Impaired Decision-Making Capacity in the Elderly King David (c. 1040–970 BCE): Was Hypothyroidism the Underlying Cause? : Annals of Indian Academy of Neurology

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Impaired Decision-Making Capacity in the Elderly King David (c. 1040–970 BCE): Was Hypothyroidism the Underlying Cause?

Mendlowicz, Mauro V.1,2,; Mendlowicz, Victoria3; Ribeiro, Nathália3; Nardi, Antônio E.1; Gekker, Márcio1

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Annals of Indian Academy of Neurology 26(2):p 183-186, Mar–Apr 2023. | DOI: 10.4103/aian.aian_825_22
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On a cold day, nearly three thousand years ago, a carefully choreographed royal audience took place in the royal palace in Jerusalem. The outcome of this audience changed the history of a young, small, and unstable kingdom and, perhaps, of the whole world. The book of I Kings (1: 11–31) describes the events as follows:

11Then Nathan asked Bathsheba, Solomon’s mother, “Have you not heard that Adonijah, the son of Haggith, has become king, and our lord David knows nothing about it? 12 Now then, let me advise you how you can save your own life and the life of your son Solomon. 13 Go in to King David and say to him, ‘My lord the king, did you not swear to me your servant: “Surely Solomon your son shall be king after me, and he will sit on my throne”? Why then has Adonijah become king?’ 14 While you are still there talking to the king, I will come in and add my word to what you have said.”

15So Bathsheba went to see the aged king in his room, where Avishag the Shunammite was attending him. 16 Bathsheba bowed down, prostrating herself before the king. “What is it you want?” the king asked.

17She said to him, “My lord, you yourself swore to me your servant by the LORD your God: ‘Solomon your son shall be king after me, and he will sit on my throne.’ 18 But now Adonijah has become king, and you, my lord the king, do not know about it. 19 He has sacrificed great numbers of cattle, fattened calves, and sheep, and has invited all the king’s sons, Abiathar the priest and Joab the commander of the army, but he has not invited Solomon your servant.20 My lord the king, the eyes of all Israel are on you, to learn from you who will sit on the throne of my lord the king after him.21 Otherwise, as soon as my lord the king is laid to rest with his ancestors, I and my son Solomon will be treated as criminals.”

22While she was still speaking with the king, Nathan the prophet arrived. 23 And the king was told, “Nathan the prophet is here.” So he went before the king and bowed with his face to the ground.

24Nathan said, “Have you, my lord the king, declared that Adonijah shall be king after you, and that he will sit on your throne? 25 Today he has gone down and sacrificed great numbers of cattle, fattened calves, and sheep. He has invited all the king’s sons, the commanders of the army and Abiathar the priest. Right now they are eating and drinking with him and saying, ‘Long live King Adonijah!’ 26 But me your servant, and Zadok the priest, and Benaiah son of Jehoiada, and your servant Solomon he did not invite. 27 Is this something my lord the king has done without letting his servants know who should sit on the throne of my lord the king after him?”

28Then King David said, “Call in Bathsheba.” So she came into the king’s presence and stood before him.

29The king then took an oath: “As surely as the LORD lives, who has delivered me out of every trouble, 30 I will surely carry out this very day what I swore to you by the LORD, the God of Israel: Solomon your son shall be king after me, and he will sit on my throne in my place.”

31Then Bathsheba bowed down with her face to the ground, prostrating herself before the king, and said, “May my lord King David live forever!”

The Old Testament is not considered a historical document although some biblical material may lend itself to historical examination.[1] A foremost example of the latter is the “Succession Narrative” (SN) or “Court History,” a block of biblical text comprising two Samuel 9–20 and two Kings 1–2 book sections that describes how Solomon rather than any of his several elder half-brothers came to succeed their father, King David. It has been proposed that SN was written during the reign of Solomon in the tenth century BCE or shortly thereafter and some recent influential scholarship accepts this text as objectively historiographical.[2] The royal audience that resulted in the anointment of Solomon as the next ruler of the United Monarchy of Judah and Israel is the core of the SN. The young Solomon was only the fourth son in the line of succession, but a series of Game of Throne-like events[3] involving rape, revenge, murder, betrayal, and medical issues led to this very unlikely outcome with unforeseen consequences.

