Migrating Metaphors: Why We Should Be Concerned About a ‘War on Mental Illness’ in the Aftermath of COVID-19

In the aftermath of the ongoing COVID-19 pandemic, there is a predicted (and emerging) increase in experiences of mental illness. This phenomenon has been described as "the next pandemic", suggesting that the concepts used to understand and respond to the COVID-19 pandemic are being transferred to conceptualize mental illness. The COVID-19 pandemic was, and continues to be, framed in public media using military metaphors, which can potentially migrate to conceptualizations of mental illness along with pandemic rhetoric. Given that metaphors shape what is considered justifiable action, and how we understand justice, I argue we have a moral responsibility to interrogate who benefits and who is harmed by the language and underlying conceptualizations this rhetoric legitimates. By exploring how military metaphors have been used in the context of COVID-19, I argue that this rhetoric has been used to justify ongoing harm to marginalized groups while further entrenching established systems of power. Given this history, I present what it may look like were military metaphors used to conceptualize a "mental illness pandemic", what actions this might legitimate and render inconceivable, and who is likely to benefit and be harmed by such rhetorically justified actions.


Article abstract
In the aftermath of the ongoing COVID-19 pandemic, there is a predicted (and emerging) increase in experiences of mental illness. This phenomenon has been described as "the next pandemic", suggesting that the concepts used to understand and respond to the COVID-19 pandemic are being transferred to conceptualize mental illness. The COVID-19 pandemic was, and continues to be, framed in public media using military metaphors, which can potentially migrate to conceptualizations of mental illness along with pandemic rhetoric. Given that metaphors shape what is considered justifiable action, and how we understand justice, I argue we have a moral responsibility to interrogate who benefits and who is harmed by the language and underlying conceptualizations this rhetoric legitimates. By exploring how military metaphors have been used in the context of COVID-19, I argue that this rhetoric has been used to justify ongoing harm to marginalized groups while further entrenching established systems of power. Given this history, I present what it may look like were military metaphors used to conceptualize a "mental illness pandemic", what actions this might legitimate and render inconceivable, and who is likely to benefit and be harmed by such rhetorically justified actions. maladie mentale avec la rhétorique de la pandémie. Étant donné que les métaphores déterminent ce qui est considéré comme une action justifiable et la manière dont nous comprenons la justice, je soutiens que nous avons la responsabilité morale de nous interroger sur les bénéficiaires et les victimes du langage et des conceptualisations sous-jacentes que cette rhétorique légitime. En explorant la manière dont les métaphores militaires ont été utilisées dans le contexte du COVID-19, je soutiens que cette rhétorique a été utilisée pour justifier les préjudices subis par les groupes marginalisés tout en renforçant les systèmes de pouvoir établis. Compte tenu de cet historique, je présente ce à quoi pourrait ressembler l'utilisation de métaphores militaires pour conceptualiser une « pandémie de maladie mentale », les actions que cela pourrait légitimer et rendre inconcevables, et ce qui est susceptible de bénéficier et d'être lésé par de telles actions justifiées par la rhétorique.
In the aftermath of the ongoing COVID-19 pandemic, there is a predicted (and emerging) increase in experiences of mental illness. This phenomenon has been described as "the next pandemic", suggesting that the concepts used to understand and respond to the COVID-19 pandemic are being transferred to conceptualize mental illness. The COVID-19 pandemic was, and continues to be, framed in public media using military metaphors, which can potentially migrate to conceptualizations of mental illness along with pandemic rhetoric. Given that metaphors shape what is considered justifiable action, and how we understand justice, I argue we have a moral responsibility to interrogate who benefits and who is harmed by the language and underlying conceptualizations this rhetoric legitimates. By exploring how military metaphors have been used in the context of COVID-19, I argue that this rhetoric has been used to justify ongoing harm to marginalized groups while further entrenching established systems of power. Given this history, I present what it may look like were military metaphors used to conceptualize a "mental illness pandemic", what actions this might legitimate and render inconceivable, and who is likely to benefit and be harmed by such rhetorically justified actions.

