified, distorted, disparaged, and lumped all people over age 70 into an inaccurate whole. Many octogenarians are cognitively and physically healthy, and the right person at Biden’s age might have made a fine candidate—as would a person who uses a walker or other assistive device, whatever their age.
By staying in the race after he began to present such a concerning picture of health, Biden himself may have contributed to public conflations of old age and frailty. The driving analogy is apt: Most of us will need to retire from driving at some point, and it’s a much more positive experience for those who get to choose when to stop. Still, retiring from driving, work, or anything else can feel like that much harder a choice to make in a country where the Republican presidential nominee has used his considerable platform to suggest, repeatedly, that people who are old or not fully able-bodied are not worthy of our compassion or attention.
Ironically, Trump is now the oldest candidate ever to be nominated for president. He has made a show of his relative robustness compared with Biden, a line of argument that puts him in a precarious position. Although he doesn’t appear frail, health records released during his presidency indicated that he was obese and had hypercholesterolemia and heart disease. And although he doesn’t drink alcohol or smoke, he eats a lot of fast food and seemingly doesn’t exercise beyond slow-paced golf games. It’s impossible to diagnose a person from afar, but his multiple instances of inaccurate recall and disjointed, tangential speech call into question his basic communication and leadership abilities, and raise the question of cognitive change beyond that of normal aging. If Trump came to my clinic, I would do the same physical and cognitive assessment on his as I would on Biden. I would also explore his interest in taking a healthier approach to aging given how his many risk factors increase his chance of adverse health events, functional loss, and death. I hope Trump’s doctors are having such conversations with their patient now.
For Biden’s part, he now has to engage in another difficult—though also potentially exciting—conversation with himself and his family: What comes next? Clearly, after 81 years, most of his life is behind him. No one chooses how many years they have left. But with the privileges of free time and enough money, he can choose how to pursue his own health and happiness—to consider what matters most to him, what he enjoys most, and what he wants to do to avoid regrets when he comes to the end of his life.
Most people do not become president, so most people are not going to move into old age with a list of regrets that could include stepping aside in a presidential election and, perhaps, watching their opponent triumph. They would not include wondering if, after all, they might have won, if their best-case scenario had indeed been possible. I hope Biden never has those thoughts. Instead, I’d like to see him take a new leadership role by choosing a different best-case scenario: one in which he demonstrates how to embrace the opportunities of advanced old age, even if they are as simple as reliably getting a full night’s sleep and spending time with his family.