No-one hypoxic or hospitalised with COVID-19 should have the power to launch nuclear weapons

President Trump’s failure to delegate authority during his illness is a danger to the world.

President Trump’s illness with COVID-19, part of a severe, ongoing pandemic he has frequently dismissed, is attracting a lot of attention. However one aspect not getting enough attention is the potential effect of illness – any illness – on a person’s capacity to make careful, balanced decisions.

The most consequential decision any human being could make would be to launch nuclear weapons. Such a decision need not be calculatingly deliberate. It could be a fevered misjudgement; as a result of pressured anger clouding judgement during an immediate crisis. It could be made in the mistaken belief of being under nuclear attack as a result of a multipronged cyberattack corrupting nuclear weapon early warning, command and control systems; or in some other combination of human and technical failure, mayhem, madness and illness.

President Trump is one of a very small number of human beings able to launch nuclear weapons on his sole personal authority. He can decide alone to launch nuclear weapons, without consulting anyone. At all times, the ‘football’ – the materials and codes contained in the briefcase that accompanies him everywhere, contains all that he requires to issue an order to launch nuclear weapons. It went with him to the Walter Reed Medical Centre hospital.

Mr Trump’s judgement in ‘normal’ circumstances has repeatedly raised serious concerns, including quite a number among the world’s most prominent of those in the best position to judge – psychiatrists. His male sex, age (74) and obesity put him at high risk of severe illness with COVID-19. It has been reported by his doctor and/or White House chief of staff that Mr Trump has had a high fever, has had reduced oxygen saturation in his blood (indicating significant impairment of lung function) on at least two occasions and that medical imaging has shown pathological changes in his lungs. He has been treated with an experimental monoclonal antibody cocktail, supplemental oxygen, the antiviral drug remdesivir, and dexamethasone, recommended for patients with severe and critical illness and not generally used in mild or moderate cases.

Low blood oxygen (hypoxia) is a potent cause of impaired mental functioning. COVID-19 can involve not only the lungs, but multiple other body systems, including the heart and nervous system. It can directly affect cognitive capacity and mental functioning both acutely and longer term. Medications can also cause side effects, and the more medications are used concurrently, the greater the likelihood of interactions and adverse events. Side effects from most medications are more common among older people. Steroids like dexamethasone can have mental/psychological effects, including anxiety, euphoria, mood swings, and psychotic episodes which can include both manic or more commonly depressive states, paranoid states and acute toxic psychoses.

Sudden deterioration occurring up to around 10 days after illness onset is well known for patients with COVID-19, especially among older individuals. Some develop blood clots in their lungs or other organs, including the brain, causing a stroke. The day President Trump left hospital, his physician advised Mr Trump was not “out of the woods yet.”

No human being is infallible. No human being should have the power to unleash indiscriminate radioactive incineration that would end humanity and most life on earth in an afternoon. Mr Trump retaining control of the US nuclear arsenal during a significant illness associated with low blood oxygen adds an additional, alarming level of risk that puts the whole world in even greater danger of a presidential misjudgement with irreversible, cataclysmic consequences. If Mr Trump has not voluntarily delegated nuclear launch authority during his illness, the cabinet or the Congress should delegate it for him without delay, and then act to remove sole presidential authority to launch nuclear weapons for any president.

A/Prof Tilman Ruff AO is an Infectious diseases and public health physician, co-president of International Physicians for the Prevention of Nuclear War and founding chair of the International Campaign to Abolish Nuclear Weapons (ICAN).

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Tilman Ruff AO is Co-President of International Physicians for the Prevention of Nuclear War (Nobel Peace Prize 1985); and co-founder and founding international and Australian Chair of the International Campaign to Abolish Nuclear Weapons (ICAN), awarded the 2017 Nobel Peace Prize, the first to an entity born in Australia.

A/Prof in the Nossal Institute for Global Health, Tilman was inaugural head of travel medicine at Fairfield Hospital and Royal Melbourne Hospital, vaccines medical director for GSK for Australia/NZ/Oceania, international medical advisor for Australian Red Cross, and inaugural member of the WHO Western Pacific Region Hepatitis B Immunisation Expert Resource Panel.

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