When Mortality Is a Matter of State: Medicine, Power, and Truth

Abstract

This article shows how “reasons of state” can sometimes influence end-of-life care decisions made by top politicians. Drawing on Ivan Illich’s concept of “medical nemesis” and the myth of Tithonus and Eos, it argues that the success of medicine in prolonging life can, paradoxically, increase suffering and raise ethical dilemmas, particularly when medicine is used to ensure the continuity of power. Through the analysis of four historical cases—Franklin D. Roosevelt, Francisco Franco, Josip Broz Tito, and François Mitterrand—the article highlights some issues related to the concealment or deliberate manipulation of information about the health of political leaders, invasive and disproportionate medical interventions, and various conflicts that can arise between clinical goals and political objectives. The article then adopts the doctrine of the “king’s two bodies”, revived in contemporary times by Ernst Kantorowicz, to interpret these dynamics as attempts to merge the leader’s mortal body with an eternal political body, generating a dangerous identification that fuels therapeutic excess. By decoupling the natural body from the political body, the study calls for transparent and ethically grounded frameworks capable of balancing privacy, continuity of government, and limits on the use of medical care.

1. Introduction

Ivan Illich, in Medical Nemesis [1], argued that disease, disability, and suffering are more prevalent today than in the past, and that the paradox behind this is the very success of medicine. While medicine has succeeded in combating disease, this success is partial, as it often does not eliminate disease but merely prolongs life in a diseased state. In some cases, however, prolonging life can be undesirable due to suffering, pain, and poor quality of life. Today, people live longer with chronic diseases, terminal cancer, neurodegenerative diseases, and so on. Medical nemesis therefore consists of the fact that, today, disease and disability are more prevalent precisely because the elderly and the chronically ill, i.e., those most afflicted by various diseases, live longer than in the past.

Some cases of excessive prolongation of the terminal phase of life, beyond what should be considered clinically appropriate, echo the condition described in Greek mythology, which depicts the ill-fated love between the goddess Eos and the mortal Tithonus [2]. Having fallen in love with the mortal Tithonus and fearing that she would lose him to death, Eos begged Zeus to grant him immortality. Zeus granted her wish, but Eos soon realised she had made a terrible mistake, because, although she had asked for immortality for Tithonus, she had forgotten to ask for eternal youth for him. Thus, as the years passed, Tithonus grew old, weak, sickly, and frail, to the point of begging for death as a mercy.

If this myth can cause fear in many of us, given that in the future we may be entrusted to the sometimes invasive care of biomedicine, it should cause even more fear in people who hold high public office, as they may be subjected to aggressive, invasive or futile medical treatment for political reasons (for the so-called ‘reason of state’), i.e., for reasons that go beyond good medical practice and sound clinical logic.

The connections between health, medicine, and politics are often far more intimate than is generally acknowledged. Yet, inexplicably, they remain largely unexplored.1 In the past, there have been several attempts to extend the lives of important heads of state beyond all reasonable limits. The death of these individuals would have caused enormous political and social upheaval, as well as posing a great danger to the entire political community, at least in the minds of those seeking to prolong their lives.

The death of an important political leader who has governed the country for many years can cause dangerous power vacuums, bloody internal conflicts, and the collapse of fragile international agreements. The very illness of a leader can give rise to unbridled ambitions on the part of rival leaders or other politicians from various camps. Sometimes the illness and death of a political leader can be kept strictly and jealously hidden from public view, if only to ensure a smoother transition of power. Among the most grotesque cases of concealment of the truth about the health of political leaders are those concerning the final phase of the history of the Soviet Union. The health of Leonid Brezhnev, Konstantin Chernenko, and Yuri Andropov at the end of their lives was shrouded in a thick cloud of mystery. The last case, that of Yuri Andropov, former head of the KGB, who became the new leader of the USSR after Brezhnev’s death in 1982, is emblematic. On 18 August 1983, the 68-year-old secretary of the CPSU received a delegation of American senators and, after this meeting, literally disappeared into thin air. During August, September, and October 1982, no one in Moscow said a word to the Soviets or the world to explain where the leader had gone. It was only at the end of October that Leonid Zamyatin, spokesman for the Soviet government, announced with great seriousness that Yuri Andropov “had a cold”. The cold must have been quite serious, because on 7 November, the leader of the USSR was not seen at the traditional parade on Red Square, an absolutely unprecedented event [6]. Nothing more was heard of him until 9 February 1984, when his death was announced—not from a cold, but from kidney failure, as was later learned from unofficial sources.

In certain cases, information regarding a leader’s illness or terminal condition is deliberately withheld at the request of political actors in his inner circle—sometimes even without the leader’s own awareness, either because he has not been fully informed or because his physical or cognitive state prevents him from comprehending the gravity of his situation. In other cases, it may be the leader himself who wants to hide his condition from the public for political reasons, for reasons of national interest, to safeguard his country’s position on the international stage, or simply because he intends to stand for re-election and fears that bad news about his health could harm his election campaign.

