In international relations theory, realists generally follow the rational choice or national actor with the assumption that states and their leaders make policy on the basis of calculated self-interest. They follow a utilitarian and pragmatic philosophy in which "decision makers set goals, evaluate their relative importance, calculate the costs and benefits of each possible course of action, then choose the one with the highest benefits and lowest costs" (Goldstein and Pevehouse 127). Individual leaders will have their unique personalities, experiences and psychological makeups, and some will be more averse to risk than others, but essentially they all follow a rational model of policymaking. American presidents are generally skilled politicians as well or they would never have achieved such high office in this first place, and this means that their rational calculations will always include public opinion, the needs of their electoral coalitions and the wishes of various interest groups. On the other hand, IR theorists must necessarily raise the question "to what extent are national leaders (or citizens) able to make rational decisions in the national interest" (Goldstein and Pevehouse 129). Some leaders may have health issues that affect their physical and mental capacity and ability to make decisions, such as Woodrow Wilson after his stroke in October 1919 or Franklin Roosevelt and his severe health problems during the last year of his life. Others might be suffering from some severe psychopathology such as paranoia, depression, obsessive-compulsive disorder or borderline personality disturbances. On the foreign policy stage during the 20th Century, Adolf Hitler, Joseph Stalin, Richard Nixon and Lyndon Johnson have been strong candidates for possible psychiatric impairment. All people in high office are likely to have well-developed ideas about history, politics and ideology, and will also have all the normal human tendencies toward wishful thinking, filtering out unfavorable or unwanted information, and making judgments based on emotions rather than reason. In some cases, however, such as Hitler, Wilson, Nixon and Johnson, physical and psychological disability could have severely damaged their rational decision making over time.
When Woodrow Wilson had his stroke in October 1919, the U.S. Senate was considering the Versailles Treaty and whether the United States would join the League of Nations. For Wilson, no other issue of his generation was as vital, for he was convinced that another world war would break out in twenty years if the U.S. did not participate in the new international organization. When the Senate rejected the treaty, all future presidents from Franklin Roosevelt onward derived the lesson that the failure of the U.S. To support the postwar peace settlement did make the Second World War inevitable. Yet at this crucial juncture, Wilson was not only bedridden but at times close to death, and he was never able to walk again. His wife, Edith Galt Wilson, and personal physician Dr. Cary T. Grayson, concealed the true extent of his incapacity from Congress and the public. Had Wilson been in good health, he might have been able to obtain ratification of the Versailles Treaty with some reservations, but in this condition, hardly able to speak, write or move, "his capacities became compromised by the interaction of his physical illness, his prior personality, and his social and political environment" (McDermott 46). Many bureaucracies could function on their own, basically on automatic pilot, but this was not true of the State Department and foreign affairs in general, which "needed more executive leadership and decision making than they received" (McDermott 47). Instead, Edith Wilson and Dr. Grayson were running the White House, with the intention of protecting the health and public image of the president. They did not even show him all of the documents and information that a healthy and active chief executive would be expected to study and absorb, and they also forged his signature on legislation, memoranda and executive orders, to avoid overtaxing his strength. In reality, Wilson was no longer able to function as president, but Edith Wilson and Dr. Grayson decided on their own that the office should not be turned over to the vice president.
Adolf Hitler's entire political career was decided to overturning the Versailles Treaty and establishing a new Germanic empire that would dominate Europe, and perhaps no other world leader in history has been as subject to speculation about whether physical and psychological illness affected his rational decision-making capacity. That Hitler was a cunning and ruthless politician and diplomat is beyond doubt, but he also seemed to have a certain mania for destruction and, ultimately, self-destruction. No written evidence exists today from any psychologist or psychiatrist who actually examined Hitler, although his political opponents in Germany allegedly had reports from military psychiatrists in the First World War that Hitler was no promoted above private first class because of mental and emotional instability, and that his temporary blindness at the end of the war was a hysterical or psychosomatic reaction rather than caused by poison gas (Waite 350). Other German doctors believed that the physical tremors observed in the last year of his life could have been caused by Parkinson's disease, the amphetamines provided daily by his personal physician, Dr. Theodor Morrell, or perhaps even advanced syphilis that had affected his brain and nervous system. Hitler evidently feared that he might have been contracted the latter in Vienna or during World War I, although his Schick and Wassermann tests for the disease were negative (Waite 254). From a psychiatric viewpoint, Hitler may have been a borderline or schizoid personality, with both neurotic and psychotic symptoms, and his "fantastic view of the world…had very little relationship to external reality" (Waite 359). If his racist and militaristic ideology was based on his own delusions and paranoia, though, these were very widely shared at the time. His obsessions about the Jews and the body of the 'healthy' Aryan Volk are well-known, and psychiatrists have traced these back to his unfavorable childhood circumstances, such as his abusive, alcoholic and authoritarian father and his idealized mother who died of cancer when he was still an adolescent. His hatred of the Jews and other 'non-Aryans' was clearly pathological, and he frequently expressed as desire to kill them with his own hands. As early as 1922, he was on record stating that he would hand all the Jews in Germany and leave their bodies on the public gallows "as long as hygienically possible" (Waite 363).
Two American presidents who have received much of the blame for the debacle of the Vietnam War and Watergate, Lyndon Johnson and Richard Nixon, have also been considered narcissists, paranoids or borderline personalities by various critical observers over the years. Johnson admitted that he was driven over the edge by the protests against the war, by students singing that 'horrible song' of "Hey, hey, LBJ, how many kids did you kill today?," and they by his nemesis Robert Kennedy entering the primaries to unseat him in 1968. Some of his closest advisors like Richard Goodwin thought him paranoid in the clinical sense, and his press secretary Bill Moyers secretly obtained such a diagnosis from a psychiatrist (Heinrichs 30). Like Richard Nixon, he was deeply insecure about his humble background, his lack of an Ivy League education, and all personal slights and hints of disrespect, both real and imagined. Both men were obsessed with their public images, required constant reassurance and approval, and were highly suspicious about the loyalty of even their closest associates. Nixon admitted that one of the reasons he installed the White House taping system that finally destroyed him during Watergate was his fear and distrust of those around him, and that they would all turn on him in the future. They were also obsessed with John F. Kennedy and his "obvious success, wealth, good looks, and…personal skills," all of which they lacked (McDermott 181). In…