The Trouble With Medicine's Metaphors

Using military terms like "battle" and "fighter" to help patients conceptualize their illness can sometimes harm more than it helps.

I checked her morning labs and they didn’t look good.   

Last year, she gave birth to her second child. Last month, she was diagnosed with leukemia. When I entered her room early one morning, she looked despondent. “Please know you’ve got a great team caring for you,” I told her. “We’ll fight this together.”

She looked pensively out the window as the sun began to rise. “Yes,” she finally said. “I’m a fighter.”

As I left the room, I couldn’t help thinking of another “fighter”—my aunt, who passed away from lymphoma nearly a decade earlier. I’ve long wondered whether that word—fighter—and the other military language used to help her conceptualize her disease did more harm than good. Did she, on some level, feel she lost the battle because she didn’t fight hard enough? Might she have suffered less at the end if she hadn’t felt compelled to try one more drug, determined to soldier on?

The words we choose to describe illness are powerful. They carry weight and valence, creating the milieu in which goals of care are discussed and treatment plans designed. In medicine, the use of metaphor is pervasive. Antibiotics clog up bacterial machinery by disrupting the supply chain. Diabetes coats red blood cells with sugar until they’re little glazed donuts. Life with chronic disease is a marathon, not a sprint, with bumps on the road and frequent detours.  

One study, from 2010, found that physicians use metaphors in almost two-thirds of their conversations with patients who have serious illnesses. Physicians who used more metaphors were seen as better communicators. Patients reported less trouble understanding them, and felt as though their doctor made sure they understood their conditions.

Metaphors are a fundamental mechanism through which our minds conceptualize the world around us, especially in the face of complexity. But evidence suggests they do more than explain similarities—they can invent them where they don’t exist, and blur the lines between the literal and the figurative.

One such example comes from research conducted by Lawrence Williams and John Baugh, suggesting that people often confuse physical warmth with social warmth. In their study, a researcher asked participants to briefly hold either a hot or iced coffee on their way to the experimental room, seemingly before the experiment had begun. Later participants read an ambiguous description of an anonymous individual. Those who had held the hot coffee were more likely to rate that individual as having “warmer” personality traits like generosity and compassion. In another study, participants who held the warm coffee were more likely to choose to give a gift to a friend than to take it for themselves.

Other work done by Chen-Bo Zhong and Katie Liljenquist explores the Macbeth Effect, in which suggestions of moral impurity stimulate a desire to cleanse oneself physically in an attempt to wash away one’s sins. In a series of studies, the authors found that participants prompted to think of their own or others’ moral indiscretions were more likely to rate cleaning products as more desirable than other products, and were twice as likely to choose an antiseptic wipe over a pencil when offered a gift for participating. Even more interesting is participants’ unspoken perception that washing their hands restores their moral integrity. Those who were reminded of their unethical behavior and had the opportunity to clean their hands after were almost 50 percent less likely to help out with another study, suggesting that subconsciously they felt physical cleansing had absolved them of previous unethical behavior.

These unconscious processes seem to play out even when we analyze complicated, cerebral issues. In another study, researchers asked people to help solve a city’s crime problem, which was described either as “virus infecting a city” or a “wild beast preying on a city.” People who got the “virus” frame were far more likely to propose solutions involving social reform to address root causes like poverty and lack of education, while those receiving the “beast” frame were more likely to propose solutions involving catching criminals and enforcing laws more strictly. Almost none of the subjects identified the metaphorical frame as being important to their decision-making process, instead crediting hard data like statistics and facts. But the magnitude of the metaphor effect was larger than pre-existing differences of opinion between liberals and conservatives.   

If thinking of a virus affects how we address crime and punishment, might thinking of conflict and combat—as I encouraged my patient to do—affect how we address a virus?

Military metaphors are among the oldest in medicine and they remain among the most common. Long before Louis Pasteur deployed imagery of invaders to explain germ theory in the 1860s, John Donne ruminated on the “miserable condition of man,” describing illness as a “siege…a rebellious heat, [that] will blow up the heart, like a Myne” and a “Canon [that] batters all, overthrowes all, demolishes all…destroyes us in an instant.”

Presented by

Dhruv Khullar, M.D., is a resident physician at the Massachusetts General Hospital and Harvard Medical School. His work has also appeared in the New England Journal of Medicine, The New York Times, and Politico.

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