INTRODUCTION
Since COVID-19's initial identification in late 2019, metaphors of COVID-19 have permeated contemporary discourse. While a variety of metaphors have been used (1), the military metaphor commonly occurs in a variety of contexts (1)(2)(3)(4)(5). The military metaphor is present in rhetoric such as "the war on COVID-19", "frontline healthcare workers", "tightened borders", and vaccines and masks as "the best defence". War metaphors justify certain actions and condemn others (6). This justification has implications for how we conceptualize the pandemic and the ethics of certain actions, which in turn influences where we direct resources, what policies we put in place, and what actions we take on a daily basis (6)(7)(8).
Concerns about the increase in mental illness resulting from the COVID-19 pandemic have led the predicted rise in cases of mental illness to be described as the "next pandemic". This rhetoric permeates both public media and scientific discourse with article headlines such as "Indigenous communities facing dual pandemic" (9), "Mental health is the next pandemic" (10), and "The next pandemic: impact of COVID-19 in mental healthcare…" (11). This transfer of pandemic rhetoric into discussions of mental illness has the potential to shift how we conceptualize mental illness and subsequently how we respond to it. Given that military metaphors have shaped the conceptualization of a 'pandemic' in COVID-19, and this conceptualization of 'pandemic' is now being mapped on to mental illness, we may expect to see military metaphors mapped onto mental illness in the same way they were used during the COVID-19 pandemic. This transfer of metaphors from one disease to the next can be seen throughout the 19 th and 20 th centuries, from tuberculosis to cancer (12); the diseases that are more likely to be 'metaphorised' are those that were, at that time, least likely to be understood. I argue that given the implications and concerns surrounding military metaphors in COVID-19 and healthcare ethics in general, if this rhetoric is adopted to describe mental illness in a post-COVID context, we risk continuing to dismiss the societal structural Page 14 components of mental illness and put those who are already the most marginalized at the greatest risk of injustice and exploitation. These metaphors lead to questioning the ethics of using language that may shape our conceptualization of justice as well as its relationship to beneficence, autonomy, and non-maleficence, in a way that disproportionately negatively effects marginalized groups.
To make this argument, I first outline how metaphors reflect and reinforce the power structures within the society where they are produced, and how this shapes not only language and knowledge, but also actions at individual and collective levels. Next, I explore how the military metaphor has been used in the context of the COVID-19 pandemic and the effect this has on justifying and legitimating existing power structures and the exploitation of those already left vulnerable by such structures. Given these effects, I identify some likely consequences of adopting military metaphors to conceptualize mental illness post-COVID, with particular attention to how these metaphors reinforce a biomedical understanding of mental illness to the exclusion of other possible conceptualizations. I discuss who this is likely to benefit and to harm and argue that we have a moral obligation to interrogate what appears 'natural' within metaphorical systems that promote particular conceptualizations of moral values. This may be particularly true when metaphors are legitimated by and legitimate systems of domination and oppression.

HOW METAPHORS REFLECT AND REINFORCE POWER STRUCTURES
The relationship to power has been a central concern to those studying metaphors since at least the time of Aristotle (13). This concern stems from metaphors' function as not just describing, but also creating the world by influencing actions and decision making, while rendering other options inconsequential (13,14). "Metaphor makes us see one thing as another by making some literal statement that inspires or prompts the insight" (15, p.47). Metaphors are composed of two domains: the target domain and the source domain; they take the expressive form of 'target domain' is 'source domain' (14,16). For example, in the metaphor "the body is a machine", the body is the target domain, and a machine is the source domain. Metaphors work by mapping the concepts associated with the source domain onto the target domain (14). In doing so, certain shared concepts are highlighted, while others are obscured (13)(14)(15). For example, concepts highlighted in "the body is a machine" metaphor are the mechanical or electrical components of body systems. Cognitive and emotional components may become less obvious. In this way, metaphors validate certain components of reality while rendering others unintelligible.
