‘Is something neurologically wrong with Donald Trump?’ Yes, was Professor James Hamblin MD’s answer after the headline trumpeted in the Atlantic in January 2018. Yet in the election year that followed it was Biden who was being hidden in the cellar while Donald Trump embarked on an exhausting series of campaign rallies, giving largely unscripted bravura performances to his fanatical followers. Meanwhile on the rare occasion when his handlers let him out, Biden stumbled. On one occasion he forgot which state he was in. Shockingly, America’s Democrat-dominated media stayed silent about Biden’s failing health throughout the presidential campaign.

Though even Democratic commentators have noted the decline in 78-year-old Biden’s mental faculties since the election, curiously Hamblin, a staff writer on the Atlantic and a professor of public health at Yale, seems to have gone silent on the subject of presidential health. But nobody should be surprised by Biden’s decline. Cognitive impairment is normal in the elderly.

No decent (or sane) person wants Biden to be senile. But facts must be faced. In the past few weeks President Biden has had some startlingly incoherent moments; on International Women’s Day, having announced female military promotions, Biden forgot the name of his defense secretary or even the place where he worked (the Pentagon). Afterwards when he left the dais, he looked lost. On another occasion when reading from another autocue script he referred to Vice President Kamala Harris as ‘President Harris’; an avalanche of mirthful online memes followed. Then he outdid his online caricature by falling down three times while climbing the stairs to Air Force One. Overall, the current picture of his health is one whose severity goes way beyond Biden’s gaffe-prone history.

In spite of the White House’s assertions of Biden’s good health, both Republicans and Democrats have publicly commented on his apparent mental and physical frailty. As early as last Easter Bernie Sanders’s supporters were promoting the hashtag #WhereIsJoe and questioning his mental state.

Vladimir Putin has even joked about it. Last week Biden remarkably described Putin as a ‘killer’, the sort of remark that, if made by Donald Trump, would have had the liberal press describing the former president as an unhinged maniac. In response a smiling Putin looked at the camera and said, ‘Be healthy. I wish him good health. I say it without irony or as a joke.’ Putin hammered home the point about Biden’s faculties when he later challenged Biden to a debate: ‘to continue our discussions, but on the condition that we do this actually live, online, but without any delay, but right in an open, direct discussion.’

Few close observers now doubt that Biden, the leader of the ‘free world’, has some mental issues. The question is how long can the charade continue? Some two months into office, Joe Biden has so far avoided facing a press conference as president. The pressure to do so has mounted; his first will take place on Thursday March 25., we are told. It will be a testing moment for Biden’s handlers. Can they prep his answers? Will the questions be predetermined? Will he wear an interactive earpiece?

Last week Fox Business anchor Stuart Varney speculated that Biden would use a teleprompter that was capable of producing pre-scripted responses to questions asked in real-time. Conspiracy theories about the upcoming press conference abound; will Biden be given drugs to help him concentrate?

One of the problems with dementia is that decline is not usually linear. Lucid periods can break through moments or longer of obvious cognitive disability. Biden could have a good day on Thursday. But if he fails the press conference test, what then? Apart from impeachment, the only way to remove the President is via Section 4 of the 25th Amendment of the US Constitution ,which was propagated after the assassination of President Kennedy. Section 3 has been used three times in cases of physical incapacity; in 1985 President Reagan handed power to Vice President George Bush when he had colon surgery and President George W. Bush handed over power briefly to Dick Cheney twice when he was sedated for colonoscopies.

But Section 4 has never been used, even though it was widely discussed in relation to removing Trump. The wording is as clear as mud:

When the Vice President and a majority of either of the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the president pro tempore of the Senate and the speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of office the Vice President shall immediately assume the powers and duties of the office as Acting President.’

You wonder whether Joe Biden’s mental health is the subject of daily discussion in the White House. According to Michael Wolff, author of Fire and Fury: Inside the Trump White House, staffers would apparently say things like, ‘We are not at 25th level yet.’ Surely staffers are saying the same things about Biden now. But who is going to pull the trigger? Kamala Harris would be reluctant take the opprobrium of publicly announcing that her boss was out of his mind — particularly when his popularity in the opinion polls is still rising.

You might further wonder what would happen if a cabal of ‘principal officers of executive departments’ wrote their declaration letter and then Biden refused to accept its conclusions. As President Carter wrote in 1994 in the Journal of the American Medical Association, ‘The great weakness of the 25th Amendment is its provision for determining disability in the event that the president is unable or unwilling to certify to impairment or disability.’

The processes of Section 4 are not quick. A declaration letter has to be sent to Congress within four days. At which point Congress is allowed two days to convene and a further 21 days to vote on the mental fitness of the president. Only if the vote to remove the president gains a two-thirds majority would the vice president become acting president. The process sounds messy. Apart from taking almost a month, the US government would have to decide who took decisions in case of an emergency — such as a Chinese attack on Taiwan for example.

It might be simpler for the Democratic hierarchy to sustain Biden in his incapacity, something that might already be happening. Kamala Harris, Nancy Pelosi and Antony Blinken could manage in a triumvirate. Perhaps even the President’s wife Jill, an English teacher, could play a significant part. She might of course decide to spare her husband’s suffering and likely humiliation by forcing him to resign. On the other hand she might take a liking to high office.

Stranger things have happened. After President Woodrow Wilson, upon returning to Washington from negotiations at the Treaty of Versailles in Paris, suffered a severe stroke in October 1918, for the last year of his presidency his wife Edith effectively ruled the United States. The extent of Edith Wilson’s power was such that she has sometimes been described as the first woman president. Jill Biden could be the second; and in theory it could be for the full term.