This has been a tortured administration for doctors. The respective scandals of physicians Tom Price, Ronny Jackson, and Harold Bornstein are raising questions for the profession about how it polices itself—and about what role doctors should play in the political process.

On Tuesday, in contradiction to his previous statements, Bornstein claimed that he had taken dictation from then-candidate Donald Trump himself in his health assessment. (This was the letter to the American people that bore Borenstein’s name and which said that Trump’s “physical strength [was] extraordinary” and that he “will be the healthiest individual ever elected to the presidency.”)

“He dictated that whole letter. I didn’t write that letter,” Bornstein told CNN. Trump has not yet responded publicly to confirm or deny the claim.

How unusual would this be?

My editor asked me this question—and if such an act could cost Bornstein his  medical license. I thought the answer was obvious, but then a reader on twitter asked much the same: “What does this mean, as a doctor? Is this against standards and regulation?”

Yes. It is. For a patient to dictate his own assessment is not just rare, but unheard of. If a doctor offers to let you dictate your own assessment, seek a new doctor. It is unethical, unprofessonal, and dangerous.

In a basic, elementary-school ethical sense, it is always wrong to sign one’s name to the words of someone else. Even if you entirely agreed with the words, and could have foreseeably written them yourself, it would be misleading to imply that they were yours.

At the very least, doctors’ assessments must be their own words. A doctor does rely on a patient’s reports in reaching that assessment, of course. The doctor may write that a person has no problem with headaches, for example, if the patient denies having headaches. But at least then the doctor is acting in good faith, to the best of her knowledge.

The absence of headaches would also be a reported fact in a medical record, in a section distinct and different from the doctor’s subjective assessment. Even if a patient lies throughout an interview—denying any sort of symptoms or medical history—it is up to the doctor to synthesize and decide what to make of everything in the ultimate assessment.

If what a patient is reporting to a doctor aligns with what the doctor can examine physically, a doctor will typically proceed under the pretense that people are generally honest with their doctors because they want help. For example, people want headaches to go away, so they don’t lie about not having headaches. Dishonesty prevents help. But the dynamic changes when a person is undergoing evaluation for purposes of a job. Here the skepticism bar is raised. For example, in many jobs it is insufficient for a doctor to simply ask about recreational drug use. Instead they administer a urine test.

There is no formal demand for empiricism in the evaluation of a president or presidential candidate. I’ve argued previously that there should be. A committee of appointed and accountable physicians could administer a battery of tests and use a transparent evaluation process to ensure that a candidate was able to execute the duties of office, and that the American people were at least aware of any potential issues, so that could be factored into voting, or removing a person from office.

Without such a process, we are left with the opaque assessment of individual doctors. Both who have cleared Trump for office have now been disgraced, raising questions for the American people, much less the global community, about the President’s fitness.

Still the most relevant question is not about Trump’s health. Nor is it an ethical question about the actions of Bornstein. What matters most are the actions of Trump, now the most powerful person in the world. If he indeed dictated this letter—and this is well supported even by a glancing linguistic analysis—then it is his ethics that should be called to question.

Whether or not Harold Bornstein loses his medical license is not material to all but a few hundred gastrologically afflicted residents of Manhattan’s upper east side.

Billions more people are implicated if this letter is evidence of Trump’s willing to lie to circumvent and subvert a critical vetting process, to baldly misrepresent himself by using people like Bornstein for his own gain. The relevance of Trump’s actual health status—whether or not he takes a medication for hair loss, and if his body-mass index does indeed qualify him as “obese”—all of this sort of data pales compared to what such an act of forgery would say about his morality; his sense of honesty, transparency, decency, and accountability; his actual fitness to serve as President of the United States.

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