The fight is on: military metaphors for cancer may harm patients

I'm not a fighter. Or at least I'm not a fighter when the fight is pointless and ultimately a fight 'to beat' metastatic cancer is pointless in the majority of circumstances.

I think this use of the military metaphor has arisen in large part because of our culture of denial around death, which has become more entrenched as death becomes less of a commonplace experience for us. It also chimes with modern Western ideas about fighting injustice. That is a compelling idea (how could anyone say fighting injustice was bad?), unites most of us with common purpose and helps us feel good about ourselves -- look at the popularity of the ALS Ice Bucket Challenge, even if most people never donated in the end. It's evidently 'unjust' to 'die before your time' and so it seems natural to us and far easier to use the language of fighting and battles than the language of acceptance and understanding. Who wants to be seen to be a fatalist, a quitter, a nihilist even, when all around everyone else is fighting the good fight and is even rooting for us to fight that good fight too?

There's a perpetuating factor in this as well, one which I hardly dare mutter in these pages, for fear of the reaction it will elicit, but here it is, whispered very quietly: oncologists. As a GP in the UK, I had the not infrequent experience of visiting a cancer patient at home after they had just had a cycle of chemotherapy for metastatic cancer to find them almost moribund and with them and their relatives quite unaware of the reality of their situation. This was made worse by the fact that I had often lost contact with these patients for the preceding months as they were swept up into the chemotherapy machine and seemed to disappear from my primary care radar. Etched on my mind still is the awful experience of having to rapidly change course and impart to the patient and their relatives that they would not be having any more chemotherapy and that ‘this was it’, something they had thought at worst was a very long way off and at best may never happen.

There are many fine oncologists who take a wide overview of their patients, present realistic options and deliver holistic care in partnership with patients and relatives. I applaud them. Some of them will no doubt jump to the defence of their profession on this page and I applaud that too. Before I go, however, I am going to offer the age-old joke for the reflection of all trainee oncologists and I am going to ask that they do their utmost to move beyond the military metaphor and remember that the outcome – appropriate levels of treatment followed by a 'good' death with, where possible, appropriate preparation – is so much more important than the process – cycles of chemotherapy of marginal, if any, symptomatic benefit often wrapped within a military metaphor that allows evasion of difficult conversations, but which squanders the little time left, which could perhaps be better spent in other ways.

So, here it is, the age-old joke (and, remember, jokes only become age-old if they have a kernel of truth to them). You’ve almost certainly heard it before, but for some reason I only heard it recently for the first time:

The grieving relatives revisit the grave to pay their respects the day after the burial of their 90 year-old mother who had renal failure, heart failure, a hemiparesis after a stroke and metastatic breast cancer. Lo! They find the grave is empty! It has been dug up. The coffin is lying on the ground, open.

“But where is mum?!” They cry in anguish to the superintendent of the cemetery.

“Oh, don’t worry,” says he, “The oncologists dug her up and took her for her next cycle of chemo.”

My huge regard for Margaret McCartney has increased further on reading this piece by her. She somehow so often manages to say what I wish I could express but am not articulate enough to do so. Her integrity shines through in all she says and she shows no partiality.

The Beatson and Cancer Research have undoubtedly got this wrong and it is far better that a respected local professional speaks out than for patients to suffer in silence at such unhelpful tub thumping.

Also pleased to see that this was a commissioned piece and that the editorial staff apparently recognise that other folk may share her concern about a campaign based on "fight(ing) the good fight with all thy might". Thank you, Dr McCartney.