Doctors don’t die the way most Americans do. Physicians know what the end of life looks like. They recognize the signs, and they know when it’s time to land the plane rather than circle in a holding pattern. Most importantly, they know what should not be prolonged merely because it can be.
I’ve spent 47 years working closely with doctors. Some of that insight has rubbed off on me. I’ve written with physician colleagues about end-of-life care, and I have advance directives in place to relieve my family of the burden of impossible decisions should I lose the capacity to decide for myself.
There is a parallel between our national tolerance for medically futile health care expenditures and the absence of any systematic mechanism to address neurological and cognitive decline in elected officials.
At first glance, the absence of any formal “fitness standard” has sound structural underpinnings. In a representative democracy, authority flows from voters, and the system is deliberately cautious about allowing unelected actors to override that mandate.
But what if elected officials — voluntarily or by expectation — adopted their own advance directives governing circumstances under which cognitive decline would trigger independent assessment?
Each official could designate a small panel of medical professionals to evaluate capacity if behavior clearly suggested serious impairment. Not a partisan tribunal. Not a political weapon. Simply a pre-committed mechanism of accountability, chosen while fully capable.
Hand-picked physicians might be inclined toward generosity. But three clinicians exercising professional judgment would represent more structure than we have today — where the only corrective mechanism is an election that may be years away.
Advance directives step in when cognition cannot. We accept that reality in medicine. We resist acknowledging it in public life.
Roughly one-third of Americans have advance directives in place to guide end-of-life decisions. That proportion should be higher.
None of our elected officials have comparable mechanisms to govern the end of their careers.
That proportion should be higher too.