As can be seen, such opaque behaviour erodes public trust in political and medical authorities. Yet it can sometimes be very difficult for healthcare professionals to resist external pressure, which can be intense—particularly, though not exclusively, in autocratic regimes. What is ultimately compromised are the principles of professional ethics and conduct.

Another ethical issue that is often raised in such cases concerns fairness and justice, especially when scarce and expensive resources are used in contexts of great inequality. In low-income countries, heads of state sometimes have access to the highest level of medical care, including at foreign healthcare facilities. The case of Omar Bongo, former president of Gabon, is one of the best known and most discussed. Bongo travelled extensively to various European clinics, accompanied by a large entourage, to undergo costly treatment at the expense of the state, dying of bowel cancer in 2009 at a clinic in Barcelona [7]. Similarly, former Zimbabwean president Robert Mugabe died in 2019 at a clinic in Singapore, where he was receiving specialist treatment not available in his country [8].

2. Case Selection

Among the many case studies available for our reflection on the relationship between medicine, power, and truth, I have selected four that I consider particularly significant. These are cases in which death affected very long-lived leaders, certainly among the longest-lived in the recent political history of their respective countries. In this sense, their deaths constituted an important historical moment, one of great transition and sometimes even of difficulty or danger for their country. It is therefore precisely at such significant moments that political pressure on the medical profession can become particularly strong and therefore worthy of investigation.

The first case we will examine is that of the 32nd President of the United States, Franklin Delano Roosevelt (1882–1945), the longest-serving president in US history and the only one to win four presidential elections [9,10]. Roosevelt led the United States out of the Great Depression and guided the country through the Second World War, making America a global superpower. His illness and death marked one of the most tragic and difficult periods in American history, namely World War II [11]. The discussions surrounding the treatment he received from doctors in the final stages of his life were particularly intense and significant [12].

The second case we will look at is that of Spanish dictator Francisco Franco (1892–1975), the man who dominated Spanish politics from the second half of the 1930s to the mid-1970s [13,14]. Such a long and enduring rule was bound to create serious transition problems, especially as the European and international political context had changed significantly in the final phase of Franco’s regime, pushing Spain towards democratic political and institutional change. The final phase of Franco’s life was therefore greatly influenced by the strong concern of his entourage that his death could open the way to government for politicians not aligned with the regime. When his clinical condition proved to be extremely critical, doctors, under pressure from politicians, carried out highly invasive and aggressive interventions [15] to keep him alive in view of important political deadlines, when certain positions considered strategic for influencing the subsequent evolution of Spanish politics were to be renewed.

The third case we will examine is that of Josip Broz Tito (1892–1980), leader of communist Yugoslavia from 1945 to 1980 [16,17,18]. In the last months of his life, many doubted that his successors would be able to maintain the unity of Yugoslavia, a mosaic state composed of various ethnic groups, cultures, and religions, often in bitter conflict with each other [19,20]. Tito’s personality and charisma had undoubtedly played a key role in preserving national unity despite deep internal divisions, and his death was therefore widely perceived as a harbinger of significant political instability and, in the longer term, the potential outbreak of civil war. All these fears were confirmed by subsequent historical events and the bloody Yugoslav wars that broke out a decade after Tito’s death, leading to the dissolution of Yugoslavia [21]. This helps to explain the pressure that political leaders may have exerted on Tito’s doctors to prolong his life at all costs, at times allowing political imperatives to override clinical judgment. Among the various procedures carried out in the final days of his life was the amputation of his left leg—an operation that, in this context, assumed a powerful symbolic dimension, foreshadowing the future dismemberment that Yugoslavia itself would eventually endure.

The final case I wish to examine is that of French President François Mitterrand (1916–1996) [22,23,24]. This case differs significantly from the previous three. At the time of his death, France was neither embroiled in a major war, as Roosevelt’s America had been, nor undergoing an institutional or regime transition, as in Franco’s Spain, nor facing the gradual descent into civil war, as was the case in Tito’s Yugoslavia. However, Mitterrand certainly has one thing in common with the three previous heads of state: longevity. Mitterrand was the longest-serving president of the Fifth Republic, having completed two full seven-year presidential terms, something that had never happened before him and will never happen again, given that the presidential term in France, for which candidates can only run twice, has been reduced from seven to just five years. Mitterrand’s case is particularly significant for the purposes of this analysis, as he was diagnosed with prostate cancer in 1981, at the very beginning of his first presidential term—a fact that remained concealed from the public for many years, extending well into his second term. This case raises important ethical questions about the tension between two competing principles: the right to privacy, which every individual is entitled to, and the duty of transparency expected of public figures, especially when their health may directly affect national political stability. The knowledge that a presidential candidate is suffering from a serious illness, for instance, could meaningfully influence the outcome of a democratic election.

