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What happens when U.S. presidents get sick? History offers clues

President Donald Trump’s coronavirus diagnosis has raised pressing questions about what happens when a president becomes ill in office.

Shortly after 1 a.m. ET Friday, the White House shared a signed memo from Dr. Sean Conley, current physician to the president. In it, Conley confirmed Trump and first lady Melania Trump had tested positive, and suggested that the couple would remain in quarantine at the White House, where they would continue to work. However, Trump was transported to Walter Reed Military Medical Center on Friday after he required supplemental oxygen to boost his blood oxygen level, which can be a sign of severe COVID-19.

“President Trump remains in good spirits, has mild symptoms, and has been working throughout the day,” White House Press Secretary Kayleigh McEnany told reporters at the White House Friday. “Out of an abundance of caution, and at the recommendation of his physician and medical experts, the President will be working from the presidential offices at Walter Reed for the next few days.” (McEnany announced on Monday that she too had tested positive for the virus.)

After a weekend stay, during which he received multiple experimental treatments for the virus, Trump tweeted on Monday that he would be leaving the hospital that evening. Conley cautioned in a news briefing the same afternoon that it would still be days before they could say the president was out of danger.

This isn’t the first time the public has faced whether a president’s health could interfere with their ability to serve their role. Both natural illness and assassinations have placed the nation’s line of succession on shaky ground in the past, and presidential historians agree that the country has been poorly served when leaders chose to conceal their true health status rather than being honest.

The Trump campaign announced that all of the president’s activities will be conducted virtually and at the moment, the vice presidential debate between Vice President Mike Pence and Sen. Kamala Harris is still scheduled for Oct. 7.

The PBS NewsHour contacted presidential and medical historians to learn what protocols Americans might expect to see unfolding in the coming days.

Have we been here before?

While the novel coronavirus is new, historians point to a few standout examples of when a president became ill in the past.

One of the most famous cases of a president’s health drawing national concern occurred in 1919 after President Woodrow Wilson caught influenza during treaty negotiations after the end of World War I, said Barbara Perry, director of presidential studies at the University of Virginia’s Miller Center. Wilson later attempted to conduct a whistlestop tour of the U.S. West to promote the League of Nations and to rally the public ahead of his attempt at a third term in office. During the tour, on Oct. 2, 1919, he suffered a massive stroke and took months to recover.

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While he was bed-ridden, first lady Edith Wilson conducted much of the business of the White House, but there was no true line of succession, Perry said.

Several presidents have tried to conceal their serious medical problems and “it has always been bad for the country,” presidential historian Michael Beschloss said.

The American public needs to know the exact specifics of Trump’s health and if and how that changes in the coming days, said Dr. Howard Markel, a PBS NewsHour columnist who directs the Center for the History of Medicine at the University of Michigan. If presidents become incapacitated or worse, someone needs to be in position to meet the constant flow of demands made on the Oval Office at all times, he said. Markel likened it to be “being on call every day for four years at a hospital.”

“One’s physical and mental health are paramount to that job,” he said.

What happens when presidents get sick?

In 1963, President John F. Kennedy was assassinated. His vice president, Lyndon B. Johnson, was sworn into office, standing next to first lady Jacqueline Kennedy, still wearing a coat stained with her dead husband’s blood.

It’s one of the most extreme examples of when the country has needed to call on a successor on a temporary or permanent basis after a president died or became unable to carry the duties of the Oval Office. Ratified in 1967, the 25th Amendment to the Constitution set up a line of succession and what terms needed to be met for the amendment to go into effect.

But the amendment is too vague and has largely gone unused, said Jeffrey Engel, who directs the Center for Presidential History at Southern Methodist University in Dallas.

“We don’t have a lot of practice with the 25th Amendment,” Engel said. “The most important element of presidents ceding power to their vice presidents historically has been their willingness to do it.”

READ MORE: Presidents get sick and die. What happens next hasn’t always been clear

Since the amendment was passed, presidential historian Michael Beschloss said, it has been used twice by President George W. Bush while undergoing colon procedures in 2002 and 2007. In both cases he temporarily ceded power to Vice President Dick Cheney.

Beschloss argues the amendment is underused.

“It’s been largely a failure because most presidents have been afraid to use it,” he said.

When President Ronald Reagan was shot in 1981, his administration prepared unsigned letters to transfer power under the 25th Amendment, if needed. His wounds were more serious than they appeared, and the president nearly bled to death, Perry said.

History does point to one example of a president being very forthcoming about his health. In 1956, the U.S. was in the middle of the Cold War, and President Dwight D. Eisenhower needed to undergo intestinal surgery. Rather than be tightlipped about the operation, Eisenhower urged his administration and the medical team to tell the press everything (even commenting on his bowel movements), Beschloss said, adding that Eisenhower also faced re-election five months later.

“He knew that Americans felt that their personal security depended on his ability to lead, and he wanted to reassure them that he was able to serve as president,” Beschloss said.

Presidents must be forthcoming with the public about the state of their health and what kinds of treatment they are receiving, he added.

“If you run for president, your obligation is that if you have a life-threatening illness, we have to know all about it.”