In early August 2016, when we began to write this response to the peer commentaries at the invitation of the AJOB editorial team, a new article appeared in The New York Time’s series “Cell Wars” which explores innovative immunotherapy to “combat” cancer. The new article entitled “Setting the Body’s ‘Serial Killer’s Loose on Cancer” reports a “daring” new treatment “after a long, intense pursuit” (Pollack 2016). For the pioneering researchers and the reporting journalist, the patient’s T-cells are considered the “soldiers” of the immune system. Genetically engineered, multiplied in the laboratory, and injected back into the patient’s blood in millions or billions, the cells are charged like “a vast army of tumor assassins” to “destroy” cancer cells. In the spirit of heroic warriors, one researcher expressed wishes to “conquer” cancer before his death to “end this Holocaust”. Throughout the article (around 5,000 words in length), “kill” or “killer” is used 16 times, “destroy” seven times, and “fight” seven times (one of researchers’ fights was not with cancer but over credit). Words such as “healing” or “care” do not appear at all.

Why has the language of medicine—the art and science of healing—become so violent? Are militaristic metaphors really necessary and ethically justifiable? In our original article, we utilized an interdisciplinary literature review, transcultural dialogue, and philosophical analysis to examine the historical-cultural roots of ubiquitous military metaphors in medicine (and particularly HIV cure research). We identified a series of perils involved, and proposed a more peaceful one—the journey metaphor—as an alternative. We concluded that, ethically speaking, the violent metaphors in medicine are “ironic, unfortunate, and unnecessary”.

Nine thoughtful commentaries to our article provide further arguments and evidence in support of our general conclusion, as well as constructive criticism. Key points of consensus include: (a) metaphors are essential for human thinking and actions, and those employed in representing medicine need to be carefully scrutinized; (b) military metaphors are more harmful in some areas of healthcare than others; (c) uses of metaphor should underscore the healing, caring, and humanizing dimensions of healthcare; (d) more empirical research on metaphors, particularly those incorporating patient experiences, are needed.

For Hauser and Schwarz, recent extensive experimental research in cognitive science and psychology demonstrates the essential role of metaphors in human mental proceedings and the negative effects of militaristic metaphors in the medical domain. Guta and Newman offer further contextual information—the political environments following September 11—for the popularity of the militaristic language in HIV research and care. Drawing upon the ancient wisdom from Hippocratic medicine, Gillett stresses companionship and humanness for HIV care. George and his collaborators outline problems of militaristic metaphors through examining the phrase “War on Alzheimer’s”. They argue that, as dementia associated with aging is radically different from infectious diseases, a militaristic language “dehumanizes the affected” through reinforcing fear, anxiety, and stigma. In palliative care (which aims to relieve suffering), Trachsel considers that it is “absurd, grotesque, and undignified” to apply military metaphors like “killing”, “battling” and “defeating” to end-of-life or dying patients. In treating cancer patients, the main harm of military metaphors (according to Malm) is overdiagnosis and overtreatment. Malm’s commentary offers a counter-account to the violent and sentimentalist language prevailing in the aforementioned NYT article on cancer treatment.

Some alternatives are put forward to help move beyond military metaphors. While endorsing journeys as “shared human experiences”, Perrault and O’Keefe point out that the journey metaphor has its own pitfalls, as journeys can arrive at undesirable and frightening places. They advocate for the plural or mixed metaphors approach so that messages can be individualized to suit the needs of different patients. For George et al., the alternative lies in “narrative strategies” and “ecological metaphors”. We agree that the journey metaphor should not be the only one promoted for use, and that other peaceful and constructive metaphors should be developed and popularized.

The main counterpoint to our argument is that military metaphors can have practical utility for patients. Chambers calls our attention to late-Wittgenstenian philosophy of language and argues that the key question is not about the nature of metaphors, but their uses in certain social contexts. Reflecting upon his personal experience of illness, he refers to metaphors as “equipment for sickness”. According to Chambers, military metaphors can therefore be useful in particular medical settings (such as emergence medicine), but not in others (such as hospices). Similarly, Tate and Pearlman express concerns for our indiscriminate rejection of military metaphors. For them, these metaphors can act as “a powerful source of strength and determination” for some patients, while being “a source of frustration and despair” for others. We concede that, in some contexts, military metaphors (especially those that are mild or pacified) could play a positive role in medicine to some limited extent. This, too, is an area for future empirical research. Our argument is that even if this turns out to be the case, use of military metaphors should be an exception rather than the rule.

As mentioned in the concluding section of our article, the inadequate discussion of the role of military metaphors for patients constitutes a major limitation of our research. Like Chambers and Tate and Pearlman, we call for more studies on how patients use metaphors in first-person narratives. We would not be surprised if military metaphors are also pervasive in patients’ experiences and narratives of illness, and have both positive and negative effects. From an ethical viewpoint, the popularity of the militaristic language among patients does not mean that it is morally justifiable. From the social-cultural and pragmatic perspective, this popularity likely reflects the dominion of the militaristic mentality expressed in everyday language and the unavailability of better alternatives.

It is beyond question that the use of military metaphors is almost always well intended (for the NYT article, to portray the dedicated scientific undertakings of researchers and glorify new medical advances). However, further investigation is greatly needed to explore the use of metaphors that empower patients and mobilize pioneering research without the unintended harms associated with militaristic ones. These harms are documented in numerous previous works, our article, and most of the commentaries. Here, let us highlight a harm for the society at large, a harm we mentioned in our article but just in a passing way: the unintended legitimization and glorification of war and violence. One may argue that the fact that even medicine—the art and science of healing—has so willingly and frequently resorted to the militaristic language (e.g. the NYT article)ⁱ has unintentionally contributed to the persistence of many different types of violence in the world today. At least, it does not help the society to contain violence. The popularity of the militaristic language is founded upon an assumption that, so long as the end is good, such means as war and violence is ethically justifiable. Ironically and unfortunately, most wars were waged and most actions of violence committed because they were believed to be necessary for the perceived “good and glorious” ultimate end.

Healing and war (the major form of sanctioned violence and killing) are inherently in opposition. The habitual use of militaristic metaphors and the violent language in medicine should be renounced because they profoundly undermine efforts to humanize healthcare. Patients’ bodies and minds should not be battle grounds or war zones on which health providers fight. It is a perennial challenge to uphold and realize the vision of medicine as the art of healing and caring, a vision shared in different cultures and societies (e.g., in Chinese cultures, the age-old idea and ideal of “medicine as the art of humanity or humaneness”). In our times, one of the first steps to reinforce this ethical vision is to resist dominating, violent language in biomedical research and healthcare. This task is especially urgent for emerging areas, such as immunotherapy for cancer and HIV cure research. Patients and societies can be better served if these remarkable medical advances are represented through more humane metaphors and language from the onset.