3. First Case Study: Franklin Delano Roosevelt

The sudden death of Franklin Delano Roosevelt (also known as FDR) on 12 April 1945 was a truly crucial and far-reaching event in American history. FDR became president of the United States in 1933, during the Great Depression that followed the Wall Street crash of 1929. He managed to lead the country out of that great crisis, providing strong and authoritative leadership, with a solid and effective political vision [9,10]. From the early 1940s onward, Roosevelt led the country through an equally challenging and complex historical period—one marked by one of the deadliest and most geopolitically far-reaching wars in human history. In April 1945, when FDR died, the Axis powers had not yet surrendered in Europe, and Japan still maintained significant military strength.

Roosevelt’s health had never been very good. In 1921, at the age of only 39, FDR fell ill with a paralysing disease, which at the time was diagnosed as polio, losing the ability to move and walk without assistance. Despite this disability, with great determination, he managed to climb all the steps of a truly brilliant political career, becoming governor of New York in 1928 and president of the United States in 1933. He was re-elected to office three times, but during his third and fourth terms, his health began to decline rapidly. In 1944, his condition was quite serious, and he often felt weak and fatigued due to heart disease and severe chronic hypertension [25]. In March 1944, Dr. Howard Bruenn, a well-known New York cardiologist, diagnosed him with heart failure and severe chronic hypertension, with a blood pressure of over 200/120 mmHg [26]. These conditions would be easily treatable today, but at that time the only treatment options were rest, diet (sodium restriction) and medication [27], such as digitalis (which strengthens the heart) and sedatives.

Despite these critical conditions, FDR continued to govern and take on demanding responsibilities. His participation in the Yalta Conference in February 1945 is well known. Photographs, along with accounts from Stalin and Churchill, reveal his fatigue, difficulty speaking clearly, and trouble concentrating.

On 12 April 1945, FDR suffered a massive stroke [27], which caused a massive cerebral haemorrhage [27]. Despite signs of irreversible decline, his medical team decided to undertake a series of interventions, including oxygen therapy, intravenous fluids, and cardiac drugs.

In the final stages of his illness, Roosevelt was cared for by his personal physician, Admiral Ross McIntire [28], who also served as Surgeon General of the U.S. Navy. In addition to overseeing the president’s medical care, Dr. McIntire faced the delicate responsibility of deciding how much information about Roosevelt’s condition to share—and with whom. McIntire therefore determined what and how much medical information to share with Roosevelt himself, his family, the US administration, and the public. This gave Dr. McIntire a great deal of power and, at the same time, raised questions about the proper management of that power. Dr. McIntire was bound by a dual duty of loyalty, to the patient on the one hand (as his personal physician) and to the state on the other (by virtue of his military position). Whether McIntire handled this power well and whether he was truly loyal to his patient and to the state is still a matter of heated debate [12,25]. To understand the extent of McIntire’s power, suffice it to say that not only the public, but even Congress and Vice President Truman were not fully informed of the president’s health [12,25]. The fact that Roosevelt himself, his aides, and the highest political authorities did not have all the medical information at that juncture was a very serious problem [12,25]. Roosevelt was the repository of extremely sensitive and confidential information regarding war strategies, delicate diplomatic negotiations, and the progress of the atomic bomb programme. Clearly, were the president’s life not in jeopardy, disclosing such information during wartime would pose serious risks, including leaks or espionage. However, if his condition were indeed critical, it would be essential to inform the highest levels of the administration—under strict secrecy—to ensure continuity of government and political leadership. Finally, FDR’s election to a fourth term might also have turned out differently if the public had been adequately informed of his health condition [12,25].

4. Second Case Study: Francisco Franco

Francisco Franco ruled Spain from the end of the Civil War in 1939 until his death in 1975 [13,14]. His passing marked a pivotal turning point in Spanish politics and society, initiating a profound process of political and institutional transition. Unsurprisingly, the final stage of his illness was marked by intense tensions and competing interests—both from those seeking to delay the transition and from those eager to accelerate it.

From the late 1960s onward, Franco’s health steadily declined due to multiple organ failure, cardiovascular disease, Parkinson’s disease, gastrointestinal disorders, and other chronic illnesses. In the final months of 1975, his condition worsened rapidly, requiring intensive and invasive medical care. The multidisciplinary team responsible for his treatment included some of Spain’s most renowned surgeons, cardiologists, nephrologists, and pulmonologists, led and coordinated by Dr. Vicente Gil. Consultations on Franco’s health, the treatment to be undertaken, and the information to be released involved both medical and political authorities, making the decision-making process very complex. Everything was handled in a climate of poor transparency, reflecting the regime’s desire to have absolute control over the situation and to manage the narrative of Franco’s illness, even resorting to vague or misleading medical bulletins.

Franco’s final days were characterised by aggressive medical interventions which could be described as futile care, prolonging his suffering [15,29]. The medical team, alongside politicians in contact with them, aimed to keep Franco alive until November 26, when a series of strategic political appointments—crucial for the future election of the President of the Government—were set to be renewed.

