Periodic Assessment of Nuclear Executives
Proposal for Periodic Assessment of Nuclear Executives to Ensure Their Mental Capacity
Introduction
The purpose of this paper is to raise awareness about the risks posed by flawed decision-making due to impaired mental capacity in a leader who has nuclear weapons at his command. It offers an option for mitigating this risk by proposing periodic assessment of the mental capacity of these leaders.
Leaders of nation states may have supreme power in certain circumstances, and, while they may take advice, the final decision-making is theirs. Impairment of mental capacity may lead to a decision which could be globally catastrophic if it involves nuclear weapons. Decisions made by national leaders regarding nuclear war are so far-reaching, that it is wise – and indeed necessary – for additional safeguards to ensure that those who will make those decisions have the mental capacity to do so.
This paper sets out the current situation with regard to such safeguards, then explores what we mean by mental capacity in this context, followed by a proposal for the elements of an assessment, a model for appointment of assessors and their powers to act, and a brief review of related work.
We propose that the supreme leader of a nation with responsibility for ordering the use of nuclear weapons should be subject to annual assessment, also influential members of the group who are involved in advising on the use of nuclear weapons. The assessment proposed may also be used if serious concerns arise about the fitness of an individual between the annual assessments.
Present situation
At present it appears there are no arrangements in place in the US, in UK or Germany to assess the mental capacity of leaders. The US does have a statutory mechanism for removing an impaired leader but in the UK and Germany there is none.
US
Section 4 of the 25th amendment of the Constitution provides for the situation where a President becomes disabled to such a degree that he or she cannot fulfil their responsibilities. The 25th Amendment includes powers to remove the President from office, temporarily or permanently. However, implementation of Section 4 would be fraught with political and constitutional implications, and it does not refer specifically to the requirement for medical assessment.
UK
In the UK, it appears that there is no specific procedure for dealing with a situation where the Prime Minister appears to be lacking mental capacity. A recent question to an MP resulted in a search of the House of Commons Library resulting in the following response:
“…if the Prime Minister appears to have lost the ability to function, mentally or physically, it is the responsibility of the Cabinet to ensure that effective decision-making can be preserved. This can be achieved either by pre-emptive delegation of responsibilities, or by securing the removal of the Prime Minister and replacement with someone else.
The detail of the nuclear weapons protocols is partly classified information, but the general
understanding is that there are pre-emptive arrangements in place to ensure another minister can take decisions in the temporary absence or inability of the Prime Minister. The main difference between the UK and the US is that these arrangements are not legally codified and can be changed unilaterally by the Prime Minister.”
It could be argued that the arrangements should be legally codified to prevent them being subject to change by the Prime Minister (if, for example he or she was in a hypomanic delusional state). And to rely on Cabinet deliberations without clear guidelines may result in unacceptable and dangerous confusion and delay, especially in times of escalating international tension or war.
Germany
In Germany there is no legal requirement for the Chancellor to undergo a health assessment or to disclose information about their health, nor is there a clear path for action if they appear to have a health condition which may cause them to become unfit to work.
Mental capacity
Mental capacity is defined here as the ability to understand information relating to the consequences of a decision and to come to a sound decision based on this information.
Mental capacity in leaders may be adversely affected by
- Delusional mental states
- Dementia
- Confusional states brought on by physical illness
- Substance misuse including alcohol or drugs
- Stress of isolation from everyday life
- Hubris leading to overconfidence, unwillingness to take advice and, in some cases, paranoia.
Structure of the Assessment
The assessment should include:
- Tests of cognitive function
- Assessment to identify physical health condition that may be affecting mental capacity, its nature and the extent of impairment
- Assessment of psychological health or cognitive impairment where it may adversely affect mental capacity
- Testing for use of alcohol, and recreational drugs such as cocaine, ketamine, cannabis etc.
