The Kobayashi Maru test

Ben Hoban is a GP in Exeter


There is a kind of inevitability about the use of fighting metaphors in medicine, from the ‘War on cancer’ to treating people aggressively and battling an illness. If we are indeed at war with ill health then it is a conflict which on the whole we are used to winning. Even when we cannot cure or prevent it, we still expect to assert our control over disease by prolonging life as long as possible; and even at its very end, we do the same through the ritual of treatment escalation plan forms, syringe drivers and care pathways.

We are trained to do this, and it is difficult to stop and admit that at times our enemy has the upper hand. Even in cases where there is no immediate risk of death, but where chronic pain or other disabling symptoms drain the juice out of life, it feels wrong to tell patients that we have been outmanoeuvred and have nothing left to offer, and so we shrug our shoulders and add another prescription to the list. Maybe it will help.

His behaviour is that of the archetypal hero, who must always overcome the monster or die trying.

A number of storylines within the Star Trek franchise refer to a combat simulation in which a stranded civilian starship, the Kobayashi Maru, must be rescued from enemy space, but in which any attempt to do so inevitably results in failure. The mission is impossible: it is intended as a test of character rather than tactical ability, of the capacity to recognise defeat when it is inevitable and act with equanimity. Captain Kirk refuses to accept this, however, and instead wins the unwinnable scenario by reprogramming the simulation. His behaviour is that of the archetypal hero, who must always overcome the monster or die trying. We can admire honourable defeat, but given the choice, we prefer success. Acceptance is for losers, it would seem.

A similar emphasis on success and the nagging fear of failure pervade many consultations. Good doctors make things better, and we want to be good doctors, but what do we tell our patient when it becomes clear that whatever we do, we cannot win this fight? There is always room to bluff, to add more medication or make another referral, and yet even as we do this, we know that we will have the same consultation again soon, and the bluff will have become less convincing. If all we have to offer is false hope and the illusion of control, perhaps it would be better for everyone if we admitted it.

I wonder if sometimes the difficulty we face as doctors is precisely that we try so hard, often heroically, to make things better, to fix the problem or manage the symptoms, when what many patients want above all is for us to acknowledge that like them, we are helpless, that they face something truly unfixable and unmanageable, and that their experience of fighting an unwinnable battle makes complete sense. They already know they are beaten, and every well-intentioned suggestion is an implicit rebuke that they have given up too soon. They are demonstrating character by accepting what they must, and we are teasing them with promises of success.

They already know they are beaten, and every well-intentioned suggestion is an implicit rebuke that they have given up too soon.

The impact of recognising this can be transformative, changing the terms of the consultation from one in which the only possible outcomes are victory or failure to one in which doctor and patient become united against an infinitely powerful enemy. There is no shame in defeat here. Rather, in the face of such an opponent, success is measured in simple tasks achieved, in negotiating each day with its attendant challenges, in keeping going when keeping going seems impossible.

The danger of letting the moment pass, of holding onto our heroic aspirations, is that we start to see our patients as somehow at fault, ill because they have not tried hard enough to become well, and that we grow to resent them too for reminding us of our own inability to heal them. How many heart-sinks arise through just this process?

In our ongoing professional struggle on behalf of our patients, there will always be some battles that we can win and others that we cannot. By acknowledging this and allowing more than one kind of success, we may find ourselves redefining the terms of some of our most difficult consultations to make them winnable after all. Perhaps we are more like Captain Kirk than we realise.

Featured Photo, Star Trek in the Library by Andrew Papanikitas, 2023

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