In early November, Franco suffered acute gastric haemorrhage and underwent a gastrectomy. He then developed severe cardiac arrhythmia and renal failure, compounded by severe respiratory distress and multiple organ dysfunction. He suffered a series of cardiac arrests, followed by resuscitation with cardiac massage and electric defibrillation. The renal failure was treated with peritoneal dialysis. He also developed a form of recurrent pneumonia that caused respiratory failure, which was treated with respiratory support, tracheal aspiration, and repeated bronchoscopies. He underwent multiple surgeries: gastrectomy, drainage of fluid accumulations, and surgical attempts to control gastrointestinal bleeding. He received massive blood and plasma transfusions. He was given various medications, including antibiotics, corticosteroids, and cardiotonic drugs (digitalis) [15,29]. On 19 November, his entourage and family finally decided to disconnect Franco from the machines that were keeping him alive artificially [30]. On 20 November 1975, Franco was pronounced dead.

5. Third Case Study: Josip Broz Tito

Josip Broz Tito was first the architect and later the leader of the Socialist Federal Republic of Yugoslavia [16,17,18], a federation formed in 1945 after World War II, composed of six republics (Slovenia, Croatia, Bosnia-Herzegovina, Serbia, Montenegro, and Macedonia) and two autonomous provinces (Vojvodina and Kosovo). It was therefore a mosaic country, in which three main religions were professed: Catholicism, Orthodox Christianity, and Islam. These religious denominations often intertwined with the various national cultures, sometimes taking on nationalistic contours and coming into conflict with each other. The official languages spoken in Yugoslavia were Serbo-Croatian, Slovenian, Macedonian, and Albanian, but there were also unofficial languages such as Hungarian and Bosnian. There were two alphabets: Latin and Cyrillic. Such a mosaic of states, ethnic groups, religions, and cultures, which had often been in conflict and fought each other throughout history, could hardly have lasted without the presence of a strong leader such as Tito [19,20,21]. For this reason, Tito was the subject of a veritable process of mythologisation and personality cult, through the widespread dissemination of his image throughout the country, but also through ceremonies, songs, poems, and novels devoted to him [31] (p. 323). A nursery rhyme from Tito’s time defined Yugoslavia as follows: “six states, five nations,2 four languages, three religions, two alphabets, and only one Tito” [32] (p. 35).

Tito was born in 1892 and, when admitted to a hospital in Ljubljana in January 1980, he was approaching his 88th birthday. His condition was serious, as he had long suffered from diabetes and arteriosclerosis, with more recent complications including peripheral vascular disease and severe circulatory problems [16,33,34]. When an artery in his left leg became blocked, resulting in tissue necrosis, infection, and sepsis, doctors decided to amputate the limb [16,34,35]. Despite the amputation, Tito’s condition continued to deteriorate as the infection and sepsis progressed. In the days following the operation, multi-organ failure, renal dysfunction, and respiratory complications developed [16,34,36]. The doctors intervened with dialysis, mechanical ventilation, antibiotic therapy, and various supportive therapies, despite the underlying pathophysiology being irreversible [16,34,37]. Vascular surgery was also performed to improve blood circulation [16]. He underwent prolonged intensive care for several months [36,37].

In this case, as in the previous case of Francisco Franco, we are faced with interventions that, according to current standards, could be defined as futile, invasive, or even aggressive. The autopsy results also confirmed the aggressive nature of the medical interventions performed. The pathologists who examined Tito’s body were very struck by the seriousness of his physical condition at the time of his death: his body was severely compromised, with damaged organs and clear signs of prolonged suffering [16,37].

From the reports, it is not clear what Tito’s wishes were and how aware and informed he was of his situation. It appears that he had opposed the amputation of his leg and that the doctors had decided to proceed only after he had lost consciousness. The decision-making process regarding his care was certainly shared between the medical team and political advisers. The whole affair was handled in an atmosphere of great secrecy, tension, and uncertainty [16].

In this case, as in the previous ones, there is a conflict between the goals of medicine—alleviating suffering and preserving dignity in dying—and the goals of politics, which clearly differed from those of good medical practice. One political objective in this case was to portray Tito as a strong, indomitable leader, capable of fighting even against illness and death, thus helping to fuel his cult and promote his mythologisation. A second political objective was to preserve the stability and unity of the nation, which saw Tito as its linchpin. A third objective was to lengthen the transition period in order to build a new leadership that could provide a sense of continuity and control in a period of great uncertainty. Finally, the politicians closest to Tito, those who had benefited most from sharing his power, may have feared losing their influence in the transition process.

6. Fourth Case Study: François Mitterand

François Mitterrand was President of the French Republic for two terms, from 21 May 1981 to 17 May 1995 [22,23,24]. He died on 8 January 1996. Eight days after his death, his personal physician, Dr. Claude Gubler, decided to publish a book entitled Le Grand Secret [38], written together with journalist Michel Gonod, through Plon publishers. In this book, Dr. Gubler made a sensational revelation, namely that President Mitterrand had been suffering from locally advanced prostate cancer since his first election as President of the Republic in 1981. The content of the book was previewed, even before its publication, in an article that appeared in Le Monde on 10 January 1996 [39], which was soon picked up by the American press [40,41].

