“There is the ‘fight’ or ‘crusade’ against cancer; cancer is the killer disease; people who have cancer are ‘cancer victims.’” – Susan Sontag in Illness as Metaphor

“While many doctors speak of themselves as “problem-solvers” or as “working out puzzles,”, some use a more vivid metaphor, likening themselves to “detectives,” thereby picking up on the parallel between the ways in which members of the two professions collect and analyze evidence.” Michelle Hanne in Diagnosis as Metaphor

When concepts are too complicated to understand, we often turn to metaphors to help explain them. When speaking to children, this is often the approach we take to help answer the many questions they tend to ask. We often tell them that life is a rollercoaster, or when they are scared, we tell them not to be a chicken. In the same way, physicians often turn to metaphors to help better explain to patients what it is that is going on with their bodies. While some argue that metaphors help patients better understand their pain, and comfort them when facing deadly diseases, such as cancer, others argue that they give patients a false sense of security and that the use of metaphors in medicine can actually be quite dangerous. As with explaining complex concepts to children, metaphors often oversimplify illness in the eyes of a patient, and when this oversimplification and false hope does not result in the curing of a disease, it can lead to much greater pain and suffering than if patients were just told the truth. If throughout their treatment they are given the impression that their illness is not complex and they will likely survive it, the patient will experience greater disappointment if this does not work out than if they were, from the beginning, given the truth about the complexity of their illness and the probability of it being cured. Two metaphors that are often used in the field of medicine are the ideas of “the fight or crusade” against illnesses such as cancer, and the idea of the “Physician as a detective”. While both attempt to help patients better understand their illness and the journey that they will have to go through in order to deal with it, they take different approaches in doing so. While the war metaphors make the patient feel as if they must be strong at all times and can never show emotion because they must “defeat” their illness by fighting a war, the metaphor of the physician as the detective gives patients more reassurance as they know that their doctor will take a more holistic and gentle approach to their treatment than if the patient had to fight a “war” on their own. While both metaphors have their benefits and downfalls, making the connection between a physician and a detective is more effective because it helps patients feel as though they have more support and a better chance at survival, while war metaphors make patients feel isolated and unable to share their emotions because they must be brave and win the “war” against their illness on their own. 

In her book, Illness as Metaphor, Susan Sontag, a patient of cancer herself, speaks about the common reference of the treatment of a patient with a disease as a “fight” or a “crusade.” In making this reference, Sontag brings up the idea that the disease is often seen as the culprit, but this blame is then shifted onto the patient. Sontag states that “ Widely believed psychological theories of disease assign to the ill the ultimate responsibility both for falling ill and for getting well” (Sontag, 57). When having an illness, the patient is thought to first somehow have developed it, and must now go through the “crusade” of curing it. A crusade is often characterized as a long and passionate fight against something that you feel strongly about. In describing the illness as a crusade, the patient is unconsciously made to think that the disease is the “enemy” that they must battle. At the end of most crusades throughout history, such as religious crusades, or in works of fiction, the “evil,” or the “enemy” is defeated. In the case of a patient dealing with a deadly disease, this then gives the patient false hope that they too will surely win their battle against whatever disease it is that they are fighting. They are given the blame for developing the illness, but are also burdened with the responsibility to defeat their “enemy,” by “winning the crusade.” The word “crusade” differs from “fight” in that it shows immense amounts of passion involved in whatever is being fought for. In this way, when a patient is told that they must fight a “crusade,” they are likely to be more physically and emotionally invested in their “quest” to win and will most likely not want to show emotion or weakness because they want to “win” so passionately. In religious crusades, for example, soldiers are willing to sacrifice anything in order to win and will never admit defeat or surrender, which are things that are possible in a “fight” or a “war”. This becomes dangerous when a patient refuses to accept the truth that their illness is too strong or that they have not “won” their “crusade”. The strength of the word itself makes the metaphor extremely dangerous.

This metaphor becomes even more lethal to the patient, however, when they must come to terms with the fact that they have lost this “fight”, as many often do. As Sontag goes on to explain, “And conventions of treating cancer as no mere disease but a demonic enemy make cancer not just a lethal disease but a shameful one” (Sontag, 57). When describing an illness as a war or a battle that must be fought and conquered, the risk that comes with it is the chance that the patient might not win this battle, which then leads to them thinking that they were not strong enough. The term often used when a patient dies of a disease, especially one like cancer which has an extremely high mortality rate is that the patient “lost the battle with cancer.” Not only does this then emphasize that the patient will not live, but also creates a sense of shame for them, in that they were not able to “win” this crusade that the doctor had told them they were fighting. It downplays the patient’s experience and makes them seem weak, which becomes more important when the patient’s problem is something involving mental illness. If a patient already struggling with mental illness such as depression is then told that they are too “weak” and that they are “losing their battle,” this is likely to make the condition worse for the patient and lessen their will to continue treatment. 

Similarly, as the act of fighting a disease is called a “fight” or a “crusade,” the patient themself then becomes a “fighter,” as brought up by Dhruv Khullar in The Trouble with Medicine’s Metaphors. When speaking of his Aunt’s death due to lymphoma he states, “I’ve long wondered whether that word—fighter—and the other military language used to help her conceptualize her disease did more harm than good. Did she, on some level, feel she lost the battle because she didn’t fight hard enough?” (Khullar). While physicians often use the metaphor of a patient as a fighter as a means to give them the courage to go through their treatments and be strong enough to “fight through” the pain, there are both negative and positive outcomes that come with this choice of using warfare terms when referring to patients and their illnesses. The patient could interpret the word “fight,” as though they are battling their own body. We put too much burden on the patient and expect them to be strong in their conflict with their own body by describing it as a “fight”.

