Stop using military metaphors for disease
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4706 (Published 12 July 2012) Cite this as: BMJ 2012;345:e4706
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Make your own metaphor - Coping is as individual as you are.
Dear Sir
Wiggins (Personal View BMJ 2012; 345 e4706),explains the shortcomings of military metaphor in dealing with cancer and calls for new ones. Many are available, often relating to being on a journey, being lost, of falling into the unknown and being isolated.
I took up a career in medicine after treatment for a neuroblastoma and have had many interesting discussions with my own patients and in patients’ organisations. All metaphors are limited, people with cancer know we are not only affected by the illness but by the labels society places on us which reflects the fear that most people have of the disease. We soon learn that we have to find our own way.
There are different mental adjustments to cancer 1 and Kubler– Ross2 has described the grief cycle demonstrating differing attitudes whilst assimilating bad news.
How we (doctors and nurses) influence our patients coping abilities requires more research and some interesting work has begun as part of the DoH/Macmillan survivorship initiative3.
Often words are not enough and the paintings by Michelangelo Petrone4 can help to bring comfort and meaning to the experience.
There are many sources of help for patients such as Macmillan Cancer Support patients organisations where patients can explore what best help them, given the opportunity many will work out their own. One much publicised example being Dennis Potter who named his tumour ‘Rupert’.
Wiggins’ Personal view will hopefully prompt a debate on how we can best help our patients come to terms with their illness. Coping is not an absolute science but it is a subject that is being studied5 .
My own experience is that those patients who do wish to, can find much help in support groups6 .
Eric Watts DM FRCP FRCPath
Retired Haematologist
1 Greer , S et al 1990 Psychological response to breast cancer and 15-year outcome Lancet 335(8680)p49-50
2 Kübler-Ross, E. (1969) On Death and Dying, Routledge
3 http://www.ncsi.org.uk/
4 mapfoundation.org
5 Coping the psychology of what works Ed Snyder, C.R.1999 Oxford University Press
6 www.nationalcancer.org
Competing interests: No competing interests
I read Natasha Wiggin’s (1) article with interest, 24 hours or so into my third cycle of chemotherapy for metastatic colon cancer. Our use of metaphor does appear to follow societial preoccupations – e.g. the persistence of seafaring metaphor in common parlance and those of war and combat when utilized in biomedical practice and so beautifully illustrated by Susan Sontag in her two seminal essays (2).
Those of us with the disease at my Cancer Centre, talk openly with each other about our shared experience. Together we create our narratives and, it is this fortnightly or three-weekly conferencing that gets us through as we collectively receive (or perhaps I should say, are infiltrated by) our drugs intravenously.
With these people I hear little metaphor, but I do hear talk of feelings, friends, families and the wider impact of the illness. When family visit, or medical staff are in attendance, the conversation often changes, and I begin to hear metaphors.
It occurs to me that metaphor may fill the space created by uncertainty. And so where there is uncertainty, and ignorance, both within the physician and within the patient, we use metaphor to bridge those uncomfortable gaps in conversation when we don’t know what to say - an awkward and ill-considered attempt to make both sides feel better. I hear this too from friends in their written and spoken communications (mostly written) and in family groups and, of course, also from the health care professionals. But it doesn’t seem to be a part of the here and now conversations between those of us in the centre.
I suggest that more active listening and less talking to fill the uncomfortable silences could improve the quality of communication with my physician, my nurses and my family – to allow our mutual ignorance and uncertainty to be shared. This way we may feel more human and less embattled.
(1) Personal View: Stop Using Military Metaphors for Disease. Natasha M Wiggins: BMJ 28 July 2012: Volume 345: p31.
(2) Susan Sontag: Illness as Metaphor. 1978. AIDS and its Metaphors, 1988
Competing interests: No competing interests
I enjoyed Natasha's comments and I am in full sympathy with the sentiment stated.
Not only are these military metaphors biologically and psychologically bankrupt; they are actively obfuscating. We become blinded to a deeper understanding and, in consequence, fail to maximise manipulative power.
I have proposed that the primary "purpose" of an immune system is to maintain and, where appropriate, restore tissue homeostasis. Both cancer and infection should gain from ceasing to regard the purpose as a war, where an army of immune cells are sent in to do battle with the enemy. It may be better to view things from the perspective of "how and why did the process of tissue homeostasis fail?" All of us will eventually reach a point where tissue homeostasis collapses and we will die. But we can aim to overturn premature plunges into this outcome.
The advent of a cancer conspicuously indicates that homeostasis has failed. The so-called "war" is already lost unless external intervention can tip the balance. The exciting promise is that we could develop a deeper understanding of how (in cancers) macrophages change their role from the disposal of garbage to encouraging regeneration. In cancer, this regeneration is corrupted and regulatory T-cells support that corruption. We may, fairly soon, begin to understand how we could restore tissue homeostasis and have the immune system carry out our surgery for us.
Competing interests: No competing interests
Re: Stop using military metaphors for disease
There is arguably one useful military metaphor in medicine: the ‘military-industrial complex’, a metaphor for the healthcare complex (‘medical-industrial complex’).
Competing interests: No competing interests