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Fighting an illness, losing a battle: Do war metaphors impact patient experiences?

In our ongoing series discussing the impact of metaphors, we examined how language of war is used for debates and arguments. The use of war metaphors in the English language extends beyond arguments. Metaphors help us link abstract concepts and experiences with more concrete ones. But metaphors can also inform our experiences by highlighting or hiding aspects of the concepts they’re conveying.

Conversation around metaphors in the world of healthcare, particularly in oncology, have displayed this very clearly over the past 40 years. Susan Sontag, author and cancer patient, wrote an entire book entitled Illness as Metaphor.

The topic? How punishing metaphors around illness can be.

The trap of “fighting” illness

In 1971, President Nixon declared war on cancer and signed the National Cancer Act into law. Now we say “she beat cancer.” We hear patients say “we’re going to fight this” when they receive their diagnosis. The use of military metaphors to describe illness is not uncommon, and can be traced as far back as John Donne’s Devotions Upon Emergent Occasions written in 1627. But The National Cancer Act and the establishment of the National Cancer Institute “codified the use of the military metaphor in cancer medicine,” and it has since been a prevalent metaphor, used by patients and the medical community, as well as the media.

Yet the usefulness of war as a metaphor has been called into question by the same community – patients, oncologists, and researchers alike – because understanding cancer in terms of war has problematic implications. Many people have weighed in on this topic. Just a few include author and cancer patient Lisa Adams, who wrote,

“When I die don’t say I “fought a battle.” Or “lost a battle.” Or “succumbed.” Don’t make it sound like I didn’t try hard enough, or have the right attitude, or that I simply gave up. When I die tell the world what happened. Plain and simple. No euphemisms, no flowery language, no metaphors.”

Framed in similar terms, Xeni Jardin, in response to the news of Senator McCain’s cancer diagnosis wrote “For me, cancer never felt like a war. Cancer wasn’t something I ‘had,’ but a process my body was going through. … I am no warrior. I just showed up to my medical appointments, did what I was told, and lived as best I could.”

From a research perspective, there seems to be a consensus that the cancer as war metaphor may be counterproductive. One study examined whether war metaphors would make people more likely to take steps that would prevent them from developing cancer. Many cancer-prevention behaviors, however, are what the scientists describe as self-limiting. That is, the behaviors require abstaining from an action that could make you more at risk for cancer. They wondered whether, because “self-limitation is not closely associated with fighting enemies,” people who used that metaphor would be less likely to self-limit. The results “suggest that enemy metaphors in cancer information reduce some prevention intentions without increasing others, making their [enemy metaphors’] use potentially harmful for public health.”

Simplifying the language of disease

Within the medical community, oncologists have weighed in with some suggestions for changing the metaphor, as well as a good reason not to get rid of metaphorical thinking altogether. In one article, several oncologists explain that telling patients about the pathological processes of their disease is often unsatisfying for the patients. Metaphor, they say, gives both parties a common language that builds “shared understanding” and provides them with “both simplification and connection.” Still, they don’t come to a clear consensus on which metaphor would be most useful.

One pediatric oncologist said, “I think that even very young children quickly learn to associate war and battles with dying and death, so I think that is a pretty scary way to frame it for a child.” He then describes using the metaphor of “work” – that treatment is going to be “very hard work.” Their ultimate recommendation comes as a reference to the work of bioethicist George Annas, who advocates for an ecology-based metaphor for disease. The ecology metaphor emphasizes ideas of balance, sustainability, conservation, and responsibility, as these ideas correlate well with the concepts of intervention and prevention prevalent in the medical community.

Ordering from the metaphor menu

Amidst all this discussion, Elena Semino, a linguist and professor at Lancaster University, has taken a different approach. Rather than focusing on one metaphor, she has collected a corpus of data on all the different metaphors used by patients, caregivers, and medical professionals and analyzed that data. Her team found a lot of variation in the metaphors people choose – cancer as unwelcome lodger, cancer as a scary fairground ride, cancer as imprisonment, cancer as a marathon, etc. – but ultimately found that violence metaphors (war, battle, fight) and the cancer as a journey metaphor are the most commonly used, especially by patients.

They examined the data to see whether, of the two, one metaphor is negative and the other positive, and found that no such blanket statement applies. The violence metaphors were often disempowering to people. For example: if the patient does not want to fight, if the patient feels like a foot soldier while the doctors are the generals, or if the patient feels like they don’t have the tools needed for the fight. Most especially negative, Semino says, is when “Patients feel responsible for not getting better when the treatment doesn’t work.” In other words, patients may blame themselves. Some people, though, found motivation, encouragement, and identity in thinking of themselves as fighting, particularly younger people or those in certain stages of disease.

Given this individual variation, and the creativity of the other metaphors they found in the data, Semino’s group has worked on what they call a “menu” of cancer metaphors, a collection from which people can pick the metaphor that serves them best. “We’re different in every other way,” Semino says, “Why shouldn’t we be different in what metaphors are helpful for us when we are sick? We just found evidence that that is the case.”

Simply put, metaphors matter. They shape our thinking, and in so doing also shape our lived experiences: like the cancer patient who is getting progressively sicker, and whose emotions are further complicated by a sense of failure to beat the cancer and win the fight. And no metaphor is perfect – they all break down at some point. Yet sometimes these metaphors are so ingrained in our thinking that it is no small effort for us to identify and question the ways they impact our behavior.

Kate Dzubinski is a Certified Medical Interpreter whose background draws from the southern US, Austria, and northeastern Spain. She grew up speaking four languages, and currently works as a hospital interpreter, continuing education developer and lead facilitator in the Interpreter Training department at ALTA Language Services.

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