Stop using military metaphors for diseaseBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4706 (Published 12 July 2012) Cite this as: BMJ 2012;345:e4706
- Natasha M Wiggins, core medical trainee, Oncology Department, Essex County Hospital, Colchester CO3 3NB
In oncology I come across this terminology often: patients “battle” and “courageously fight” against cancer; some “win” and some “give up the fight” and “lose.” The biomilitary metaphor has subtly worked its way into our psyche over centuries. When the remarkable metaphysical poet (and suspected drama queen) John Donne thought he was dying he wrote Devotions Upon Emergent Occasions, in which he described his illness as a “cannon shot” and a “siege [that] blows up the heart.” In 1864, Louis Pasteur used invasion imagery to introduce his fundamentally new germ theory of illness to the public. Then, in 1971, US president Nixon publically declared “war” on cancer, calling it a “relentless and insidious enemy.” Newspapers have been affirming this battle ever since.
It is difficult to think of alternative metaphors. The concept of body as battlefield is instilled in us through school textbooks with images of cells “battling” for supremacy and survival. Consider the language of immunology: lymphocytes are “deployed” or “mobilised,” and our “main line of defence” involves “killer” cells.
Since the days of Nixon’s war, advances in medical science have made it clear that cancer is not one but many enemies. Indeed, the Pulitzer prize winning oncologist Siddhartha Mukherjee stated, “It is a puzzle, you cannot win a puzzle, you can only solve it.” Are people with aggressive or advanced disease fighting less hard? This “fighting” involves loss of dignity, changing personality, and feeling awful. Is there any less courage in facing your fate? Has someone “given up the fight” if they make an informed choice to decline treatment based on the risks and benefits?
Cancer is personified, unlike most other diseases, as “the malignant bastard” or the “emperor of maladies.” Perhaps this is connected to our perception of the body turning on itself or the links between cancer and lifestyle choices. Further personification enables cancer to become the enemy. But cancer is no longer the only disease described by metaphors of war.
When the University of Nottingham opened its new facility dedicated to studying and controlling “superbugs,” the Guardian newspaper interviewed its director, Richard James, about why such a research centre was necessary. He said, “This is a sophisticated army with astonishing weapons. And each time we develop something new, [bacteria] develop a defence for it.”1 James’s comment stating that he anticipated an “antibiotic apocalypse” provoked the chief of nursing to accuse him of scaremongering.
So why not just drop the metaphor altogether? The theoretician Neil Pickering says, “Models are based upon metaphors, but metaphors need not be based upon likenesses or other observable phenomena. In this respect they seem groundless.”2 He feels that “notions of metaphor make science too much like poetry.” I beg to differ. It is hard to prepare for the loss of control—not just of your body, but of your whole life—that having cancer can cause. Many patients explicitly say that they feel better with a knowledge and understanding of what is happening to them. Metaphor can be vital to the explanation of such a disease process because it enables communication of complex theories to an audience with little scientific knowledge.
So how might we replace the battle concept? Perhaps the most romantic substitute I’ve heard was in a play about mouth cancer: “Death came and gave me a flower, he asked me to hold it in my mouth, he said he would be back for it in six months.”3 This quixotic image may not wash with someone struggling with the impracticalities of having mouth cancer, but it does enable the beginning of a discussion on alternative references that don’t explicitly imply such pressure to be positive about the diagnosis, to be proactive, to fight.
The subconscious impact of our daily use of allegories can easily be underestimated. Although the biomilitary metaphor will sit well with some people, by applying it to every patient we may be setting some of them up to “lose.” A patient recently wrote to the Independent, questioning its use of this symbolism in an article: “She did not lose the fight, any more than I won it because I’m still alive. This makes it sound as if we can do something about our cancers. Worse, it makes dying into a personal failure.”4 Medical science has progressed further than Pasteur could have dreamt, yet his allegory remains. It is time we found something new.
Cite this as: BMJ 2012;345:e4706
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.