- Testing for steroid therapy and prescribed psychoactive drugs such as antidepressants and tranquillisers, which may affect judgment
- Consideration of other conditions where there is evidence that they are adversely impacting on capacity (e.g. hubris – see below)
- Consideration of personality disorders which could affect decision making
- Cognitive grasp of the full consequences of initiating or participating in a war involving nuclear weapons.
It is important to stress that the focus of the assessment would not be to make a formal diagnosis, but to identify any condition that is affecting an individual’s mental capacity. Where the impairment is mild, therapeutic options and suitable follow up will be arranged. Where there is severe impairment, the report will need to notify the body with the necessary powers to act (see below).
If any individual refuses assessment, the appointed assessors would take this into account.
Appointment of assessors and the powers to act on their report
A useful model from the US sets out a procedure to ensure a balanced political representation of those appointing 11 nonpartisan members of an oversight Commission. This should allay fears of political bias or too much power in the hands of the medical assessors. A Bill, H. R. 1987, To establish the Oversight Commission on Presidential Capacity, was introduced to U.S House of Representatives in 2017. Under the Bill, if there are concerns about the President’s fitness, an Oversight Commission would undertake a medical examination of the President to determine whether he or she is mentally or physically unable to discharge the powers and duties of the office. The power of the Commission would come under Section 4 of the 25th Amendment.
The proposal in the Bill would be for a Commission comprising:
- Two clinical members appointed by the majority leader of the Senate
- Two clinical members appointed by the minority leader of the Senate.
- Two clinical members appointed by the Speaker of the House of Representatives.
- Two clinical members appointed by the minority leader of the House of Representatives
- Two members each of whom has served as President, Vice President, Secretary of State, Attorney General, Secretary of the Treasury, Secretary of Defense, or Surgeon General
- one appointed jointly by the two appointing individuals above who are members of, or caucus with, the Democratic party;
- one appointed jointly by the two appointing individuals above who are members of, or caucus with, the Republican party;
- One member, to serve as Chair, appointed by simple majority vote of the 10 members of the Commission.
The model for appointment of assessors would, of course, need to be tailored to the needs and constitution of each country. The clinical assessors should include physicians, psychiatrists, and psychologists.
The proposal in the US is that the Commission would determine whether the individual is ‘temporarily or permanently impaired by physical illness or disability, mental illness, mental deficiency, or alcohol or drug use to the extent that the person lacks sufficient understanding or capacity to execute the powers and duties of the office of President’. This would then be addressed under the powers set out in Section 4 of the 25th amendment of the Constitution.
The Airline Pilot Model
In the US, the Federal Aviation Administration (FAA) regulations require airline pilots to undergo a medical examination with an Aviation Medical Examiner every six months to five years, depending on the type of flying they do and their age (every six months over the age of 60). This examination includes comprehensive procedures to evaluate pilots’ psychological health. Certain conditions such as psychosis, bipolar disorder, some types of personality disorder and substance abuse automatically disqualify a pilot from obtaining an FAA medical certificate. See Annex for details of the assessment and how the FAA encourages pilots to seek help if they have a mental health condition. Most conditions, if treated, do not disqualify a pilot from flying (only 0.1% of medical certificate applicants who disclose health issues are denied).
The position of airline pilots is different from that of a head of state: an airline pilot is employed within a management structure; they are not at the top of the hierarchy; and they are not working in a system in which there are political opponents intent on undermining their position. However, if we accept the need for assurance of a basic level of mental capacity for pilots who have the lives of several hundred passengers in their hands, it seems reasonable to require regular assessment of those who hold responsibility for decisions which may result in the deaths of millions or even billions of people and widespread destruction of the global environment.
Previous related work
Lord Owen’s book, In Sickness and in Power, examines illness in heads of government during the last 100 years and sets out the case for mandatory public independent medical assessments of heads of governments after they have taken office.
Building on the work of Owen and Davidson Jean-Paul Selten proposes seven diagnostic criteria for the hubris syndrome while pointing to the practical difficulties in examining their validity and reliability. The proposed diagnostic criteria are:
- A syndrome characterized by a personality disturbance that represents a change from the individual’s previous characteristic personality pattern and has been present for at least three months.
