“And what does the doctor recommend?”

America is “the land of the free and the home of the brave,” and my patients would never let me forget it. While staunchly libertarian politics aren’t really mainstream in most parts of the USA, many of the people I worked with back in the States were fierce defenders of their medical decision-making capabilities. And, I believe, rightfully they should be.

With benefits and risks to every decision, many patients were already informed consumers by the time they entered my office. Maybe they’d seen some advertisements on TV for a medication or had read about their presumed diagnosis online. One way or another, it was pretty rare to meet patients who didn’t have an opinion about what might be the right treatment for their specific ailment.

And many times they were right. Why shouldn’t they get to have a say in which direction their care might be heading, especially when psychiatry can be a very gray and nebulous science? We don’t have specific blood tests and X-rays to determine the specific diagnosis or indicated treatment course. Compared with oncologists, who often have a dizzying array of results from multiple blood tests that they’ll use to hammer out a personalized treatment regimen, we psychiatrists often look like we’re banging stones together hoping for a spark.

But with years of experience and emerging clinical data, I was always grateful for the privilege of providing my patients with the pros and cons of available treatment options. This way I would help them make their own decisions about the treatment plan that best reflected their wishes.

And then I followed my lifelong dream and came to Eretz Yisrael, where I discovered that many of my patients were less interested in benefits and risks and were instead focused on hearing an answer.

Tachlis! That’s the word I kept hearing. And not because people are less educated or less well-read in this country. I’ve had many patients who were professionals — doctors and lawyers — and there have been plenty of avreichim and kollel families who come in with an extensive understanding of the scientific research behind mental illness and its treatment.

Rather, there seems to be a different philosophy among many of my patients here in Israel that could best be summed up in the phrase I’d grown to expect: “And what does the doctor recommend?” It’s not that I don’t have my own thoughts about what might be best, it’s just that the benefits versus risks are often significant and the answers aren’t always black and white.

Avrumi was one such case. A young man with a history of hospitalizations for schizophrenia, Avrumi hadn’t fully responded to treatment. He had already tried three different medications and his family was losing faith in the ability of psychopharmacology to bring their son “back to normal.”

“I think it’s time that we discuss something out of the box,” I told Avrumi and his parents during a consultation. “There’s another very powerful medication and it’s worth considering.”

“If you say so, Doctor Freedman, then we will give it a shot,” said Avrumi.

“It’s not really that simple,” I explained. “About 10 percent of patients will be ‘super-responders’ and can get back on track completely. School, work, family, living independently, a real recovery. But the drug also comes with a number of serious side effects, including metabolic changes, seizures, and the risks of a life-threatening blood condition.”

“But if you think it’s worth it, then let’s go ahead,” said Avrumi’s father.

I reviewed the benefits and risks of the treatment, but the family wasn’t interested in listening anymore. “Don’t you want to go home and think about it, consult with other professionals?” I asked them. “No,” they said. They wanted me to make the decision for them.

Tachlis! By now, I was expecting the next question: “So does the doctor think we should do it?”

I told them I’d have to consider it. According to many of the Western medical ethicists out there, this wasn’t my choice to make. But times were different and there were other experts to consult with on this one.

Rav Avigdor Nebenzahl, rav of Jerusalem’s Old City and one of the gedolim of Eretz Yisrael, has been quietly driving a renaissance of Torah learning in the Old City. Each time I walk through Jaffa Gate to meet my chavrusa, I feel inspired to join the ranks of young men dedicated to strengthening the Torah’s presence in Hashem’s chosen city. Following my morning seder, I left my chavrusa and walked on over to one of the many batei medrash where Rav Nebenzahl brings hundreds of men to learn each day. Directly opposite the Kosel, I patiently waited for my opportunity to approach him as the Rav finished up his daily halachah shiur given to an overflow crowd.

As the shiur ended, the regular talmidim were respectful of a new face in the beis medrash and I found myself at the front of the line. A bit nervously, I introduced myself as a relatively recent immigrant to Israel and a psychiatrist with a question about treating my patients.

With my nerves stretched in the presence of such a tremendous talmid chacham, I was somehow able to muster up the courage to ask my question: “How should I assist my patients in a situation when it’s not clear what the right answer is due to the nature of the field? If I’ve already laid out the benefits and risks, can I conscionably provide an answer if they want me to make the decision for them?”

Rav Nebenzahl looked me in the eye and smiled in the unique manner of a true gadol. He seemed to penetrate my soul and said, “When they are asking you to make a decision, give them an answer.”

I needed a bit of clarification. “Kevod Harav, but sometimes I have to make an estimation to the best of my knowledge…”

“Don’t focus on what you can’t know. Make a decision to the best of your ability. Issues of life and death require decisions.”

He smiled at me again and gave me a brachah to be matzliach. As he walked away, I could only imagine how many times he’d made his own psak on issues of life and death.

I walked out of the beis medrash and gazed toward the Kosel, Har Habayis, and Har Hazeisim to its side. I said a brief tefillah for siyata d’Shmaya and made a neder to give a donation to Rav Nebenzahl’s kollelim. It would be in the merit of Avrumi, that he should be one of the 10 percent who would experience a complete recovery with the treatment. Given the specific details of his case, this seemed to me like it was the correct choice for the patient. It was time to call Avrumi and to let him know that we’d give the new medication a shot.

Originally featured in Mishpacha, Issue 693. Jacob L. Freedman is a psychiatrist and business consultant based in Israel. When he’s not busy with his patients, Dr. Freedman can be found learning Torah in The Old City or hiking the hills outside of Jerusalem.  Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com.