Gubler’s account reveals that Mitterrand underwent medical tests following back a leg pain that prevented him from climbing stairs and playing tennis. Even at the funeral of Egyptian President Anwar al-Sadat on 10 October 1981, Mitterrand showed some difficulty in moving, dragging one leg slightly. On the advice of Dr. Gubler, on Saturday 7 November 1981, Mitterrand underwent a scintigraphy scan under a false name at the Val-de-Grâce military hospital. The results of the examination showed the presence of prostate cancer with bone metastases. The prognosis was rather worrying: 50% of people in Mitterrand’s condition were statistically destined to die within a maximum of three years of diagnosis (sometimes even within a few months). According to the statistics, only one in ten patients survived for ten years or more [41]. Fortunately for Mitterrand, he ended up in that latter 10% with the highest survival rate, but this fortunate outcome could obviously not have been predicted at the time of diagnosis.

Upon hearing the news, the president instructed his doctor not to disclose anything about it. Only the president’s family, his mistress Anne Pingeot, and the politicians closest to him—Jacques Attali, Pierre Bérégovoy, and André Rousselet—were informed. In addition, at the president’s request, the doctor was to publish reassuring (and misleading) health bulletins, without any mention of the cancer, in order to protect the national interest and France’s image.

Immediately after the diagnosis, Mitterrand underwent radiotherapy to destroy the cancer cells and hormone treatment to prevent them from reforming or, at least, to slow their growth. All the syringes and materials used were destroyed by Dr. Gubler with the utmost discretion once the treatment was over. The team caring for the president was composed of individuals bound by the strictest secrecy. The president’s health was considered a “state secret”. Consequently, Dr. Gubler used the term “sciatica” instead of “cancer” in his statements.

The treatments proved effective. From 1984 onwards, the president recovered fairly well from his illness, although he was forced to take medication every day. This improvement prompted him to run for a second term in the 1988 elections, a decision he made on his own, without consulting his doctors.

The cancer returned in 1990, to the point that the American magazine Time wrote an article with a rather eloquent title (France: Mystery Malady [42]), a few months after Mitterrand’s visit to US President George Bush.

On 11 September 1992, the president underwent endoscopic resection surgery at Cochin Hospital and the disease was made public, with the (false) addition that it had just been discovered. In July 1994, Mitterrand underwent further surgery and a series of radiotherapy sessions. The last year of his presidential term, 1995, was particularly painful for the president, who was only able to carry out his duties thanks to strong painkillers.

Dr. Gubler’s book sparked a wide debate and an intriguing legal dispute, which is certainly worth summarising, even if only briefly.

On 18 January 1996, the Paris Court of First Instance, at the request of the family, issued a precautionary order against the publisher Plon, prohibiting the distribution of Dr. Gubler’s book for alleged breach of medical confidentiality.

On 5 July 1996, Dr. Gubler was sentenced to four months’ imprisonment, suspended, for breach of professional secrecy and suspended from the medical profession for one year.

On 14 December 1999, the French Court of Cassation definitively upheld the ban on the publication of the book.

On 18 May 2004, the European Court of Human Rights in Strasbourg, while recognising the legitimacy of the emergency order prohibiting the distribution of the book, nevertheless rejected the justification for the “indefinite” ban on its distribution. According to the Court, the ban on publishing information of significant public interest had to be justified by a “real and immediate risk”, not by mere retrospective concerns about privacy or reputation. For this reason, the Court held that, nine months after the precautionary measure, the public interest in the free circulation of ideas had become paramount.3

As can be seen, the Mitterrand case is more recent than the other three we have discussed. A major difference from those earlier cases is the presence of the Internet, which did not exist during the times of Roosevelt, Franco, and Tito. This factor played a significant role in the Mitterrand case, as the online dissemination of content made it much harder to keep certain secrets than in the past. In this particular instance, a cybercafé in Besançon published Dr. Gubler’s text online, despite the ban on its printed distribution. This sparked an important debate in France and beyond about freedom of expression on the Internet and the applicability of print bans to web content.

7. Conclusions

7.1. The King’s Two Bodies

In the 16th century, the Elizabethan jurist Edmund Plowden coined the doctrine of “the king’s two bodies” [43], according to which the king possesses both a natural, human body—subject to corruption, death, and old age—and a political body, which is immaterial, invisible, and therefore free from childhood, old age, and all the limitations and frailties to which the natural body is subject. This doctrine is based on certain medieval theological elaborations concerning the nature of Christ and the mystical body of Christ.

