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Donald Trump may or may not be mentally ill. He may or may not have an organic brain disease. Despite those unknowns, a group of prominent mental health professionals today agreed that they have an ethical obligation to expose to the public every instance of reality distortion, impulsive decision-making, and violation of presidential norms of behavior that singularize the Trump presidency.

At a conference held at Yale University Medical School and led by Bandy Lee, assistant clinical professor in law and psychiatry, mental health experts met to discuss whether their professional responsibility includes a duty to warn the public of dangers posed by President Trump’s behavior. For them the issue is no longer what psychiatric diagnosis Donald Trump merits or not. It is how to avert the "malignant normality"—as psychiatrist Robert Jay Lifton called it—now threatening American democracy.

But the conference itself exemplified the unusual problems created by the 45th president. Even in organizing the gathering, Lee said, she encountered “a sudden wave of fear" that led to withdrawal of official support from the school of public health and the department of psychiatry, where she specializes in studying and treating violent offenders and preventing violence. "Colleagues are concerned about the repercussions of speaking,” she observed, because they lack legal protections from a president who has demonstrated his willingness to publicly target those who say something he doesn't like.

Further, ever since 1973, mental health experts have been professionally restrained by the Goldwater Rule from commenting on the mental fitness of any person they have not personally examined. Although the rule was established by the American Psychiatric Association and psychologists are not expressly forbidden from making public pronouncements about the mental health of public figures, the American Psychological Association has affirmed the rule and psychologists generally abide by it.

In recent years, however, mental health experts have begun speaking out against the rule. For psychologist John Gartner, who has garnered over 41,000 professional signatures to a Facebook petition stating that mental health experts have a duty to warn the public of the dangers posed by Trump’s behavior, the rule is obsolete, established before diagnostic criteria abandoned Freudian interpretation in favor of observable behavior. “It’s fighting an old war,” says Gartner, whose petition was a stimulus for the conference.

Nevertheless, John Krystal, chairman of Yale’s psychiatry department, cited the Goldwater Rule in explaining why he “would not support holding this conference under the auspices of the department of psychiatry.” Lee says she was moved to action because the restrictions the rule places on psychiatry make it a medical oddity. “Why is mental illness exceptional to other medical illnesses?”

Charles Dike, professor of law and psychiatry at Yale, believes the Goldwater Rule is still relevant today, and the evidence to determine the mental fitness of a public figure can be obtained only through personal examination. What’s more, he says, the primary responsibility of a psychiatrist is to a patient, not to the public: “We are not police.”

For Harvard psychiatrist Judith Herman, the signs of Trump’s mental instability are so visible professional expertise is not even needed to recognize them. Still, last fall, she wrote a letter to then-President Obama expressing alarm over the mental health of the president-elect and requesting he undergo a full neuropsychiatric and medical evaluation. She, too, found colleagues unwilling to sign the letter because of ethical restraints and/or fear of being targeted. But she also noted that many in the mental health community have principled concerns about the political use and potential for misuse of psychiatry.

“This issue is not whether Donald Trump is mentally ill but whether he’s dangerous,” James Gilligan told the conference. “Nothing is more important today.”

Currently professor of psychiatry at New York University and longtime director of mental health for the Massachusetts prison system, Gilligan contends that a private interview is not necessary to assess Trump’s dangerousness: “He publicly boasts of violence and has threatened violence. He has urged followers to beat up protestors. He approves of torture. He has boasted of his ability to commit and get away with sexual assault.” The danger is visible to everyone, but for professionals, he says, it is “irresponsible” to remain passive in the face of it.

“Professional ethics matter,” Lifton told the conference. The question is how the ethics are framed— “technicized” as in the Goldwater Rule or seen as a larger obligation. Mental health experts, he says, have an ethical requirement to expose “malignant normality,” the adaptation to and normalization of dangerous behavior that occurs in the absence of speaking up. “It’s important for professionals to point out Trump’s assault on reality and his attempts to impose it on the rest of us.”

An audible gasp of understanding rose from the audience when he ended his remarks with a line from poet Theodore Roethke: “In a dark time, the eye begins to see.”