- The personality disturbance meets the criteria for a personality disorder, except the onset in late adolescence or early adulthood.
- The personality disturbance has developed after achieving overwhelming success or gaining considerable power.
- The personality disturbance is characterised by the emergence or marked increase of pathological traits within the domains of dissociation and disinhibition.
- The pathological trait(s) within the domain of dissociality include grandiosity: believing that one is superior to others; self-centeredness; feelings of entitlement; condescension toward others.
- The pathological traits within the domain of disinhibition are one or more of the following: impulsivity, irresponsibility, recklessness, and lack of planning.
- The disturbance is not accounted for by another mental or behavioural disorder and is not a pathophysiological consequence of a health.
In a book published in 2017, The Dangerous Case of Donald Trump, 27 psychiatrists considered the threat posed by the President as evidenced by his behaviour and public pronouncements. They recommended that an independent, nonpartisan panel of mental health and medical experts be convened to evaluate the President’s ability to fulfil his responsibilities.
A paper published in 2023, ‘Mental health-related limitations and political leadership in Germany: A multidisciplinary analysis of legal, psychiatric and ethical frameworks’ points to studies that highlight associations between severe mental disorders and poor decision making, diminished cognitive function and worse role outcomes. It acknowledges the importance of analysing functional capacity and suggests that ‘together with a symptom-based diagnosis, measuring severity and functional capacity may shape clinical, legal, and political responses.’ The paper proposes a tool such as the Mini-ICF-Rating for Mental Disorders, which assesses capacity based on role responsibilities across 13 traits related to functional capacity. The paper points out that identifying possible mental illness should not exclude an individual from office but should prompt additional assessment about severity and likely impact on the responsibilities of the role.
Conclusion
Nuclear deterrence is a theory, a social construct that is capable of failure. It may change from being a theoretical strategy designed to keep the peace into an historic act of destruction of inconceivable magnitude on human life and life-support systems on our planet. While we continue to work towards the elimination of nuclear weapons, it is vital to address factors that could make nuclear war more likely. Lack of mental capacity in those with power to initiate nuclear war is one such factor which this paper seeks to address by raising awareness of the need for a periodic review of the mental capacity of leaders of nuclear-armed states.
Richard Lawson
Rosemary Field
14 April 2025
Annex
Pilot Medical Certifications and How Mental Health is Assessed
The FAA’s regulations require airline pilots to undergo a medical examination with an Aviation Medical Examiner (AME) every six months to five years, depending on the type of flying they do and their age. Aviation Medical Examiners are trained to determine the pilot’s mental health and fitness to fly.
Before this medical examination, pilots are required to report any health professional visits during the previous three years, all medications being taken, and other medical history on their medical application form. This form includes questions about mental health. During this examination, pilots must disclose all existing physical and psychological conditions and medications.
Based on the answers on the form and the examination, an AME may ask further questions about mental health conditions or symptoms.
The AME can request additional psychological testing or defer the application to the Office of Aerospace Medicine if he or she is concerned that further evaluation is necessary.
If the FAA receives information from another source that a pilot may have a mental health condition, the Office of Aerospace Medicine can direct the pilot to provide specific documentation and/or a psychiatric and psychological evaluation from a mental health care professional, in order to make a determination about the pilot’s suitability for certification.
If a pilot experiences an incident that appears medically related, the FAA will request additional medical information.
The Federal Aviation Administration encourages pilots to seek help if they have a mental-health condition since most, if treated, do not disqualify a pilot from flying. Only about 0.1% of medical certificate applicants who disclose health issues are denied. However, certain medical conditions automatically disqualify a pilot from obtaining an FAA medical certificate or defer the issuing of a certificate:
- attention deficit disorder
- bipolar disorder
- personality disorder
psychosis
- substance abuse
- substance dependence
- suicide attempt.
A More Peaceful World 