In recent months a growing number of mental health experts and members of the media have offered opinions on Pres. Donald Trump’s psychiatric fitness. On Tuesday 35 U.S. psychiatrists, psychologists and social workers signed a letter to the editor of The New York Times warning about Trump’s mental health.* Its signatories state—despite a self-imposed ethics rule forbidding psychiatrists from offering professional opinions about public figures they have not personally evaluated—they “believe that the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.” A number of petitions, including a Change.org petition started by psychologist John Gartner that has garnered more than 20,000 signatures, have called for the chief executive to be removed from office on the grounds he is mentally ill and unfit to perform the duties of president.

In response to these efforts, Allen Frances, an emeritus psychiatrist at Duke University School of Medicine who helped write the standard manual on psychiatric disorders, wrote a separate letter to the Times denouncing attempts to diagnose the president as mentally ill. He explains that Trump lacks the “distress and impairment required to diagnose a mental illness,” adding that bad behavior and mental illness are not synonymous. “Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy,” Frances wrote. Nevertheless, “he can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.”

Historically, psychiatrists have adhered to an ethics dictum known as the Goldwater rule, which appeared in the first edition of the American Psychiatric Association’s code of ethics in 1973. It evolved out of an incident involving presidential candidate Barry Goldwater: In 1964 Fact magazine polled 12,356 psychiatrists on Goldwater’s mental fitness to be president and published an article stating that 1,189 of the 2,417 who responded deemed him psychologically unfit for the job. (Goldwater later won a libel suit against the magazine.)

The mental health professionals writing in the Times, however, felt compelled to speak out: “We fear that too much is at stake to be silent any longer.” Susan Radant, a psychoanalyst and clinical psychologist and director of the Seattle Psychoanalytic Society and Institute, says she was motivated to sign by her worries about Trump’s competence, including his emotional stability, integrity and honesty. “I am hoping this letter will inspire both citizens and, particularly, the Congress to do their jobs,” she wrote in an e-mail, “and step in before our country and the world are permanently damaged.”

Radant thinks it is time to get rid of the Goldwater rule. She says mental health professionals are well qualified to offer certain diagnoses from a distance, pointing out the press, sans training, freely makes such assessments.

Fellow signatory Alexandra Rolde, a psychiatrist affiliated with Beth Israel Deaconess Medical Center and Newton–Wellesley Hospital, both in Massachusetts, emphasizes the letter does not attempt to diagnose Trump but rather highlights personality traits she and her colleagues find concerning. She does not believe any mental health professional should make a diagnosis without seeing a patient, but thinks it can still be appropriate to comment on how a person’s mental health may affect other people and his or her ability to perform.

The APA continues to stand by the Goldwater rule, however. When asked for comment on the Times letter, the association pointed to a letter published by APA president Maria Oquendo in August 2016. “The unique atmosphere of [the 2016] election cycle may lead some to want to psychoanalyze the candidates,” she wrote at the time. “But to do so would not only be unethical, it would be irresponsible.”

Oquendo goes on to explain that although she understands the desire to get inside the mind of a presidential candidate, especially with the abundance of information about him or her available on the internet, experts must also consider how patients might be affected by seeing their mental health provider offer a medical opinion from a distance. “A patient who sees that might lose confidence in their doctor,” she wrote, “And would likely feel stigmatized by language painting a candidate with a mental disorder (real or perceived) as ‘unfit’ or ‘unworthy’ to assume the presidency.”

*Editor’s Note (2/15/17): This sentence was edited after posting to correct the number of mental health professionals who signed the letter as initially reported by The New York Times.