This doctrine of the king’s two bodies was revisited in the 20th century by Ernst Kantorowicz in his book The King’s Two Bodies: A Study in Medieval Political Theology [44]. As Kantorowicz shows, the doctrine served to justify the continuity of the state, particularly during transitions of power. After the king’ death, there was an apparent power vacuum and a disruption in the continuity of governance until a new king was crowned. To prevent this problematic interruption, the concept of the king’s mystical body—which never dies—was developed.4 By passing from one king to another in a virtually unbroken succession, this body encapsulates the essence of sovereignty and royal authority. When a king dies, the political body is transferred from his natural body—now lifeless and stripped of royal dignity—to another natural body. We are therefore dealing with a legal fiction: the idea of a “fictitious person”. This concept proved immensely influential in subsequent eras and gave rise to a series of related notions that remain relevant today. Consider, for example, the idea of the “legal person”, a concept we frequently encounter and one that is a direct offshoot of the doctrine of the king’s two bodies. Kantorowicz perceptively defines this legal fiction as a “mystical fiction” with theological roots, which was adapted by English jurists of the Tudor era into the myth of the state [45,46].

The distinction between the king’s two bodies also provided a framework for justifying revolutions, allowing one to claim that they were “fighting the king to defend the king”. The execution of Charles I Stuart on 30 January 1649 can thus be interpreted as a sentence carried out on the king’s natural body in order to preserve the political body. Likewise, the theory of the king’s two bodies conceives the political body not only as a head but also as many limbs or parts that interact with one another, yet may also come into conflict. Sometimes other members of the political body, such as Parliament or the high court of justice, may come into conflict with the person of the king if he is an obstacle to the political body. In such cases, the high court of justice or Parliament could take on the task of embodying royal authority, declaring the will of the king, understood as the political body, even against the person of the king, understood as the natural body.5

Kantorowicz published his work in 1957, after the collapse of the Nazi regime. A Polish Jew who had fled Nazi Germany to escape persecution, he used the book’s introduction to express what had been his clear opposition to German National Socialism and its mystical cult of the leader. In doing so, Kantorowicz sought to counter accusations that had been unjustly directed at him following the publication of his earlier work on Frederick II [47], first released in 1927 and later embraced by some within the Nazi movement. In fact, the theory of the king’s two bodies serves as a powerful tool for critiquing the mystical cult of leadership that was central to Nazism. According to the theory of the king’s double body, the mystical cult of the leader constitutes a form of pathological identification between the king’s natural body and his political body—as exemplified by Louis XIV’s famous declaration, L’état c’est moi (“I am the state”). In reality, the state functions properly only insofar as the political body and the natural body remain clearly distinct—that is, when the role embodied by the political body can be seamlessly transferred to successive natural bodies. In this sense, overly long-lasting leaderships are inherently risky, as they increase the likelihood of pathological drift: over time, the political body may collapse into, or become indistinguishable from, the natural body.

The theory of the king’s two bodies thus provides a valuable framework for interpreting the issues explored in this study. It is evident that in both Franco’s Spain and Tito’s Yugoslavia, there emerged a mystical cult of the leader and a corresponding identification between the political body of the state and the natural body of the leader. In these contexts, the attributes of the political body—which, as Plowden notes, is without childhood, old age, or any of the limitations and vulnerabilities to which the natural body is subject—were, whether consciously or unconsciously, projected onto the leader’s natural body. In light of this, the underlying rationale for the aggressive medical interventions and extraordinary efforts to preserve the leader’s natural body—identified eo ipso with the political body—becomes more intelligible.

The case of Tito’s Yugoslavia also highlights the limitations of the doctrine of the king’s two bodies, which originates in theology and does not always translate seamlessly into political theory. In the theological context, the mystical body of Christ is, by definition, eternal. In contrast, the political body of the state cannot appropriately be endowed with such permanence. The political body of the state may outlive the physical body of the sovereign, but it can never be eternal, as it belongs to the realm of the earthly, not the metaphysical. Consequently, there are circumstances in which not only the natural body but also the political body of a leader may be placed in mortal jeopardy. This was precisely the case in Tito’s Yugoslavia during the final stages of his life. His death brought with it the risk of civil war and, ultimately, the potential dissolution of the political body of the state—a risk that materialised a decade later. In Tito’s case, the danger was that the king would be buried with his crown, and that the death of the natural body would be accompanied by the death of the political body.

In Francisco Franco’s case, the risk of complete state fragmentation was perhaps less acute, although Spain was marked by centrifugal forces—many of which persist to this day—that his nationalist regime suppressed with an iron fist. Franco’s case, however, highlights another important dimension: the political body is never purely abstract or formal. It always possesses concrete, material characteristics. The authoritarian, autocratic, and nationalist political body envisioned by Franco and his supporters was fundamentally different from the political body that, given the new international context, was likely to emerge after his death—one that ultimately set Spain on the path towards democratisation. Even in Franco’s case, then, the death of the king signified the death of the political body—but only of that particular form of political body. For some, this prospect was deeply unsettling, which likely explains the effort to prolong his agony for as long as possible.

