Much of medical intervention is presented in military terms. We talk of “fighting” malaria or AIDS, “arms races” between pathogens and the drugs to hold them in check, and the conquest of various pathogens. While there are instances in which battle metaphors are useful in medicine such as when we explain HIV to patients with limited health literacy as literal battle between soldiers (white blood cells) and foreign invaders( the virus), I argue it also carries a potentially deleterious impact of how health systems operate.
I entered medical school as an aspiring pediatric oncologist so perhaps I am biased but cancers seem to be the constellation of conditions most deeply steeped in battle metaphors. It is my assertion that this characterization plays a large part in the underutilization of palliative care to the detriment of both the health system and patients’ quality of life. The reading and a general awareness of the present state of our healthcare system underscores the potentially enormous financial burdens of medical care. A study from the Mount Sinai School of medicine indicates that “hospital costs for those in the palliative care group were 22 percent lower than for those in the usual care group. Also, costs were up to 32 percent lower for palliative care patients with the greatest number of health problems.” Additionally, “among patients with advanced cancer and other serious illnesses, aggressive treatments are often inconsistent with patients’ wishes and are associated with worse quality of life compared to other treatments”. Despite this clear evidence, physicians typically receive little guidance on how to communicate with dying patients and their families. Additionally palliation or hospice is perceived as tantamount to medical failure and desertion of the patient. This all clearly reflects our society’s need to battle until the end. But let us take a closer look at this mentality. Most of our therapies are toxic: they cause depression of the immune system, fatigue, rash, nausea, vomiting, neuropathy, and so forth. In addition, in today’s insurance landscape, many of our therapies can lead to financial toxicity as well.
JAMA oncology urges us to abandon the battle metaphor for cancer and I am inclined to agree both for the sake of bending the cost curve of end of life care as is so vital to our overall health system but arguably even more so for patients’ dignity and quality of life.