When talking about cancer, metaphors matter

Cancer is hard to talk about. It’s serious, often frightening, and complicated. So, as with many complex topics, we often turn to metaphor. In discussions of cancer, metaphors are rampant. One in particular — that of a fight — is especially common.

She’s battling cancer
He’s putting up a real fight against his disease
You can beat this

Almost five years ago, someone I’m close to was diagnosed, and I started to realize how inappropriate this language felt — at least for this particular case I was witnessing. There was no fighting. There were bed-bound days, invasive procedures, and sympathy cards. One might say that just showing up to every appointment — especially those where you know you’ll feel terrible afterwards — is fighting, but that’s not how it looked to me. So I started to wonder: how does this pervasive “fight” metaphor affect the way we think about cancer? Are there better alternatives?

I was intrigued to find that I wasn’t the first who had asked these questions, and that there’s actually a substantial field of research on language related to illness. There were also articles in popular media, which would pop up without fail each time a famous person was publicly diagnosed with or died from cancer. People were not only using fight-related language to talk about cancer (e.g., Ruth Bader Ginsburg v. Cancer), but they were also questioning whether that language was appropriate (John McCain did not ‘lose’ his battle with glioblastoma — because cancer is not a war) and offering up alternatives (Cancer is a Journey, not a Battle).

But for all the interesting research and commentaries that were out there, I still wanted empirical evidence. When someone talks about “fighting a battle” with cancer, how does that affect the way we think about the illness? And if “battle” is a harmful metaphor, is “journey” better, as is often suggested?

Together with my collaborators Zsófia Demjén, Elena Semino, and Lera Boroditsky, we ran some experiments to learn more about the ways that “battle” and “journey” metaphors affect emotions and thoughts about someone who has cancer.

We learned that when people are told that someone is battling cancer, they predict that the person will be less likely to make peace with their situation and more likely to feel guilty if they don’t recover — because they should have “fought” harder.

We found this by running 5 experiments with a total of 1,629 participants. Every participant received a paragraph that talked about someone battling or someone on a journey with cancer. Aside from the metaphor, these passages were the same, and all participants indicated their agreement with the same two statements after reading:

  • He* will feel guilty that he hasn’t done enough if he does not recover.
  • He can make peace with his experience.

The fact that participants believed that someone battling would be more likely to feel guilty and less likely to make peace should give us pause. These are not optimistic beliefs and may not be conducive to healing.

But it’s also crucial to remember that this was an effect averaged over a lot of participants. It does not tell us that the battle is pernicious for all people in all cases. There may very well be people who prefer the battle metaphor, who feel energized and motivated by it, and who feel it most accurately captures their situation. But that’s a decision for people with cancer to make.

It’s not a decision for doctors, journalists, researchers, or even close family and friends to make. We should not impose our language on people with cancer (or any other illnesses, for that matter). If their experience is a battle, it’s a battle. And if it’s not a battle to them, we should not call it one.

The most important take-away for me, then, is not that we should use one metaphor and not another. It’s that metaphors are powerful tools, and we need to be thoughtful about how we wield them.

Here’s the link to the full paper. Please cite it as: Hendricks, R.K., Demjén, Z., Semino, E., & Boroditsky, L. (2019). Emotional Implications of Metaphor: Consequences of Metaphor Framing for Mindset about Cancer. Metaphor and Symbol, 33(4).

Featured image by Timothy Eberly on Unsplash

*In all studies except one, the subject of the paragraph was a male. We did this so we could most clearly understand the effects of the metaphor when all other characteristics of the information were the same. We did explore gender in one study (Experiment 4 in the paper posted above), but a lot more should be done to understand how the ways in which identity might interact with the effects that metaphors have on thinking about cancer.

The problem with things that “cause” cancer

Causation is a tough concept to wrap our heads around. In its simplest sense, we say that one thing causes another when the first made that second thing happen. This is usually a 1:1 relationship. A leads to B, regardless of whether some other things do or don’t happen, and without A, B would not happen.

One common error is to attribute causality when there is none. It’s this type of thinking that leads us to believe that we need a lucky pencil to take tests – with it, we’ll ace the test; without it, we’ll bomb. When two things are correlated (for example, losing fifteen pounds and getting asked on more dates), it’s easy to make a causal inference, even when it’s not warranted. This is the reason that science teachers drill the phrase CORRELATION IS NOT CAUSATION into students’ heads.

Image: xkcd

We can also make the reverse inferential mistake; that is, when one thing does actually cause another, we can interpret it as a correlation. This is especially true when ascribing to causation would require that we change our behavior. For example, we might be less likely to really buy into the idea that obesity leads to heart disease if it suggests that we should change our habits, instead diluting the relationship to a more correlational one in our minds, acknowledging that, yeah, people who are obese tend to have more heart disease, but there are plenty of obese people who don’t, so maybe there’s no need to cut out the Big Macs just yet. This is commonly referred to as cognitive dissonance: having inconsistent thoughts, beliefs, or attitudes, especially as relating to behavioral decisions and attitude change.

To further complicate causal thinking, many things don’t have 1:1 causes. A might cause B, but only in the presence of C, D, and E, or only in the absence of F and G. And sometimes one of those factors that mediates whether A causes B is pure randomness. This is another concept that is really difficult for humans to wrap our heads around, but randomness has played a huge role in making us the creatures we are and making the world the place it is today.

