"I don't want to be remembered a loser. I don't want my obituary to say that I lost the battle."
This is what my first patient to request medically assisted death said to me in August. He had cancer, and his chances of getting better were slim. Almost impossible. In just a week, cancer had stripped him of his identity and independence. He didn't see a point in fighting. And that did not make him a loser.
Battle language is everywhere in my profession—it's really common for us doctors to say things like "we can beat this" or "you are a fighter" to cancer patients. But not everyone finds this language inspiring.
These words are hardly unique to cancer—but somehow saying we will annihilate kidney disease or destroy asthma lacks the same appeal.Toronto's Sick Kids Foundation took a big risk extending violent, military imagery into all pediatric illnesses when it dropped its new "VS" campaign earlier this month. And with almost half a million Youtube hits and a ton of media coverage, it's certainly paying off. But the first of a series of ads—featuring children donning war paint and marching military style set to a throbbing hip hop soundtrack—made a lot of people uncomfortable.
This is because there is a growing body of evidence that imposing military metaphors on patients can actually cause harm. And the idea of extending that harm to kids is frightening.
Research from the University of Lancaster has already shown that battlefield language can lead to feelings of failure and guilt among terminally ill patients.
"When the metaphor is used in situations where the disease is incurable, that makes the person who is dying a loser and responsible for not getting better," linguistics professor and lead researcher, Elena Semino, told me.
Her latest study, to be published early next year, found that violent language was used as often in North American conversations as in Britain. But Americans avoided talking about death and used aggressive language far more in describing end-of- life care. This is probably because death is often seen as a failure in North America, and we don't like talking about when we "fail."
This is not surprising to palliative and intensive care specialist, James Downar, at Toronto's University Health Network. He says it's easier for doctors to continue with aggressive treatment than to tell a patient or family "I can't turn this around."
But he also says that labelling all patients as fighters can influence them into taking futile, potentially harmful, treatments so they are not viewed as "quitters."
Downar acknowledges that for some patients, the language of warfare can be empowering. But it can also make others feel personally defeated as their condition deteriorates.
Terminal cancer patients are not the only victims. A 2014 University of Michigan study found that framing illness within the combat metaphor reduced beneficial behaviours—like quitting smoking and avoiding unhealthy foods.
And it can contribute to the over-aggressive treatment of milder illness, says pediatric cancer researcher and radiation oncologist Edward Halperin.
Patients may overestimate their risk of dying and seek immediate treatment so they can "fight."
"It's difficult to tell patients–you have cancer, we are going to watch it–even if observation is most appropriate. We may be grossly overtreating some conditions as a result."
The language of warfare also does not resonate with David Giuliano, who was diagnosed with a rare type of tumour in connective tissue more than a decade ago.
"[Cancer] is a part of my body. To battle with it is to battle with myself. I'm looking for new metaphors," says Giuliano, who describes his cancer experience as a pilgrimage or a journey. "The battle metaphor doesn't feel right. It doesn't feel respectful."
According to Semino, it can be difficult for patients like David to choose other language to use.
"Metaphor is a resource for talking and sense making," she said, "but when battle language becomes dominant and part of public discourse, it makes it difficult to distance yourself from it and find an alternative metaphor."
Fundraisers play a large part in keeping battle language in the public dialogue. The Princess Margaret Hospital Foundation (PMHF) is no exception, raising more than $88 million last year with its core message "Conquer cancer in our lifetime."
"We firmly believe in our creed... it has mobilized our donor and volunteer community," Christine Lasky, the foundation's chief brand officer, told me.
Princess Margaret did not specifically engage groups of patients when crafting its messaging about eight years ago, said Lasky, because of privacy concerns. Instead, medical professionals were used as "spokespeople for [their] patients" and the general public included some "people who have been touched by cancer."
Meanwhile across the street on Toronto's hospital row, the Sick Kids Foundation undertook a full year of engagement with patients, families and staff for their new branding—including conversations with grieving families. It wanted to be confident it had something that would empower patients and families.
And it also had a "go big or go home" approach, according to Lori Davison, a VP with the foundation.
"We are moving into the most significant fundraising campaign in the history of Canadian hospitals, with the goal of $1.3 billion... and we know we are not going to get there by reminding people of what they already know."
The first ad was geared toward expanding the donor base to include younger and male donors, but also to "jolt the community and make people sit up and take notice," said Davison.
We shouldn't fixate on the first ad, says Jay Chaney, chief strategy officer of Cossette, the agency that developed the campaign pro bono.
"The tone evolves... we've tapped into this real, emotional experience of the hospital. We speak to the range of experiences, breakthroughs and losses that happen at Sick Kids."
The next video, due to come out November 7, features a young girl who died of cancer and has a much softer tone. And, according to Davison, the intention is not to portray those who die as weak or losers.
"We have been conscious of that perspective and sensitive to it. It's not Grace vs. Cancer. It's Sick Kids vs. Grace's cancer."
But Downar still warns that fundraising battle messaging often resonates most with survivors and those who have never been sick. "If you are going to call it a battle or fight, you have to understand you are calling a large proportion of patients losers."
Dr. Seema Marwaha is a Toronto-based internal medicine physician, communications researcher and a Munk Global Journalism Fellow.