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.”
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.