This week the World Health Organization (WHO) made a splash by releasing guidelines that placed processed meats in the same “cause” category for cancer as smoking and asbestos. What does this mean? It means that the WHO is confident that processed meats increases our likelihood of developing cancer. It does not mean that they increase our chances of getting cancer as much as asbestos or smoking do, but that they are equally confident that all of these things do in fact increase cancer risk. This is not one of those straightforward A causes B types of causation, though. We know that there are some people who eat lots of processed meats and never develop cancer. The causation is one of the more complicated types, most notably involving randomness. If someone eats a lot of these meats and then the right randomness (genetic mutations) take place, that person is more likely to end up with cancer than someone who didn’t eat any processed meat but experienced the same randomness (though that second person could very well get the disease too, as we know).

So the word “cause” is not a lie, or even an exaggeration. It’s true. But how do we interpret it? This week, it seems that most people interpreted it as the 1:1 relationship cause, accounting for much of the media hype. It might seem, then, that we should avoid this chaos-inducing word, and instead go for something less anxiety-provoking: maybe “linked to” or “associated with” would get the job done.

These weaker phrases have their own drawbacks, though, precisely because they induce less alarm. They are likely to encourage more cognitive dissonance, more of the reasoning that this is not something that affects me personally and I therefore shouldn’t feel as compelled to overhaul my sausage-filled diet.

There is probably no single verb that can be used in a headline to capture the relationship between certain behaviors and cancer risk, one that will encourage the right amount of alarm. Our best bet is to be aware that there are no perfect words to talk about complex ideas, and that means we will inevitably use imperfect words, words that mislead in different ways. Sometimes it takes some media chaos for an issue to get the attention it needs so that people can understand a situation and make informed decisions. Hopefully this is one of those times.


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Battling cancer or…?

I’ve been thinking a lot about how we talk about cancer (and illness more generally) over the past few months, one metaphor seems pervasive, almost inevitable: cancer as an enemy that we battle. We say that someone is fighting cancer, and eventually every patient will either beat it or lose his battle to cancer.

Luckily, there’s been some research on the cognitive consequences of using the battle metaphor. This article by Charlie Cooper talks about work by Elena Semino (which I’m having trouble finding). He writes that her work shows negative effects for many cancer patients when their disease is framed as an enemy to battle. It doesn’t seem surprising that this metaphor might encourage people to feel personally responsible if their health worsens. Semino does say that the metaphor isn’t necessarily harmful, though – if a patient introduces it on his own, it might be a motivator. Semino and her colleagues also found that cancer is often talked about as a journey. For example, living with cancer might mean being on the hard road. This metaphor seemed less potentially harmful, instead instilling a sense of companionship among people with cancer. The conclusions about the effects of both metaphors are based on corpus analyses, so it would be very cool to see a lab version that examines the different inferences people make about the disease when it’s framed as a battle versus a journey.

Image: http://www.cancerhealercenter.com/blogs/how-india-is-showing-the-world-a-way-to-fight-cancer/
Image: http://www.cancerhealercenter.com/blogs/how-india-is-showing-the-world-a-way-to-fight-cancer/

I did find one lab study by Hauser and Schwarz on the war metaphor for cancer, but it examined the effects on healthy people, as opposed to those living with the disease. Specifically, it looked at how framing the disease as an enemy to be fought affects people’s preventative behaviors. A number of behaviors are associated with cancer – unhealthy diet, excess sun exposure, and smoking, for example. The authors distinguished between limitation cancer-associated behaviors (things like limiting unhealthy foods) and engagement cancer-associated behaviors (things like be lean and engage in exercise). The first category contains things we should do less of, and the second contains things we should do more of.

The researchers found that when cancer was framed as an enemy, people could think of fewer limitation behaviors, and in a separate study when given the limitation behaviors, they reported less of an intention to limit these behaviors. They report that these findings are consistent with the metaphor because when we’re fighting an enemy, our priority is on attacking, as opposed to limiting certain behaviors. Thus we might expect that the enemy metaphor increased people’s intentions for engagement behaviors, but this was not the case. Further, they found that when they reworded the limitation behaviors to sound more like engagement behaviors, people were more likely to induce them if they had read that cancer was an enemy, suggesting that they avoided endorsing those same behaviors earlier because they were framed as limitation behaviors, and reading the enemy metaphor did not put people in a limitation mindset. Since referring to cancer as an enemy reduced people’s likeliness of following important limitation behaviors and did not affect their intentions for engagement behaviors, the authors conclude that the metaphor seems to bring more harm than good.

I’m excited by these preliminary results, and I’d love to see more. Are there other metaphors that might be more productive? How do these metaphors affect people with the disease? Do they affect a person’s treatment decisions? We wouldn’t need to test this on cancer patients, necessarily, but could ask healthy participants to imagine they had the disease and reason abut it accordingly. How do the metaphors affect cancer patients’ caregivers? One difficulty in addressing these questions is that whether people are exposed to the enemy metaphor or not in a lab study, they’ve almost definitely been exposed to it many times outside the lab, and those prior experiences will follow them into the lab. Regardless, the general question of the cognitive effects of disease metaphors seems to be an important and addressable question.

In my own conversations, the enemy metaphor didn’t seem appropriate in a lot of contexts – lots of patients go to doctors’ appointments and cope with treatments and side effects, all of which are unpleasant but might not really involve fighting (in fact, minimal fighting seems to be the ideal). Surely, living with cancer requires a lot of mental toughness, but many things require toughness that we don’t talk about as battles (like earning a PhD, for example – I don’t think we’d say that the average person battles grad school). Even the journey metaphor, which Semino’s team found in corpora, seems a little weird. So if we think the battle metaphor is harmful, what’s a better way to talk about the disease?