Metaphors also exist in relation to each other, forming larger metaphorical systems (14). For example, the "body is machine" metaphor is part of the system that conceptualizes the heart as a pump, veins and arteries as pipes, and the brain as a computer. This allows the idea of "clogged arteries" or a "short-circuited brain" to make sense because they align with the broader metaphorical system that has entrenched these conceptual relationships. However, because these relationships are so deeply entrenched, it becomes difficult to understand something that contradicts this conceptual system. For example, with the "body is machine" metaphor forming the foundation of the conceptual system, it becomes easy to dismiss concepts such as spirituality, humors, and chi not because they are inherently false, but because they cannot be made sense of within the conceptual system, reflected in our metaphors, that we use to define reality.
However, it is not just any reality that our metaphors define as 'true', but specifically the realities of those in power. Those in positions of power (e.g., policymakers) develop metaphors that stick and become embedded in how reality is conceptualized in a given social context (14) -these metaphors become part of the dominant discourse. The dominant discourse can be understood as the socially acceptable story or explanation in the context where it is dominant. This dominant discourse has the power and function of truth. Discourse is conceptualization textualized, and in its textual state, it is embedded in everyday life in art, media, policies and procedures, stories, clothing, and other media used to convey meaning (17). Many artefacts telling the same story form the dominant discourse. For example, artefacts that may suggest the "body is a machine" include medical textbooks that may use these metaphors in anatomical descriptions, exercise equipment, production line manufacturing systems, and office furniture design. The ideas of working particular muscle groups, using bodies as a step in the manufacturing process, and ensuring alignment of the skeletal system for optimal functioning are all supported by this metaphor system. Importantly, the people who determine the dominant story are those who hold power within the society where the discourse is dominant (18)(19)(20)(21). Those in power have a particular investment in the proliferation of discourse that maintains their status and therefore continue to entrench conceptual systems that makes this reality possible (17,21). They are also likely to create metaphors that reflect their lived experience, and in so doing, render invisible experiences that conflict (21). For example, it may lead to a medical system that produces and endorses artefacts that align with this conceptual reality -such as surgical robots, prosthetic limbs, or electrical nerve stimulators -because medical professionals maintain power and status as the "fixers of broken bodies". It may also lead to a medical system that rejects evidence that contradicts this conceptual system, such as conditions without an identifiable physical cause, or that cannot yet be fixed through technological means because it would challenge the reality that medical professionals rely on to maintain their power (22). "The acceptance of the metaphor, which forces us to focus only on those aspects of reality which it highlights, leads us to view the entailments of the metaphor as being true. Such 'truths' are true, of course, only relative to the reality defined by the metaphor" (14, p.484).
There is growing recognition that, because of the way metaphors help to re-establish and entrench systems of power, that they deserve ethical consideration (23)(24)(25). Concerns about how metaphors are used in communication with patients (24,26,27), how they influence informed consent in research (28)(29)(30), and how they influence policy decisions (6,25,31) have been raised. While their naturalized appearance may make metaphors seem to be innocuous sites for interrogation, it is specifically this feature that allows them to support systems of power in the way that they do.
The fact that metaphors appear to be settled in many areas of health care does not remove the moral and political value of examining their implications; rather, it may make it even more important to review and challenge the established metaphors that govern the various practices in each area of medicine (25, p.345).
