Dr Caitríona L Cox’s recent article expounds the far-reaching implications of the ‘Healthcare Hero’ metaphor. She presents a detailed overview of heroism in the context of clinical care, revealing that healthcare workers, when portrayed as heroes, face challenges in reconciling unreasonable expectations of personal sacrifice without reciprocity or ample structural support from institutions and the general public. We use narrative medicine, a field primarily concerned with honouring the intersubjective narratives shared between patients and providers, in our attempt to deepen the discussion about the ways Healthcare Heroes engenders military metaphor, antiscience discourse, and xenophobia in the USA. We argue that the militarised metaphor of Healthcare Heroes not only robs doctors and nurses of the ability to voice concerns for themselves and their patients, but effectively sacrifices them in a utilitarian bargain whereby human life is considered the expendable sacrifice necessary to ‘open the U.S. economy’. Militaristic metaphors in medicine can be dangerous to both doctors and patients, thus, teaching and advocating for the critical skills to analyse and alter this language prevents undue harm to providers and patients, as well as our national and global communities.
- applied and professional ethics
- health workforce
- health personnel
- interests of health personnel/institutions
- clinical ethics
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- applied and professional ethics
- health workforce
- health personnel
- interests of health personnel/institutions
- clinical ethics
In her recent article, Dr Caitríona L Cox discusses the ethical implications of labelling healthcare workers as ‘heroes,’ a metaphor that stifles discourse around the obligations to treat and to care.1 Dr Cox presents heroism and supererogatory actions in the context of epidemics, arguing that crude narratives minimise nuance and prevent discussion of the social contract between healthcare workers and society. Cox states that the hero metaphor fails to acknowledge reciprocity, obscuring the obligations of national institutions and the general public to offer structural support during crises. Narratives of heroism additionally thwart self-protective behaviours among healthcare professionals while rationalising their very expendability.
Cox’s discussion can be deepened with a narrative medicine approach. Narrative medicine is a health humanities field which combines ethics, philosophy, literary theory and creative arts to contextualise individual stories of suffering in larger structural contexts. In narrative medicine workshops, facilitators may ‘thicken a story’ by “tell[ing] it in a new way to a responsive listener”, thus finding richer meaning.2 To Cox’s argument, narrative medicine helps ‘thicken’ our understanding of the healthcare heroes metaphor by revealing greater nuance and further illuminating the consequences of militaristic language.2
Hijacked into metaphor
The hero’s journey, or the monomyth, exists in narratology as a template in which the hero answers a call to adventure, often encountering supernatural aid, challenges, defeats and transformation, before returning home. With Healthcare Heroes, we have reached what may be considered the Ordeal stage, the central crisis where the stakes are highest and the hero faces the possibility of death. In March 2020, this was marked by nationwide flyovers from US armed forces, nightly applause, billboards, and even action figures depicted as healthcare heroes. COVID-19 produced these distinctly militarised gestures, and the consequence has been a social expectation for healthcare workers to unquestioningly serve the country while sacrificing their own health and, when necessary, their life. Although some degree of risk is justified during a pandemic by the AMA code of ethics and Hippocratic Oath, the scope of personal sacrifice is difficult to discern.3 This blurring of duty may be, in part, due to militaristic language in medical training itself, like using hierarchical terms, framing medical school as boot camp, and calling hospitals ‘the frontlines’ and hard-working students ‘gunners’. The danger of militarised language in medicine, even pre-COVID-19, is the valorisation of aggression over receptivity, and the framing of doctors as soldiers, and disease, as well as patients, as the enemy.
In the context of COVID-19, the consequences of military metaphors grow more dire. As literary and media scholar Kevin Boon writes, “The greater the perceived risk of human mortality, the greater a culture’s need to reassure itself of potential survival; thus the greater its need to seek embodiment of the hero figure”.4 When healthcare workers become Healthcare Heroes, self-sacrifice can be perceived as necessary. Contrary to the military, risk of dying is not part of the professional commitment to medicine; however, militaristic metaphors obfuscate these distinctions and conflate duty with consent.
As Cox writes, so too is there little room in the Healthcare Heroes narrative to care for the mental and emotional toll of working on the COVID-19 ‘frontlines’.1 In a statement about a NYC physician who died in April 2020 by suicide, the Society for American Emergency Medicine said: “It is with profound sadness that we pause to remember another one of our heroic heroes who has fallen in the fight against COVID-19. This battle-weary warrior fought valiantly on behalf of her patients…Faithful to her calling until the end, she fought the good fight until there was no fight in her left, and on Sunday our humble hero became another casualty in this ongoing battle”.5 To mask this tragic loss in the gallant language of military sacrifice is to ignore the very real needs of those who continue to care for patients while their own physical and mental health suffers.
