The metaphor of war in medicine is pervasive. We talk dispassionately of battling cancer and fighting infections with "big gun" antibiotics. Such violent imagery in a profession that seeks to heal and comfort seems incongruous. Caring for terminally ill patients during medical school and residency has convinced me that an unthinking adoption of this metaphor can hurt our patients.
Louie was a short man, but he looked imposing as he sat at the edge of the bed with his spine ramrod straight. "Doc," he said with the imperiousness of a sergeant major, "what's the plan of attack?" I explained that I needed to hear his story before devising any therapeutic plans. With a sigh, he told me about his recent diagnosis of cancer, sudden breathlessness, and his goal of walking out of the hospital independently. In the days that followed, Louie warmed up to our team, often greeting us with an impish smile and ending each interview with the same enquiry: "So, what's the plan of attack?" Then he would express his willingness to undergo any procedures that we thought necessary.
He did walk out of the hospital when his breathlessness improved but was readmitted within a week with grim news: His chemotherapy had failed -- he had weeks to live.
When I went to readmit him, Louie was hunched on the bed facing away from me. His wife, Deb, was by him, whispering encouragements. Louie's transformation from an officer in command to a defeated soldier was stark. Gently, I informed him about hospice care, and he agreed to it. But the next day, Deb confided that I was no longer his "best friend" as Louie felt that I wasn't "fighting for him" any more.
The metaphor of conflict is popular for understandable reasons. Seeing medicine as a fray against ruthless microbes or rogue cancer cells feels intuitive. Moreover, this metaphor unites physicians and patients against a common enemy -- the disease, and, shadowed behind it, death. As physicians, we find great purpose in the role of our patients' defenders with an armamentarium of chemicals, radiation, and knives at the ready. As patients, we feel ourselves transformed from passive havers-of-disease to active soldiers determined to crush the disease's assault on our identities, our lives. Families and friends find purpose as our comrades in the war.
Metaphors empower patients by making the rationale and consequences of complex medical conditions and interventions more accessible. They offer patients a framework within which they and their families can reason and make difficult decisions. But martial metaphors often come with heavy personal and cultural baggage. Many of my patients are veterans for whom ideas of war evoke powerfully held beliefs. To many valiant veterans, death is not as daunting as the indignity of quitting. Many accept horrible side effects as inevitable collateral damage in battles against disease. As soldiers, they were trained to obey orders unquestioningly. In a medical war, doctors are de facto generals and soldierly obedience can lead to poorly considered acceptance of recommended treatments. We should think carefully before enlisting our patients, soldier or not, to wage a personal war.
As early as 1983, reflecting on medical ethicist James Childress' published concerns about war imagery in medicine, Dr. John Burnside mused on medicine as war in the Journal of the American Medical Association. In the decades since, numerous physicians have written well-worded essays on the topic. But the metaphor endures, with no deliberate, large-scale effort to find alternatives. Indeed, my microbiology textbook in medical school equated bugs and drugs with terrorists and missiles. How can doctors thus trained not reflexively resort to martial metaphors?
During rounds, I squatted next to Louie and looked him in the eye. While we had little hope of lengthening his life, perhaps we could change the way he lived it. "Louie," I whispered, "we aren't fighting a war. What we have here is an opportunity to co-author the final chapter of your life and give it a perfect ending, one in which your family finds peace." This new metaphor was not a magical salve that made everything okay, but I believe the role of an author crafting a perfect ending suited Louie better than that of a defeated soldier. Our final conversations were not about chemo but, rather, about the heritage he was proud to leave behind.
A week later, I found myself at Louie's deathbed. So-called "heroic measures" like chemotherapy and CPR were not part of his final chapter. His family encircled him. I held his brawny hand as he took his last breaths. Our focus was on the man, not the fraction of oxygen he was breathing. There were whispered stories, both funny and inspiring, of a life well lived. There were tears, but they were punctuated by laughter. There was peace, not war.
I believe that leaving the metaphor of war behind and finding more appropriate imagery will change health care for the better. After all, patients need doctors, not generals.