It is our goal to investigate the etiology of the medical and neuropsychiatric symptoms presented by the biblical King David as described in the SN and to determine whether and how they may have influenced King Solomon’s accession to the throne of the United Monarchy. It is our belief that coherent descriptions of medical signs and symptoms may help confirm the historicity of ancient texts otherwise considered by some critics as being of a strictly religious nature.


Michal, the first wife of David and youngest daughter of the late King Saul, was barren and could never generate a royal heir who would have a particularly distinguished dynastic background and a strong claim to the throne. The firstborn son of King David and his most likely successor, Amnon, raped his half-sister Tamar and was murdered in revenge by her full brother Absalom. After being pardoned by King David, the treasonous Absalom engaged in an initially successful palace coup but ended up being killed despite the desperate efforts of the betrayed father to save his life. Solomon himself had an older full brother who died, however, only a few days after birth.

The major challenge the young Solomon had to face was when his surviving older half-brother Adonijah attempted to materialize his aspirations of becoming the reigning monarch even before the approaching death of the ailing King David. With that purpose in mind, Adonijah gathered a large crowd of followers and supporters in a festive celebration at the end of which he was (illegally) proclaimed king. Understanding that the lives of those not aligned with Adonijah were hanging by a thread, the influential prophet Nathan urged Bathsheba, mother of Solomon, to approach the enfeebled King David and remind him of a promise he supposedly made to name Solomon as his successor. While Bathsheba was speaking to the king, Nathan “casually” showed up, joined the conversation, and lent credence to her claims. No such promise is found in the account of David’s life.[4–6] A consistent interpretation would be that the prophet Nathan devised a one-two-punch approach to convince a weakened King David that the latter had made a promise he wasn’t sure he had indeed made. The cunning prophet Nathan had to be familiar with King David’s current level of cognitive functioning to employ such a risky stratagem that might easily backfire. Nevertheless, the plot engendered by the prophet Nathan succeeded, and Solomon was anointed king.


The first medical fact that can be inferred from the section of SN presented above is that shortly before his death, King David was suffering from some form of cognitive fluctuations that was well known, at least to some of his courtiers, and that rendered him vulnerable to psychological manipulation.

A second medical fact can be drawn from another section of the SN (I Kings 2:1–10), where a dying King David advises his anointed successor Solomon. The king mostly orients his son on how to settle scores with King David’s old foes and to reward loyal longtime supporters. Even on his deathbed, the old king displayed an unfailing memory and political shrewdness. This relatively sophisticated performance contrasts with the cognitive impairment displayed by the audience with Bathsheba and Nathan. These observations indicate that the cognitive impairment was not global or that it fluctuated over time, with periods of normality or near normality in between.

A third point that needs to be addressed is the etiology of cognitive fluctuations displayed on occasions by King David. The SN is not a medical report. It describes only facts that are relevant to its historical-religious intents. However, since King David was patently in a bad health condition and that condition had a major impact on the ensuing events, the description of a few highly relevant signs/symptoms was made in the text. The elderly King David was suffering from a generalized feeling of cold and could not get warm no matter how many blankets covered him. His servants had recruited Avishag, the Shunammite, a young woman of exquisite beauty, with the mission of attending to him and lying by his side to keep him warm. The SN makes it clear that despite her attractiveness and although they regularly laid together in the bed, the king, who was renowned for virility in his youth, and the maid had no sexual relations. Ben-Noun suggested that the most probable causes for King David’s hypothermia were dementia, osteoporosis, hyperparathyroidism, and malignancy, with the latter being the most likely diagnosis.[7,8] Additionally, it has been proposed that King David was suffering from autonomic neuropathy,[9] Parkinson’s disease,[10] and major depression.[11,12]