An antiscience assault
Militaristic language frames illness and death as inevitable plotlines, rather than preventable occurrences backed by fact. Since spring of 2020, healthcare workers who called for stronger lockdown measures or disclosed supply shortages have been disciplined, suspended and fired.6 Perhaps most famously, when the USA’s infectious disease expert, Dr Anthony Fauci warned the U.S. Congress that a premature reopening of the economy would result in ‘needless suffering and death’, he was blocked from testifying at White House briefings. Fauci resorted to conveying urgent public health messages from academic and celebrity social media accounts. The effective gagging of physicians and nurses can be, at best, characterised as a ‘don’t ask, don’t tell’ policy, and at worst, a descent into authoritarianism.
Even after President Trump was infected with COVID-19, healthcare experts not only remained excluded from White House updates to the public but were accused of overdiagnosing people with COVID-19 for profit driven motives.7 For the first time in history, medical journals and science news outlets including New England Journal of Medicine, Nature and Scientific American endorsed a presidential candidate for the 2020 election.8
The refusal of evidence-based policy and disposal of health expertise continues to value lives with greater political power, while threatening the livelihood of the country’s poor, uninsured and working members, including healthcare workers. Through their invocations of sacrifice and moral righteousness, military metaphors may make it easier for antiscience mistrust to persist against what President Trump has called an ‘invisible enemy’, rather than a virus with understandable physiologic mechanisms.
Xenophobia: the need for external enemies
Military metaphors additionally reinforce a xenophobic nationalism, narratively pitting American ‘heroes’ against foreign ‘enemies.’ In the aftermath of 9/11, the cultural need for heroic figures raised emergency personnel, like firefighters, to the status of heroes in ways that mirror healthcare workers during COVID-19. President Bush’s use of military rhetoric to create an American identity centred on the ‘The War on Terror’ is reminiscent of President Trump’s policies—like the border wall, Muslim ban and COVID-19 regulations—which weaponise xenophobia in the name of patriotism. President Trump’s repeated referencing of COVID-19 as the ‘China virus’ perpetuates xenophobic framings consistent with the rise of anti-Asian hate crimes, including physical and verbal attacks, workplace discrimination and online harassment.9
The narrative of Healthcare Heroes reinforces tropes of villainous, external threats that encroach on the American body politic, even as a very real virus threatens the bodies of US citizens. While racism against Asian Americans persists with ties to political language and coronavirus metaphors, communities of colour carry a disproportionate burden of COVID-19-related disease and death in the USA.10 Deep-seated racial health disparities have been exacerbated by the pandemic, and metaphors that cultivate perceptions of an antagonistic Other compound the threat to Black, Indigenous, and People of Color (BIPOC) communities, including those who continue to risk their lives to keep the US healthcare system afloat.
Narrative medicine teaches us that stories affect the way policies, actions and attitudes are shaped toward justice or injustice. What has become apparent is the utilitarian stance behind the US government’s decisions: in order to maximise benefit for the greatest number of people (read: in order to open the economy), some people will have to die. Those people are the country’s most vulnerable; nursing home residents, incarcerated individuals, homeless populations, indigenous nations and communities of colour, people with disabilities, undocumented families, transportation and delivery staff, and food supply-chain employees. With the addition of healthcare heroes to this list, militarised metaphors disguise a forced conscription into this utilitarian bargain.
In its inattention to the needs of ‘essential’ workers, the US government has made one thing clear: the work may be essential, but the people are treated as wholly dispensable. The expected sacrifice of healthcare workers and suppression of scientific experts is terrifying because they raise signs of a fascist regime, which have historically begun with the silencing of scholars and abduction of activists. In this light, the ostensible valour of Healthcare Heroes can be seen for what it is or has the potential to become: a dangerous and nativist propaganda.
Trumpian politics, an ideology of oppression derived from white nationalism, has given rise to bigotry in ways that have fundamentally changed the USA. Despite President-Elect Biden’s pledge to restore the nation’s commitment to one another, and to science and research, President Trump’s polarising rhetoric will not disappear when he leaves office. Racism, xenophobia and white supremacy have long coursed beneath the surface of the USA, and they inform the nativist sentiment purported by militaristic metaphors. Analysing the Healthcare Heroes metaphor with narrative medicine reveals the extent to which language matters, and how seriously it structures the world around us.
As Cox writes, individual-focused narratives of heroic actions ultimately ignore structural contexts.1 The healthcare hero narrative intensifies our focus around individual acts of sacrifice while obscuring the systems that produce such taxing circumstances. Militaristic metaphors in medicine can be dangerous to both doctors and patients. Teaching and advocating for the critical skills to analyse and alter this language prevents undue harm to providers and patients, as well as our national and global communities.
The authors would like to thank Columbia University’s Program in Narrative Medicine for their support of this project.
Contributors All authors contributed equally and are responsible for the research, analysis, writing and editing of this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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