The cases of Roosevelt and Mitterrand are fundamentally different, as their deaths did not mark the end of the state or of that particular form of government. However, in both instances, their leaderships were among the longest in the recent history of their respective countries. Moreover, in each case, their extended tenures were followed by reforms designed to prevent the emergence of similarly long-lasting leaderships in the future. In the United States, prior to Roosevelt, no president had served more than two terms, following an established convention rooted in the precedent set by George Washington, the nation’s first president and founding father. Franklin Delano Roosevelt broke this unwritten rule—a move made possible by the extraordinary circumstances of his time and the fact that the two-term limit was a tradition rather than a legally binding restriction.

Much the same can be said of Mitterrand. No one before him had completed two full seven-year presidential terms during the Fifth Republic. Only Charles De Gaulle, before him, was elected for two terms, but did not complete his second term due to his early resignation.

In both cases, the long leaderships of Roosevelt and Mitterrand were followed by reforms designed to prevent similarly long tenures in the future. In the United States, the two-term limit became a formal legal restriction rather than merely a customary practice. In France, during the presidency of Jacques Chirac—Mitterrand’s successor—a constitutional law reduced the presidential term from seven to five years, also introducing the two-term limit.

It would be nice to think that the underlying rationale behind these reforms was to preserve a clearer distinction between the natural body and the political body, thereby preventing potential pathological drifts, forms of mystical leader worship, and dangerous conflations between the state and the individuals who embody its leadership at a given moment in history.

7.2. The Case of Illness or Incapacity of the Head of State

The cases we have examined all involve the handling and public communication of a head of state’s serious illness in ways that raise significant ethical concerns. Analysing these instances offers valuable insight into the standards that could be adopted in the future to manage similar situations more ethically.

One key theme emerging from the cases examined is the strong influence exerted on doctors by political power—whether directly by the leader himself, as in Mitterrand’s case, or indirectly through the leader’s entourage when the leader is incapacitated, as seen with Franco and Tito. Roosevelt’s case, however, presents a different dynamic: the doctor, wielding not only medical but also military authority—particularly during wartime—held sufficient power to influence the political authorities themselves.

In light of these examples, there is a clear need to guarantee the independence and neutrality of doctors, who should not serve merely as personal physicians subject to the leader’s authority. Nor should they be vulnerable to influence from the leader’s political entourage in cases of incapacitation. Ideally, the leader’s health and related information would be managed by an independent, multidisciplinary commission. Some members of this commission could be appointed by the leader as trusted advisors, while others should be selected by Parliament or the highest judicial authorities. The commission should include representatives from various medical specialities, including psychiatry, as well as bioethicists and legal experts. Their expertise would be invaluable in addressing issues of privacy and the public’s right to information relevant to the life of the state, particularly when disclosure of the leader’s health status becomes necessary.

The commission’s medical evaluations and reports should be conducted regularly, for example, every six months, with increased frequency in cases of ongoing illness, surgery, or other significant health events. Information considered to be in the public interest —and not protected by privacy laws—could be published online on the official websites of the relevant institutions.

Parliament should define as precisely as possible a (not necessarily exhaustive) list of medical and psychological conditions that constitute a state of incapacity or manifest incapacity, based on medical, psychological, cognitive, and behavioural criteria. The commission would also be responsible for promptly reporting any suspected incapacity to Parliament.

The fact that there are rules dictated by Parliament, but that, at the same time, these rules can be interpreted, from time to time and depending on the circumstances, by a commission, constitutes, in my opinion, the most balanced solution to the problem we are facing. In exceptional situations (for example, during a war), in fact, certain information regarding the leader’s health, which in normal circumstances should be made public, could remain confidential, for important reasons of state. As the philosopher Paul Ricoeur often repeated, however, there must also be a rule for exceptions to the rule, otherwise we risk absolute arbitrariness. In this case, the exception to the rule would arise from a consensus within a highly authoritative commission, democratically chosen, representing the most diverse skills and responsibilities, and not from the unquestionable judgment of a single doctor, as in the case of Roosevelt, of the leader himself, as in the case of Mitterrand, or of a group of regime politicians, as in the case of Franco or Tito6.

7.3. Futile Medical Treatment of Political Leaders, Advance Treatment Directives, and the Appointment of Trustees

In the cases of Francisco Franco and Josip Broz Tito, and to some extent Franklin Delano Roosevelt, we observe instances of futile medical care—that is, useless or even aggressive medical treatment. Such approaches contradict well-established principles of medical ethics, which have guided professional conduct since its inception. The Hippocratic Oath [48] includes the physician’s promise to do no harm, a commitment further affirmed in the first book of the Epidemics by the Hippocratic School [49] (p. 94). This is also the source of the well-known Latin maxim primum non nocere, which formulates what is now referred to in bioethical literature as the “principle of non-maleficence” [50]. The commitment not to harm therefore also includes a promise to avoid futile medical care and unreasonable therapeutic obstinacy. But what exactly does futile medical care entail? Broadly speaking, it refers to the stubborn and disproportionate continuation of ineffective medical treatments that may cause the patient significant suffering without offering reasonable clinical benefits or improvements in quality of life. However, this is a general definition that can be applied quite differently depending on the specific case. What constitutes an ineffective treatment that causes serious suffering? The severity of suffering, after all, depends on the individual patient’s ability to endure it. What may constitute excessive suffering for one person may not be perceived as such by another. The same applies to what is considered disproportionate or ineffective treatment. Medicine is a probabilistic and statistical science; the effectiveness of a treatment is often expressed in percentage terms rather than absolutes. For some patients, even a 10% chance of success may be meaningful—worth pursuing despite pain or discomfort. For others, by contrast, a treatment with only a 10% probability of effectiveness may be deemed futile, particularly when weighed against significant side effects.