The triad of King David’s signs/symptoms reported in the SN – cold intolerance, sexual dysfunction, and cognitive lapses – however, is more suggestive of hypothyroidism. Cold intolerance, one of the clinical hallmarks of hypothyroidism, a disease with protean manifestations, is found in up to 62.7–78.5%[13,14] of the patients with this disorder. The prevalence of sexual dysfunction in male patients with hypothyroidism is 59–63%.[15] The neurocognitive deficits most often seen in hypothyroidism are not typical of full-blown dementia, but isolated cognitive deficits, such as poorer memory, forgetfulness, slower thinking, reasoning troubles, and specific area dysfunctions,[16,17] are more commonly reported. A recent experimental study identified neurocognitive deficits in working memory and executive functioning in patients with hypothyroidism,[18] confirming the subjective complaints of difficulty to focus referred by up to 21.4% of the patients.[13] According to the principle of parsimony,[19] hypothyroidism could, thus, be the more plausible explanation for King David’s symptomatic triad described in the SN.

Regarding alternative diagnostic hypotheses proposed in the scientific literature, the most likely one to feature this symptomatic triad is Parkinson’s disease[10] or another synucleinopathy, like dementia with Lewy bodies (DLB). Fluctuating cognition with pronounced variations in attention and alertness is one of the four key clinical features of DLB.[20] Sexual dysfunction is very common in male patients with synucleinopathies, who typically present erectile dysfunction, ejaculation problems, and/or anorgasmia. Patients with Parkinson’s disease may also have difficulty maintaining core temperature and can develop hypothermia, due to median preoptic lesions.[21] However, a description of the most characteristic and conspicuous signs and symptoms of Parkinson’s disease (e.g., bradykinesia, rest tremor, or rigidity) and DLB (e.g., recurrent visual hallucinations or REM sleep behavior disorder) is missing from the biblical text, thus seriously weakening the case for the diagnostic hypothesis of synucleinopathy.


Whether or not King David intended to make Solomon his successor, the chain of events that culminated in the intervention made by the prophet Nathan had unforeseen consequences. The bookish Solomon became a highly successful king, something one may rightly doubt his impulsive, violent, or vain elder half-brothers could accomplish.

From the very beginning of his reign, Solomon displayed sound judgment (I Kings 3: 16–28), political adroitness (I Kings 2: 36–46), and even a modicum of necessary ruthlessness (I Kings 2: 29–34). King Solomon also showed remarkable administrative (I Kings 4: 1–16), diplomatic (I Kings 3: 1–2), and negotiating skills (I Kings 5: 1–11). The achievement of economic prosperity, internal stability, and external security allowed King Solomon to engage in the magnificent project that had eluded his predecessor (I Kings 5: 2–4), the building of the Temple of Jerusalem. King Solomon could commit vast material resources (I Kings 5: 1–11), to recruit a large workforce (I Kings 5: 13–17), and secure the technical expertise (I Kings 7: 13-51) needed to complete such an ambitious project in just seven years. After that, Solomon’s star slowly began to wane. External threats (I Kings 11: 14–23) and political unrest (I Kings 11: 26–40) marred the last years of his reign, and after his death, the kingdom split up (I Kings 12: 19–22) and was invaded and sacked (I Kings 14: 25–26).

King Solomon seized a very narrow historic window of opportunity to build the Temple of Jerusalem. It is doubtful whether any of his less-talented elder half-brothers could have accomplished this goal. Without King Solomon’s remarkable political, managerial, and diplomatic skills, there would probably be no Temple of Jerusalem. Without the Temple of Jerusalem, Judaism might not have established itself as an institutionalized religion (I Kings 12: 25–33) capable of withstanding the many challenges lying ahead. Without Judaism, probably there would be no Christianity or Islamism, at least in the forms we know today. One can only imagine a counterfactual scenario of a 21st-century Western world without synagogues, churches, or mosques where people would still worship Zeus, Mitra, or Wotan. Indeed, King David’s impaired decision-making capacity, probably due to hypothyroidism, had momentous and lasting consequences!

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Conflicts of interest

There are no conflicts of interest.


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    Cognitive symptoms; decision-making; history of medicine; hypothyroidism; sexual dysfunction

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