Bandy X. Lee is assistant clinical professor in law and psychiatry at Yale School of Medicine and a project leader for the World Health Organization. Leonard L. Glass is associate professor of psychiatry at Harvard Medical School and senior attending psychiatrist at McLean Hospital. They are co-authors of The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Professionals Assess a President.

Eight months ago, moved by what we were witnessing in the American president, we joined 25 other psychiatrists and mental health experts in putting our concerns into a book, The Dangerous Case of Donald Trump. We believed Trump’s mental state presented a danger to the public and felt we had a duty to warn them. We intended the book, which became a best-seller, as a service, putting the royalties into a fund for public good.

Since the book’s publication, however, we have faced a wave of backlash—not just from political observers but from doctors in our own field. Many commentators claimed that we were violating the Goldwater rule, the American Psychiatric Association’s ethical directive that psychiatrists should not diagnose anyone they have not personally evaluated. A past president of the American Psychiatric Association called our work “tawdry, indulgent, fatuous, tabloid psychiatry.” We heard similar criticisms last week, after Politico reported that one of us, Dr. Bandy Lee, had met with members of Congress to discuss the president’s behavior and mental health.


But these criticisms get two things wrong: first, that we are violating the Goldwater rule, and second, that we should avoid talking about the president’s mental health. Without diagnosing Trump in a specific way, as the Goldwater rule prohibits, it is not only acceptable but vitally necessary to have a public conversation about mental state of our nation’s leader.

When the American Psychiatric Association created the Goldwater rule in 1973, in reaction to an article in Fact magazine citing hundreds of psychiatrists who had said Republican candidate Barry Goldwater was unfit to be president, the association was rightly concerned that the profession’s reputation would be harmed by careless opinions made in public. But the APA recently decided to interpret the rule more strictly: Where previously it forbade only diagnosis from afar, as of March 2017 the association says it prohibits any commenting on the mental health of a public figure. Orthopedists, cardiologists and other medical authorities can enlighten the public about health issues that affect public figures, such as heart conditions—but physicians with specific training and experience in mental disorders cannot. By fiat of the APA, the Goldwater rule has effectively turned into a gag rule.

The Goldwater rule, in its original conception, served an important purpose—one that our writings and speeches have not undermined. All 27 experts who contributed to The Dangerous Case of Donald Trump took pains not to diagnose the president in the book. (Bandy, who edited the book, is a strong proponent of the Goldwater rule and particularly opposes modifying it under political pressure.) A formal psychiatric diagnosis is reached after careful study of the patient, including taking a history, performing a physical, reviewing lab results and history of past illnesses and treatments, and obtaining supplementary perspectives from close family members. A diagnosis forms the basis for a treatment plan individually designed for that patient’s future care. An individual’s dangerousness, however, can be reliably assessed by interviewing co-workers and intimates, reviewing the individual’s past statements and behaviors, reviewing police reports and, crucially, assessing context. While an in-person interview can be quite useful, it is not strictly required to assess danger.

Furthermore, we are not interested in Trump’s personal issues, which are his private affair. We comment on the traits of the president only in relation to the public office he holds, and with the express interest of educating and warning the public against danger.

Not only does our book not violate the Goldwater rule, but the APA’s expanded interpretation of it is at odds with the association’s ethics code, which actually allows psychiatrists to speak about psychiatric issues in general when asked about a public figure. In fact, the code obligates psychiatrists to “participate in activities contributing to … the betterment of public health.” Thus, quashing a conversation that serves in the interest of public health, as the APA is now doing, directly contradicts the principles of medical ethics, as well as those of the World Medical Association’s 1948 Geneva Declaration, which clarified the humanitarian goals of medicine. Both of us have resigned from the APA—Leonard Glass, once a distinguished life fellow, did so in direct response to the association’s new interpretation of the Goldwater rule, and Bandy, once a fellow, did so more than a decade ago because of the association’s close ties with the pharmaceutical industry.

It was with all of this in mind that Bandy, along with the psychiatrist James Gilligan, agreed to meet last month with a dozen members of Congress, all but one of them Democrats. (A former member had originally asked her to testify before all of Congress, but when this was delayed, a former assistant U.S. attorney arranged for her to meet with members individually.) By meeting with lawmakers, she was abiding by the APA’s ethical guidelines, which precede the Goldwater rule and instruct psychiatrists “to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government.” In these meetings, she discussed purely medical matters without partisan affiliation or investment in a certain political outcome, which is for lawmakers to decide.

While the meetings were private and confidential, in general it’s fair to say the members themselves were forthright. “You don’t have to convince us. We have been so concerned ourselves. We were eager to meet with you,” was a common answer. One lawmaker said: “I have never so waited for a meeting in 11 years.” Several Democrats said they knew of Republican lawmakers who shared their concerns but could not express them publicly. They charged us to continue educating the public.

Any president’s mental health is inextricably tied to our health as a society, and, in this case, Trump’s mental state poses a serious danger that we must be willing to discuss and address. As Bandy told members of Congress, a few signs of this danger are: verbal aggressiveness, boasting about sexual assaults, inciting violence in others and the continual taunting of a hostile nation with nuclear weapons. Additional traits that are concerning are impulsiveness, recklessness, paranoia and rage reactions; a loose grip on reality with a poor understanding of consequences; a lack of empathy and belligerence toward others; and a constant need to demonstrate power. Trump’s recent tweet insisting he is a “very stable genius,” in response to claims about his mental capacity in a recent book by journalist Michael Wolff, confirmed our concerns about Trump: He appears not to perceive how critical any defect in his mental sharpness could be, or how imperative it is that he protect the country before his own reputation.

Cognitive function, or the ability to process knowledge and thoughts, is of critical importance for the office he holds, and its decline can be another danger sign. Some observers—including his own staff, according Wolff’s book—have noted a decline in Trump’s ability to form complete sentences, to stay with a thought, to use complex words and not to make loose associations. Only a thorough examination of Trump himself and his medical records, among other sources, could yield a diagnosis of these signs. Again, a diagnosis, prognosis and treatment are Trump’s private business and not ours. What is our business, as health professionals who have a duty to the public, is whether the president and commander in chief has the capacity to serve in office. Those questions are what mobilized us to speak out about our concerns in the first place, so that we can fulfill our duties to educate and to warn the public about an erratic and unstable leader, to help protect its and our own safety and well-being.

In early 20th-century Germany, the sociologist Max Weber argued that intellectuals should not utter any political opinions or say anything that could remotely be regarded as partisan—a Goldwater rule of sorts for the era. Under Nazism, not only psychiatrists but most German clergymen, professors, lawyers, doctors and other leading thinkers became passive enablers of some of the worst atrocities under a dangerous political leader who led their country into the worst disaster in its history. It was precisely in response to Nazism that the World Medical Association issued its Geneva Declaration. Seventy years later, we must not forget the declaration’s commitment to the common good, and cannot stay silent.