The systemic and political implications of metaphors have, until recently, been explored predominantly in the context of HIV/AIDS. However, "AIDS provides a useful model of how an effective and explicitly political intervention into the representation of a medical condition can transform or even set the agenda surrounding a matter of medical concern" (25, p.362). When conceived of as a viral agent, which invokes war metaphors of invasion and destruction (25,32), HIV/AIDS requires a biomedical response that fights against the virus. This significantly lessens the impact of concurrently relevant factors, such as poverty and vulnerability to rape, which also play a large role in the transmission and acquisition of the infection, particularly in marginalized communities and outside North America and Europe (25). Furthermore, the metaphor of AIDS as a "gay cancer" obscured the impact and experience of the disease in women, which sidelined research on HIV/AIDS in female bodies, other than the risk of fetal transmission (25). The military notions of 'annihilation', 'eradication', and 'victory', which were so deeply rooted in HIV/AIDS rhetoric for the first decades of its known existence, conflict with the experience of HIV/AIDS as a chronic condition, which is now more commonly discussed (24,25,32). This has led to the question the helpfulness of military metaphors in this context, and in the context of other immunological conditions (24,33).
While much of the interrogation into the ethics of metaphors has occurred in the context of HIV/AIDS, many health experiences are conceptualized and described metaphorically. This may be particularly true for illnesses that lack a definitive biological cause or explanation, or those whose experiences are difficult to explain, such as dementia (34), endometriosis (35), cancer (32), and a variety of different mental illnesses (36,37). Health conditions that receive widespread media coverage during increases in their occurrence are also frequently metamorphosized creating a collective understanding of an emerging phenomenon, such as Ebola (38,39), avian flu (40), and foot and mouth disease (41). New health conditions may adopt metaphors of previous, no longer socially significant health conditions, such as metaphors for tuberculosis migrating to conceptualize cancer (12). These are also health conditions that are frequently stigmatized (12). As mental illness continues to illude definitive biological explanation in many cases, involves an experience that is difficult to communicate (42), draws media attention, and carries social stigma (43), it is well positioned to be socially constructed metaphorically.

THE MILITARY METAPHOR
It is the framing effect, where solutions to problems are judged to be more viable when they share a metaphorical system (44), that underscores the debate around the ethical use of the military metaphor in medicine, both in individual patient/healthcare provider communication and on a broader social political scale. At the level of interpersonal communication with patients, on one side of the debate sits the argument that military metaphors are harmful because they reinforce the biomedical model (24), preclude an appropriate understanding of certain conditions (26,33), and may leave patients feeling like the only option in their care is to fight (24). On the other side, there are the arguments that military metaphors may be the best way of communicating that patients have at their disposal (27). They may also instill a sense of agency in patients (27). In the middle lie the arguments that metaphors need to be flexible to patient needs, which may involve the use of military metaphors (27) and that the area of healthcare in which military metaphors are used matters, because they are more harmful in some areas than others (45,46). Others have argued that caution is needed in the use of dominant metaphors that silence other ways of understanding (42) and that what is problematic is the Western conception of war rather than the use of military metaphors (24).
On a broader scale, arguments against the use of military metaphors suggest that they lead to the justified over-mobilization of resources (47), glorify war and violence (46), erase the contributions of social factors to illness and disease (26), and justify casualties and collateral damage (6,31). However, because of their persuasive nature, they can also quickly and convincingly communicate the need for a large-scale response (31). It is these central concerns that have emerged in debates around military metaphors used in the context of COVID-19.

THE MILITARY METAPHOR AND COVID-19
Military metaphors were ubiquitous in public communication surrounding the COVID-19 pandemic. From Queen Elizabeth II's coronavirus speech thanking those on the frontlines, which was watched by over 24 million people (48), to then-President Donald Trump's comparison of the race to find a vaccine with the Manhattan Project's race to create an atomic bomb (6), military metaphors dominated media coverage and political messaging (1). The military metaphor allows for an enemy to be identified, which can help create a sense of calm during social upheaval as people focus on an identifiable threat (31). One of the benefits of military metaphors is that at "the communal level, they may help whole societies to mobilize human, economic, and social resources for healthcare and medical research" (24, p.5). As such, "By choosing to frame the pandemic in military terms, governments are clearly trying to communicate the gravity of this public health crisis, one that requires the type of state intervention and personal sacrifice most nations have not experienced in peacetime" (49, p.63).
