Stop telling people they're fighters who will 'beat' their unsurvivable disease

Ever since Sen. John McCain announced he had brain cancer, a chorus of voices from around the globe has urged him to “fight the cancer.”

But McCain reminds us that in the face of life-limiting illness, it's not that you're a fighter that's important. It's what you are fighting for. Families, friends and, yes, doctors of patients with serious or critical illnesses would do well to get clear on the difference.

Metaphors invoking war, battle and the fighting spirit are commonly used in response to diagnoses of cancer. They are often heard in the language of families whose loved ones face critical illnesses with poor outlooks in intensive care units. This is not surprising.  Adversity often elicits the impulse to fight. This impulse can help those facing difficult but surmountable challenges, such as some curable cancers, or survivable critical illnesses.

But should fighters always fight the illness?

What happens when the illness is not survivable — almost certainly the case for McCain?  Should we forgo the language of battle, as some palliative care experts suggest? They point out that it can create a sense of shame or failure when the disease progresses: “I must not have fought hard enough. I've let my family down.” 

Certainly, clear communication about achievable outcomes is important, so that patients are not unknowingly fighting for the impossible. As palliative and hospice care doctor BJ Miller points out, the war with death is one that, ultimately, no one wins.

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But here’s the most tragic unintended effect of assuming that fighters should battle against the disease: the missed opportunities to fight for things that are most important — and achievable. Those would include time with family, completion of estate planning, restoration of relationships and even bucket lists.

When one of my palliative care patients tells me, “I'm a fighter,” I don’t tell her that the fight is futile. Instead I ask, “Tell me, what should we be fighting for?” 

Once I know what's most important to my patients, I can draw on my medical knowledge about what is possible to help them direct their “fight” toward the achievable goals. I can also help them avoid expending what is likely a finite amount of time, energy and spirit on the ones that are unattainable. 

To be sure, some cancers are curable, and fighting with all available weapons to overcome them is a choice many would make. But other people face cancers that will almost certainly claim their lives and could result in loss of critical abilities before that. Up against a threat of that nature, it is vital we help people choose with great intention what they will fight for.

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McCain’s actions have shown us that he understands this. In the face of serious illness, he is spending time with family and speaking his mind on issues such as President Trump's transgender military ban and the pardon of former sheriff Joe Arpaio. Last month, after his diagnosis, he returned to Washington to cast a "no" vote on a flawed health bill. He continues to urge his colleagues to recommit themselves to working across party lines on health care and other issues, including his longstanding dream of immigration reform.

In his case, heroism has never been about charging recklessly against unbeatable opponents but about fighting patiently and steadily for what is right. This is the power of fighting for something meaningful.

Next time we learn of a public figure or a family member or friend who is facing a life-limiting illness, let's feel free to use the war metaphor if it feels right, but with a bit of a twist. Instead of “You can beat this,” try “What can I help you fight for?”

Kathryn B. Kirkland is director of palliative medicine at Dartmouth’s Geisel School of Medicine and a Public Voices fellow at the OpEd Project. Follow her on Twitter: @KB_Kirkland

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