Futile medical care, therefore, cannot be defined in general or abstract terms; it must always be assessed on a case-by-case basis [51], taking into account the patient’s clinical condition at a given moment and, above all, their personal wishes, tolerance for treatment-related discomfort, and other individual factors.

In light of these considerations, it becomes clear how valuable it would be for physicians to have prior instructions directly from the patient, especially in anticipation of potential future incapacity. In the cases of Francisco Franco, Josip Broz Tito, and Franklin Delano Roosevelt, key decisions—particularly during the final stages of their decline—were made without their knowledge or involvement, as they were no longer capable of participating in the decision-making process. For this reason, individuals with such high levels of responsibility should be encouraged to prepare advance treatment directives to guide physicians in acting according to their wishes, even in the event of incapacity. While it is true that such documents cannot anticipate every possible scenario and can never be entirely exhaustive, this limitation can be addressed by allowing the patient to designate a trustee—a trusted individual—who can consult with medical professionals to interpret the patient’s wishes when the directives are unclear or incomplete.

This would also avoid political pressure aimed at keeping the patient alive against their interests and wishes for political purposes or for the benefit of those around them or their political party.

7.4. The Extraordinary Nature of the Allocation of Medical Resources for Political Leaders in Exceptional Historical Situations

In the first part of this article, we cited well-known examples of unjust medical privileges improperly enjoyed by certain political leaders. One such case is that of Omar Bongo, who travelled to costly private clinics in Europe with a large entourage—expenses covered by the public coffers of a state where the population was, and still is, suffering from extreme poverty and hunger.

Beyond these cases—which are rightly condemned—it is important to consider whether, in certain exceptional circumstances, disparities in the medical treatment of high-ranking political leaders might be justified when their survival serves the general public interest, particularly during periods of national crisis or institutional fragility. There is, without doubt, a fundamental distinction between a leader who benefits from unjust privileges and one whose preservation is deemed essential for the stability and continuity of the state. Often, in a situation of danger to society, healthcare resources are allocated as a priority to categories that are essential to dealing with the dangerous situation. During the COVID-19 pandemic, for example, the vaccine was offered on a priority basis to healthcare workers in many countries, not because they were a privileged caste, but because they represented a category whose role was essential in dealing with the pandemic. In this sense, their health and survival embodied a more general social interest.

In a famous 1970 article entitled Who Shall Live When Not All Can Live? [52], James Childress explored the moral and practical issues surrounding the equitable distribution of scarce medical resources, particularly life-saving resources such as dialysis and organ transplants. In this article, Childress rejects the idea that scarce medical resources can be distributed on the basis of the social contribution that people can make, according to a utilitarian logic. According to Childress, such an allocation method would reduce the individual to their social role, leading to injustice and discrimination.

Following an opposite, egalitarian logic, Childress proposes adopting random resource distribution systems (a lottery or the “first come, first served” rule) in order to preserve human dignity, equality of opportunity and the relationship of trust between doctor and patient. Yet even in Childress’ strictly egalitarian perspective, some reasonable exceptions are allowed, including the need to save a head of state while his country is at war or facing a dramatic crisis:

In the framework that I have delineated, are the decrees of chance to be taken without exception? (…) The direction of my argument has been against any exceptions, and I would defend this as the proper way to go. But let me indicate one possible way of admitting exceptions while at the same time circumscribing them so narrowly that they would be very rare indeed.

An obvious advantage of the utilitarian approach is that occasionally circumstances arise which make it necessary to say that one man is practically indispensable for a society in view of a particular set of problems it faces (e.g., the President when the nation is waging a war for survival). (…) We depart from chance in this instance not because we want to take advantage of this person’s potential contribution to the improvement of our society, but because his immediate loss would possibly (even probably) be disastrous (again, the President in a grave national emergency) [52] (p. 353).

Therefore, the prioritisation of public resources to save the president during particularly critical moments for the state is not justified solely by utilitarians—who assess actions based on their overall societal consequences according to a consequentialist logic. Even the most rigorous egalitarians, such as Childress, acknowledge that such preferential treatment may be acceptable in extreme and exceptional circumstances. But—I would add —if this privilege, granted to the President, were to become too broad, it would have negative implications for the essential distinction between the natural body of the leader and the political body of the state, as previously discussed.