Neville Goodman’s Metaphor Watch: Rocks, horns, devils, and hard places

neville_goodmanA dilemma is not just an irritating problem, like trying to decide whether to go to Costa or Starbucks, which anyway gives the option of not having coffee at all. The essence of a dilemma (from the Greek: lemma meaning premise) is that both options have nasty consequences, but one of the options has to be chosen, hence the metaphorical horns of a dilemma. A quick scan of PubMed does reveal lots of real clinical dilemmas—a good example is how to treat a haemorrhagic stroke secondary to a left ventricular thrombus: to thin the blood (and worsen the stroke) or to thicken the blood (and proliferate the thrombus). But there are also plenty of dilemmas that are nothing more than difficult diagnoses or decisions, or questionable treatments. Dilemma can often be replaced by uncertainty. Even great uncertainty is not necessarily a dilemma.

Horns of a dilemma does allow some imaginative imagery. I like “grabbing the horns of a dilemma”; I’ll allow its application to discussion of pregnancy in a bicornuate uterus; and, although somewhat vulgar, “On a dilemma of penile horns” works as the title of an editorial about the differential diagnosis of penile excrescences, even if not a real dilemma, and their being three possible diagnoses. I don’t think you can write of something that “teeters on the horns”; that is a misinterpretation.

The horns also appear in medical writing as the devil and the deep blue sea, or, more popularly, as Scylla and Charybdis, or as a rock and a hard place. The devil and the deep blue sea are what they are: Scylla was a rock, or a sea monster, and Charybdis a whirlpool; but I’ve always thought “a hard place” as the evil alternative to “the rock” an odd phrase, not really used anywhere else. So we have the risks and benefits of warfarin treatment in atrial fibrillation for older people as the devil and the deep blue sea, screening for prostate cancer and the risk of litigation as Scylla and Charybdis, neuraxial blockade in patients with spinal stenosis as the rock and the hard place.

Hobson’s choice is not a dilemma; Hobson’s choice is take it or leave it. Too many of its occurrences in PubMed are for articles without abstracts, so I cannot tell whether its usage is generally appropriate. Catch-22 is not a dilemma either. It is sometimes described as a no-win situation, and a number of its occurrences in PubMed reflect that, but Catch-22 is more complicated than no-win. Catch-22 is a logical paradox arising from a situation in which an individual needs something that can only be acquired by not being in that very situation. This has logical similarities to chicken and egg. There are more chickens and eggs in PubMed than all rocks, hard places, dilemmic horns and Catch-22s combined, but most of them are literal chickens and literal eggs.

Neville Goodman is a retired consultant anaesthetist and a writer, and co-author of a book on medical English.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that my only competing interest is my co-authorship of a book about medical English.