Through the 2016 campaign, I posted a series called “Trump Time Capsule” in this space. The idea was to record, in real time, what was known about Donald Trump’s fitness for office—and to do so not when people were looking back on our era but while the Republican Party was deciding whether to line up behind him and voters were preparing to make their choice.

The series reached 152 installments by election day. I argued that even then there was no doubt of Trump’s mental, emotional, civic, and ethical unfitness for national leadership. If you’re hazy on the details, the series is (once again) here.

That background has equipped me to view Trump’s performance in office as consistently shocking but rarely surprising. He lied on the campaign trail, and he lies in office. He insulted women, minorities, “the other” as a candidate, and he does it as a president. He led “lock her up!” cheers at the Republican National Convention and he smiles at “send them back!” cheers now. He did not know how the “nuclear triad” worked then, and he does not know how tariffs work now. He flared at perceived personal slights when they came from Senator John McCain, and he does so when they come from the Prime Minister of Denmark. He is who he was.

The Atlantic editorial staff, in a project I played no part in, reached a similar conclusion. Its editorial urging a vote against Trump was obviously written before the election but stands up well three years later:

He is a demagogue, a xenophobe, a sexist, a know-nothing, and a liar. He is spectacularly unfit for office, and voters—the statesmen and thinkers of the ballot box—should act in defense of American democracy and elect his opponent

The one thing I avoided in that Time Capsule series was “medicalizing” Trump’s personality and behavior. That is, moving from description of his behavior to speculation about its cause. Was Trump’s abysmal ignorance—“Most people don’t know President Lincoln was a Republican!”—a sign of dementia, or of some other cognitive decline? Or was it just more evidence that he had never read a book? Was his braggadocio and self-centeredness a textbook case of narcissistic personality disorder? (Whose symptoms include “an exaggerated sense of self-importance” and “a sense of entitlement and require[s] constant, excessive admiration.”) Or just that he is an entitled jerk? On these and other points I didn’t, and don’t, know.

Like many people in the journalistic world, I received a steady stream of mail from mental-health professionals arguing for the “medicalized” approach. Several times I mentioned the parallel between Trump’s behavior and the check-list symptoms of narcissism. But I steered away from “this man is sick”—naming the cause rather than listing the signs—for two reasons.

The minor reason was the medical-world taboo against public speculation about people a doctor had not examined personally. There is a Catch-22 circularity to this stricture (which dates to the Goldwater-LBJ race in 1964). Doctors who have not treated a patient can’t say anything about the patient’s condition, because that would be “irresponsible”—but neither can doctors who have, because they’d be violating confidences.

Also, a flat ban on at-a-distance diagnosis doesn’t really meet the common-sense test. Medical professionals have spent decades observing symptoms, syndromes, and more-or-less probable explanations for behavior. We take it for granted that an ex-quarterback like Tony Romo can look at an offensive lineup just before the snap and say, “This is going to be a screen pass.” But it’s considered a wild overstep for a doctor or therapist to reach conclusions based on hundreds of hours of exposure to Trump on TV.

My dad was a small-town internist and diagnostician. Back in the 1990s he saw someone I knew, on a TV interview show, and he called me to say: “I think your friend has [a neurological disease]. He should have it checked out, if he hasn’t already.” It was because my dad had seen a certain pattern—of expression, and movement, and facial detail—so many times in the past, that he saw familiar signs, and knew from experience what the cause usually was. (He was right in this case.) Similarly, he could walk down the street, or through an airline terminal, and tell by people’s gait or breathing patterns who needed to have knee or hip surgery, who had just had that surgery, who was starting to have heart problems, et cetera. (I avoided asking him what he was observing about me.)

Recognizing patterns is the heart of most professional skills, and mental health professionals usually know less about an individual patient than all of us now know about Donald Trump. And on that basis, Dr. Bandy Lee of Yale and others associated with the World Mental Health Coalition have been sounding the alarm about Trump’s mental state (including with a special analysis of the Mueller report). Another organization of mental health professionals is the “Duty to Warn” movement.

But the diagnosis-at-a-distance issue wasn’t the real reason I avoided “medicalization.” The main reason I didn’t go down this road was my assessment that it wouldn’t make a difference. People who opposed Donald Trump already opposed him, and didn’t need some medical hypothesis to dislike his behavior. And people who supported him had already shown that they would continue to swallow anything, from “Grab ‘em by … ” to “I like people who weren’t captured.” The Vichy Republicans of the campaign dutifully lined up behind the man they had denounced during the primaries, and the Republicans of the Senate have followed in that tradition.

But now we’ve had something we didn’t see so clearly during the campaign. These are episodes of what would be called outright lunacy, if they occurred in any other setting: An actually consequential rift with a small but important NATO ally, arising from the idea that the U.S. would “buy Greenland.” Trump’s self-description as “the Chosen One,” and his embrace of a supporter’s description of him as the “second coming of God” and the “King of Israel.” His logorrhea, drift, and fantastical claims in public rallies, and his flashes of belligerence at the slightest challenge in question sessions on the White House lawn. His utter lack of affect or empathy when personally meeting the most recent shooting victims, in Dayton and El Paso. His reduction of any event, whatsoever, into what people are saying about him.

Obviously I have no standing to say what medical pattern we are seeing, and where exactly it might lead. But just from life I know this:

If an airline learned that a pilot was talking publicly about being “the Chosen One” or “the King of Israel” (or Scotland or whatever), the airline would be looking carefully into whether this person should be in the cockpit.

If a hospital had a senior surgeon behaving as Trump now does, other doctors and nurses would be talking with administrators and lawyers before giving that surgeon the scalpel again.

If a public company knew that a CEO was making costly strategic decisions on personal impulse or from personal vanity or slight, and was doing so more and more frequently, the board would be starting to act. (See: Uber, management history of.)

If a university, museum, or other public institution had a leader who routinely insulted large parts of its constituency—racial or religious minorities, immigrants or international allies, women—the board would be starting to act.

If the U.S. Navy knew that one of its commanders was routinely lying about important operational details, plus lashing out under criticism, plus talking in “Chosen One” terms, the Navy would not want that person in charge of, say, a nuclear-missile submarine. (See: The Queeg saga in The Caine Mutiny, which would make ideal late-summer reading or viewing for members of the White House staff.)

Yet now such a person is in charge not of one nuclear-missile submarine but all of them—and the bombers and ICBMs, and diplomatic military agreements, and the countless other ramifications of executive power.

If Donald Trump were in virtually any other position of responsibility, action would already be under way to remove him from that role. The board at a public company would have replaced him outright or arranged a discreet shift out of power. (Of course, he would never have gotten this far in a large public corporation.) The chain-of-command in the Navy or at an airline or in the hospital would at least call a time-out, and check his fitness, before putting him back on the bridge, or in the cockpit, or in the operating room. (Of course, he would never have gotten this far as a military officer, or a pilot, or a doctor.)

There are two exceptions. One is a purely family-run business, like the firm in which Trump spent his entire previous career. And the other is the U.S. presidency, where he will remain, despite more and more-manifest Queeg-like unfitness, as long as the GOP Senate stands with him.

(Why the Senate? Because the two constitutional means for removing a president, impeachment and the 25th Amendment, both ultimately require two thirds support from the Senate. Under the 25th Amendment, a majority of the Cabinet can remove a president—but if the president disagrees, he can retain the office unless two thirds of both the House and Senate vote against him, an even tougher standard than with impeachment. Once again it all comes back to Senate Majority Leader Mitch McConnell.)

Donald Trump is who we knew him to be. But now he’s worse. The GOP Senate continues to show us what it is.