When patients are referred to as “fighters” they may feel the courage to “soldier on” through treatment and pain in order to defeat illness and return to a healthy state. In a positive sense, being a soldier or a fighter may invoke “ideals of courage, resilience, and determination” (Khullar). The patient may feel as if they are better equipped to face their illness and treatments if their physician sees them as strong enough to be a sort of soldier in their journey to better health. However, on the opposite side of the spectrum, patients described as fighters may often also feel that they cannot express their pain or suffering because they will be seen as weak, which is not a characteristic that they want to have, as a “solder” or a “fighter” against their illness. Often, being made to think that they must be strong in facing their illness, patients seem to feel burdened and thus, also suffer emotionally and mentally, as “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” (Khullar). These patients also tend to report higher pain scores and lower coping scores. These all come as a consequence of feeling as though they are alone in their fight against their disease because they must be strong and brave against their enemy. These patients who see their illness as their “enemy” that they must “soldier” against, often do not speak to their families and doctors about their pain because it will upset their loved ones and make them seem weak. 

           On the other hand, however, when physicians are referred to as “detectives”, it can many times give both the patient and the doctor some reassurance. The diagnosis of an illness is an entire journey rather than just an investigation. Just as a detective puts forth a line of suspects and possible leads, a doctor must explore many different possible illnesses or diseases, and do many different tests in order to be able to diagnose a patient correctly (Hanne, 38). Even then, as with detectives, there is always a possibility that something was looked past and the diagnosis was incorrect. Detectives and doctors both apply deductive reasoning to reach conclusions about the “puzzles” in their field, whether that be crimes or illness. In addition, as detectives help restore order and coherence in the criminal world by finding and identifying the culprit of a large crime, doctors bring restoration into the lives of patients by identifying symptoms and causes, making a diagnosis, and ultimately working to cure the illness or disease that is bringing stress and chaos to the patient’s life. Both detectives and doctors, in that way, work to bring comfort, whether it be to society, in the identification of a criminal, or to a patient, in the work to curing an illness. 

          In addition, when comparing a doctor to a detective, the patient ultimately becomes the “case” that they must solve. The physician must work to piece together the story and solve the mystery. Speaking in medical terms, this means the doctor must run all the tests, listen to the patient’s symptoms, do research, and then try to diagnose and treat the disease. This, in turn, gives the patient more reassurance, knowing that the physician is evaluating the situation and doing everything in their power to help them. In this metaphor, it is as if the doctor is taking a more holistic approach and trying to see the illness from all different angles before giving a diagnosis (Hanne, 38). They are putting all of the variables together in order to piece together the problem before they attempt to try to solve it. As a detective would interrogate all suspects and follow all leads to make sure that they get to the right conclusion, a doctor would take into account all of the symptoms and think of all courses of treatment before deciding on one. This takes some of the pressure off of the patient in that they then know that the doctor has taken full responsibility to make sure the patient gets the best care they can offer and that, though not always successful, the doctor is considering everything and making the best decision that they can in terms of care in order to try to cure the problem. This allows the patient to trust the doctor and be able to share some of the burdens that they care in that they trust their physician enough to confide in them.

While both metaphors assign roles to either the physician or the doctor and attempt to make illness more understandable and easy to comprehend, the metaphor of a doctor as a detective does this in a more effective way. This metaphor allows the patient to be more comfortable in the care that they are receiving in that they know that, like a detective, their doctor is trying their absolute best to consider all facts and come up with a solution to the problem. In comparison to war metaphors which describe patients as soldiers and illness as war, a doctor being a detective gives a more gentle and intellectual, thought-out connotation to illness, rather than a brutal, deadly one. While war metaphors make patients less likely to share their emotional burden and lead them to think that they are “weak” if they don’t “win the battle” against their illness, the detective metaphor gives them hope and trust in their doctor and allows them to believe that they are not going through the situation on their own and that they can depend on their doctor to help guide the way through the “fight” with their illness. War metaphors require patients to deal with the situation with brute force and make them feel as if they must always be strong and power through whatever illness it is that they are dealing with. On the other hand, the detective metaphor shows more of a gentle take on treatment and allows the patient to display their emotions more without feeling weak or as if they must force anything. In either situation, it is the patient’s own mindset that determines how the metaphor functions. 

While in some situations, war metaphors may feel daunting, in others they may help the patient feel stronger. As for the detective metaphor, while in some situations it may make the patient feel as if the doctor is being more careful and gentle in treatment, in others the patient may feel uncomfortable that their illness is a “mystery” that must be solved. In either case, both the doctor and the patient are being assigned roles through these metaphors that attempt to make the situation easier for the patient to comprehend and face. In the world of medicine, however, nothing is as easy as “winning a battle” or “solving a mystery” in the ways that these situations are romanticized in media. In the end, however, these literary techniques are used merely for doctors and their patients to have a common language and for patients to be able to better express what they are going through. While the detective metaphors seem to be gentler and less isolating, and the war one seems to put an immense amount of pressure on the patient, whether or not either of these is effective is not something we can conclude for all patients, but is rather personalized for each individual. The metaphor that should be used is whichever one the patient is more comfortable with because, in the end, “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” (Khullar).