The Trouble With Medicine's Metaphors

Thomas Sydenham, the most famous physician of the 17th century, known as the English Hippocrates, is often credited with introducing military language into Western medical parlance. Writing in the mid-17th century, Sydenham declares that a “murderous array of disease has to be fought against, and the battle is not a battle for the sluggard.” His aim is to investigate illness, comprehend its character, and “proceed straight ahead, and in full confidence, towards its annihilation.” Describing his approach to venereal disease, he continues: “I attack the enemy within by means of cathartics and refrigerants.”

Over the centuries, we’ve internalized these military metaphors, so much so that we often may not recognize how they influence us. Even today, we “monitor for insidious disease,” “destroy rogue cells,” “search for silver bullets,” and “use all weapons at our disposal.” But when the purpose of treatment is not recovering from a cold, but living with cancer, should the military metaphor be retired?

Many patients may prefer not to view illness as a battle or conflict. Indeed, it seems strange that the language of healing remains so interwoven with the language of warfare, especially in the era of chronic disease, when many conditions are controlled and managed, not eradicated or annihilated.

By describing a treatment as a battle and a patient as a combatant, we set an inherently adversarial tone, and dichotomize outcomes into victory and defeat. Changes in medication regimens become setbacks or retreats, and transitions to palliative care mark the end of struggle, the battle lost. We subtly place an unfair burden on patient and doctor, when in reality, even the most courageous soldier guided by the most effective strategy is too often unsuccessful against an aggressive invader with nothing to lose.

Some have suggested that viewing cancer as a fight can lead to maladaptive coping mechanisms and encourage emotional suppression. In 1970, Polish physician Zbigniew Lipowski introduced a framework for characterizing the meaning that patients ascribe to their illnesses. These categories include viewing illness as a challenge, value, enemy, or loss, among others. Since then, studies that have interviewed cancer patients around the time of diagnosis and followed them for years after have found that patients who view their disease as an “enemy” tend to have higher levels of depression and anxiety, and poorer quality of life than those who ascribe a more positive meaning. They also tend to report higher pain scores and lower coping scores. These findings have been replicated in other conditions, including rheumatoid arthritis and sarcoidosis. More recent work has found that patients encouraged to “fight” may feel that they have to suppress their emotional distress and maintain a positive attitude to avoid upsetting family members—and clinicians.

And yet, it’s almost instinctive to think of disease, especially cancer, in the context of a battle. As Gary Reisfield and George Wilson at the University of Florida write, “there exists a seemingly perfect metaphoric correspondence: there is an enemy (the cancer), a commander (the physician), a combatant (the patient), allies (the healthcare team), and formidable weaponry (including chemical, biological, and nuclear weapons).”

Indeed, for many patients, thinking of their treatment course as a fight or battle may be helpful, an important part of their journey, invoking ideals of courage, resilience, and determination. This may be especially true when the “fight” is understood as a challenge, an opportunity for personal growth, rather than an enemy to be defeated. And since 1971, when President Nixon declared a “War on Cancer,” this imagery has been effective for inspiring the fervor and funds necessary for great advances in cancer care and research.

Ultimately, any metaphor—military or otherwise—is not inherently good or bad. Rather, the utility of each depends on a patient’s culture, values, experiences, and preferences. Metaphors allow doctors to develop a common language with patients, and offer patients an avenue to express their emotions and exert agency over their conditions. Just as patients are the deciders of the character and duration of their treatment, they deserve to be the keepers of the lens through which they view their illness. As writer Anatole Broyard put it, “Metaphors may be as necessary to illness as they are to literature, as comforting to the patient as his own bathrobe and slippers.”

I moved on to a new medical service a few days after that morning I deemed my patient a fighter. I don’t know how she ultimately fared, or whether she came to see her illness as a battle, journey, marathon, rollercoaster, chess match—or none of the above. But I do know it wasn’t my decision to make.

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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