The way we talk about illness matters. This is perhaps no more evident than in the many passionate critiques of the metaphor of the “fight” against cancer, which many of us will eventually “lose”.
In the 1970s, Susan Sontag famously exposed the negative implications for patients of this “military rhetoric about cancer”. In 2010, Robert S. Miller listed the military metaphor as one of “eight words and phrases to ban” in cancer care because, despite some finding it useful, many patients detest it. Kate Granger, a doctor with advanced cancer, warned that she would come back to curse anyone who described her as having “lost her brave fight”. She wrote:
I do not want to feel a failure about something beyond my control. I refuse to believe my death will be because I didn’t battle hard enough … After all, cancer has arisen from within my own body, from my own cells. To fight it would be ‘waging a war’ on myself.
Battle metaphors should not be imposed on patients by their families, healthcare professionals or even by well-meaning fund-raising campaigns. Not surprisingly, some official strategies have opted to talk about a patient’s “cancer journey” rather than bellicose metaphors for the patients’ experience. The Cancer Institute of New South Wales discourages the media from talking about the patient’s “fight” against cancer, instead suggesting “journey” as an acceptable alternative.
Angelina Jolie Pitt talked about her own mother “fighting” ovarian cancer for almost a decade before dying aged 56, but used a journey-related metaphor for her own life when she wrote in the New York Times after surgery to remove her ovaries: “I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared.”
A reinforcing expression
However, recent research we published in BMJ Supportive & Palliative Care shows that we should focus less on what metaphors to ban or promote, and more on how different metaphors work for people with cancer. We analysed a 500,000-word collection of online forum contributions by people with cancer. Using a combination of close textual analysis and computer-aided methods, we identified 2,493 uses of metaphors in the data, including 899 violence metaphors (such as “battle” and “fight”) and 730 journey metaphors. We then considered the implications of each use by looking at its context. There was no simple dichotomy between violence and journey metaphors.
Both types of metaphors can be used to express and reinforce a sense of disempowerment in the experience of illness, which is usually associated with negative emotions. Conversely, both can also be used to express and reinforce a sense of empowerment, usually associated with positive emotions. Empowerment here is to do with the degree of agency that the patient has, where the person actually wants to have that agency.
There is no question that violence metaphors can be detrimental for patients. They can contribute to helplessness and anxiety, for example when patients writing on the online forum say that they feel “attacked” or “invaded” by the cancer, or describe it as a “killer” that “strangles and shocks your soul”. If the battle metaphor is used for the terminal phase of the disease, it can make someone feel like a failure or guilty for not winning.
Yet in our data, the word “fighter” was always used positively to praise oneself or others for being active, determined and optimistic in spite of difficult circumstances. One person explicitly said: “cancer and the fighting of it is something to be proud of.” Amanda Bennett makes this very point in a passionate TED talk about the “exhilarating fight” she and her husband decided to fight together against the cancer of which he eventually died.
In the same way, journey metaphors can be empowering when they are used to express a sense of acceptance, purpose and control, which may even lead to finding some positive aspects of being ill, or when they are used to suggest companionship and solidarity with others – of being “all in it together.”
Journey metaphors do not position the disease as an opponent, and therefore appear to cause no harm. However, things are not quite so simple. For several patients in our data journey metaphors were disempowering. They were used to express feelings of helplessness and frustration, particularly in the face of “navigating” a journey that patients hadn’t chosen to embark on. Another person talked about people with cancer as “passengers” on a journey they could not control.
Metaphors are resources for talking and thinking about one thing in terms of another, and they come in many varieties: the patients in our data also used metaphors to do with sports, fairgrounds, animals, music, machines, and many others. When metaphors work well, they can be enlightening, comforting, and empowering. When they work badly, they can be confusing, disheartening, and disempowering.
No metaphor works in the same way for everyone. And this is particularly the case when it comes to illness. We should be enabled and encouraged to use the metaphors that work best for us. We are currently working on a “metaphor menu” for cancer patients: a selection of quotations from people with cancer that exemplify the widest possible variety of metaphors. We are exploring how this menu can be made available to patients with new diagnoses. As with dishes in a restaurant, different people will find different metaphors more or less appealing, but, ideally, each individual person will be able to recognise or discover one or more metaphors that are helpful for them.