BOOK REVIEW / National health disservice: When illness strikes the leader - Jerrold M Post & Robert S Robins: Yale pounds 19.95

ALTHOUGH Britain and the United States are both fortunate in being led by comparatively young, seemingly healthy men, youthful leaders are the exception rather than the rule. William Pitt the younger became Prime Minister at 24. Today high status and supreme power are seldom attained before late middle age, and countries throughout the world have suffered grievously because their rulers have been sick, senile, alcoholic or affected by drugs.

Some of the examples quoted in this book are familiar. Many people will know that Churchill was intermittently incompetent for some years before his final retirement because of arteriosclerosis exacerbated by alcohol and barbiturates. Anthony Eden's lack of judgement in the Suez fiasco can be attributed to his taking large doses of amphetamine. Hitler's paranoid attacks of rage and inability to recognise the reality of defeat may have been due, in part, to his quack doctor, Morell, prescribing for him no less than 73 different medicines. In 1989, Deng Xiaoping, aged 84, ordered troops to fire on unarmed students protesting in Tiananmen Square. The massacre which followed ensured that Deng will go down in history as a monster. Would he have taken such a decision if he had been 30 years younger?

It isn't always a case of those who are past it hanging on to power. Rulers are surrounded by advisers who may conspire to conceal the degree of the ruler's incapacity because their own jobs depend upon his remaining in office. This is especially the case in presidential systems and dictatorships in which most political appointments depend upon patronage, but parliamentary systems are also vulnerable. Physicians attending the great often face the ethical dilemma that what is best for the patient may not be best for the country. Churchill was advised to retire by a consultant neurologist in 1949, after his first stroke; but he did not go until 1955 because his personal physician believed it a duty to keep Churchill going in politics as long as possible.

Sometimes leaders are denied the best possible medical treatment because admission to hospital would make public the serious nature of an illness which their Cabinet colleagues wish to conceal. When Eisenhower suffered a coronary thrombosis, his doctor said that he had indigestion and delayed his admission to hospital: the doctor was lucky that his eminent patient survived and that there was no political crisis during Eisenhower's illness.

Confidentiality is a doctor's first duty, but in the case of leaders confidentiality must sometimes be overridden - as it has to be in the cases of alcoholic airline pilots and others whose disabilities could put large numbers of people at risk. It should be obligatory for every leader to sign a document permitting his doctors to disclose and discuss his illnesses with political colleagues.

Now that doctors are so good at prolonging the lives of the elderly, the world will continue to be faced with more and more ageing autocrats whose capacity for doing harm is enormous. Surely the democracies of the world should meet to draw up some ground rules for ridding themselves of leaders who have become incompetent through age or illness. The problem is bound to increase.