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What's the Prognosis?

R' Abraham Twerski MD

Rabbi Dr. Abraham J. Twerski is scion of a chassidic dynasty. He is also a psychiatrist and founder of the Gateway Rehabilitation Center in Pittsburgh, a leading program for substance abuse. Here, he answers readers' questions.

QUESTION: I'm consulting you in your dual capacity as a doctor and a rabbi because I find myself in an untenable situation and I don't know what to do.

One patient of mine is a woman who has cancer. Before the biopsy results came back, her husband told me that under no circumstances should I tell her the diagnosis if it is cancer, because she would not be able to deal with it. I, therefore, told her that she had a "growth" that we must treat. She did not ask me if it was cancer, so I did not volunteer the information.

She now must receive chemotherapy. She will be seen by an oncologist, a cancer specialist. All the patients who will be receiving chemotherapy along with her will be talking about their disease. All the posters and literature in the oncologist's office refer openly to cancer. She is not a stupid woman. There is no way that she will not know the diagnosis. Yet the husband is adamant that I dare not tell her. He said that he discussed it with his rabbi, and the rabbi agrees that she should not be told.

I see her regularly, and I really cannot relate to her properly to explain why she needs this treatment. I know that she knows, and I feel she will lose trust in me if I am not honest with her. The fact is that she does have a good chance of survival, and if I avoid the word, she may think that it is so terrible that I am afraid to say it to her. She will think her condition is worse than it is. I know how to speak to patients in a way that gives them hope and courage, but I cannot convince the husband. What is the proper thing to do?

ANSWER: If you have a relationship with the patient, you are undoubtedly capable of assessing whether she can cope with the reality. Her husband simply wants to protect her, and I can understand his feelings. However, she is your patient, not the husband. She is an adult, and you must consider what is in her best interest.

Inasmuch as you feel she has a favorable prognosis, you can assure the husband that you can inform her in a way that will not overwhelm her. You should empathize with the husband, since his intentions are certainly good, but explain to him that inasmuch as she is sure to guess the truth, acting "as if" can undermine your therapeutic relationship with her.

By all means, you should discuss the problem with the rabbi. He has only had input from the husband, and he should know your reasoning. Hopefully, that will prove helpful.

If it should get to the point where you feel you cannot possibly continue the subterfuge, and you cannot treat her under such restrictions, you may have to tell the husband that this is similar to his saying, "Treat her infection, but don't use antibiotics." He cannot put you in a position where you are responsible but cannot use your judgment. The only thing a doctor can do in such circumstances is to say, "I want to continue to help her, but if you make it impossible for me to function, I may have to withdraw from the case. You will then have to look for a doctor who can comply with your wishes."

This brings up the sensitive subject of when the patient knows the diagnosis, but wants to keep it from family members. Again, the intentions may be good, but it may result in the family not being as helpful and supportive as they can be. There is no definitive rule to cover all cases. Each situation must be dealt with individually. A person should realize that good intentions are not always right, and consult people with expertise on the subject for guidance.

The actuality is most probably that both the patient and his/her family know the truth but cannot discuss it openly because each side is trying to shield the other. This being the case, they cannot be supportive of each other and can never give voice to their true feelings -- a situation which hinders their relationship at a time when everything should be done to bolster their relationship.


QUESTION: I am an intense person. When I am tired, I have such strong feelings that I simply cannot cope with them. Due to this, I have trouble switching off and falling asleep. It bothers me tremendously because I can't communicate with anyone when I'm in such a state, and I need to give and to be there for people, but my feelings overwhelm me. How do I prevent myself from getting into such a situation, and if I ever do, how could I pull myself together and relax?

ANSWER: The human mind consists of intellect and emotion. Most people today are driven by emotion, and use their intellect to satisfy their emotional needs. That is not the way human beings should operate. Our intellect should dominate our lives. The 18th century book of chassidic philosophy, "Tanya," says that the capacity for intellect to dominate over emotions is actually inborn, but we fail to exercise this capacity.

When you say that you are an intense person, you are describing how you are all of the time or at least most of the time. There are times when we should indeed be intense: when we are doing something very important. The surgeon who focuses and concentrates his attention on the operation is intense. The golf pro who wants his putt to place the golf ball in the hole is intense. These are very important actions to them. Each of us has things we do that warrant such concentration or focusing.

But life is made up of many aspects that do not warrant such attention. There are many things that are relatively insignificant, although at the time we are involved with them they seem to be of enormous importance. I have seen people rush to make a flight to take them to an important meeting. I have also seen people rush with the same intensity to catch an elevator, even though it will only be two minutes before the next elevator is available.

Incidentally, I made a decision that I would never run for an elevator. Two minutes are not that important. It took great restraint to hold myself back. But once I achieved this, it had a ripple effect, and I became much more calm, even when heavy traffic threatened my missing a plane.

What happened was that as a high-intensity person, I endowed too many things with importance. Allowing the elevator doors to close without me was the beginning of an attitudinal change.

Not everything that happens during the average day is so important that one should be so intense. A good test about the importance of something is to think, "How important will I rate this five years from now?" In my book, "It's Not as Tough as You Think," I gave many examples of things that appear to be of momentous importance at the moment, but when you look back at them years later you see how trivial they really were.

When the great blackout happened in New York City, there were weddings that had been meticulously planned for six months. Suddenly there were no lights, no transportation, and no cooking. This was a major disappointment to the wedding parties. Most couples whose weddings were ruined by the blackout saw it as a calamity. Many have already put it in perspective. As for others who may still be upset, I assure you that they will not give it a second thought when they take their children to the chuppah twenty years from now.

Look ahead five or ten years. Will the present incident loom as large then? Will you consider it as having been a rather minor annoyance? If so, think of it that way now.

Do this simple exercise. Write down the things that upset you each day. Put the papers away, and look at them again six months later. I am sure that, in retrospect, you will find that you aggravated yourself unnecessarily.

Make a list of the things you must do today that you see as being very important. Review the list three days from now. You will find that many of the things shrank in significance in just three days. Tension and relaxation are more dependent on a state of mind rather than on actual facts.

In addition to gaining a better perspective, you might pick up one of the books on relaxation exercises. Practice them, even if they seem silly to you. Give yourself time to learn how to relax. This will not be effective immediately, but with ongoing practice you will find that you can bring on a state of relaxation that will diffuse your tension.

You can see the vicious cycle you are in. When you're tired, you may lack the energy or acuity to resolve problems, and they may, therefore, take on a much greater magnitude. If stress and tension interfere with your sleep, you will be less rested the next day, which will impair your ability to cope optimally.

Caution: Do not turn to alcohol or tranquilizers to deal with stress and tension. These are potentially addictive, and should not be used with any regularity.

One more thing. There are gears on a car that allow a person to coast at 70 miles per hour, and more powerful gears for going up a steep incline, but these cannot achieve much speed. If, after reaching the top of a steep hill and being on level land, the transmission is stuck and you can't shift to the cruising gear, you will not be able to go fast. The more powerful gear has its place, but is actually slower.

At earlier phases of our lives we may have to be more assertive and aggressive as we compete for various things. When we reach a point where we can "coast," we should be able to do so. If we are stuck in the more assertive and aggressive lifestyle, we will be expending more energy with less results.

We may have to relearn a lifestyle rather than just continue with habitual behavior.

Reprinted with permission from Innernet and excerpted with permission from "DEAR RABBI, DEAR DOCTOR." Published by ArtScroll/Mesorah Publications Ltd.



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