Military metaphors not only influenced individuals' conceptualizations of the coronavirus as an enemy in a war (3), but also influenced behaviour and led to responses on individual and social levels that resembled those expected during war. Like during war time, the media focused on infection and death rates (6), which, at the time of writing, were still being reported daily. Women hand-stitched masks for frontline healthcare workers (7), invoking images of women manufacturing protective equipment and clothing for soldiers during World War II. Tributes to those on the frontlines from urban balconies (50) invoked images of veteran's homecoming parades. The actual Canadian Military, in "defense teams", were deployed to areas overwhelmed by the virus (51). These actions make sense within the conceptualization of the pandemic as a war and align with the previous responses expected during wartime in Canada.
War, therefore, provided a conceptual structure within which the pandemic and its expected response could be conceptualized and enacted. While this had benefits -of convincing the public to use masks as "battle armour" and to "shelter in place" (50), and arguably saved lives -it is important to also interrogate at what cost these benefits came and to whom. Furthermore, it is important to question, given the implications of this metaphorical system, if we are willing to accept this cost of waging war on "the next pandemic", notably "the war on mental illness", in the same way as we did for COVID-19.
War-making is one of the few activities that people are not supposed to view "realistically", that is, with an eye to expense and practical outcome. In all-out war, expenditure is all-out, imprudent -war is by definition an emergency in which no sacrifice is excessive (12). I argue that the war metaphor for COVID-19 justified making sacrifices such as leaving healthcare providers unprepared and adopting health policy decisions that disproportionately affected women, Indigenous, Black, and lower-class peoples, and yet advanced the agendas of those in political power. If the war metaphor is therefore applied in the same way to a "mental illness pandemic", I argue that this discourse will continue to entrench existing systems of power in similar ways to those evidenced during the COVID-19 pandemic, and that this undermines medicine's commitment to justice.

JUSTIFYING POOR PREPARATION
Describing COVID-19 in military terms justified leaving healthcare providers unprepared by framing the response as a kind of "tactical improvisation" (52). This absolved government and health administrators from the responsibility to have been prepared for a pandemic prior to its occurrence (52): "Improvisation has been discursively situated as a defensive tactic within the metaphorical framing of illness as war, which is a result of its association to the military through mottos such as 'improvise, adapt, and overcome'" (52, p.1). The need to improvise also emerges in portrayals of the virus as changing, mutating, developing variants, and the change in strategy that is required to continually defend against an ever-changing offense.
What is left out of the need to improvise in the war on COVID-19 is that there were things which could have been planned and prepared for that would have decreased the amount of improvisation needed. For example, there could have been enough ventilators available ahead of time to support a pandemic-level response and there could have been enough personal protective equipment available for healthcare workers to be protected while caring for patients (53). This could have alleviated the need to improvise decision making protocols for who does and who does not receive resources that can have life-or-death implications when resources are limited. There could have been research into the transmission and treatment of highly contagious coronaviruses, and work towards the development of a vaccine prior to requiring global lockdowns. In fact, there were attempts to do this, however they were not funded because it was not a research priority. Hungarian biochemist Katalin Karikó, whose work on messenger RNA led to the development of the COVID-19 vaccine, was repeatedly denied grants that would have allowed her to pursue this work as early as the 1990's (54,55). We can only postulate whether, had research funding in this area been considered a priority and allocated to researchers like Karikó, the infection rate would even have reached pandemic proportions. Framing the COVID-19 pandemic as a war that needs to be responded to as it unfolds obscures the fact that there could have been protective equipment, treatment resources, and preventative vaccines, that might have prevented COVID-19 from reaching pandemic proportions in the first place.
If we next are facing a war on mental illness, we risk also adopting the motto to "improvise, adapt, and overcome" in this context, which absolves those who hold power from having put systems and services in place that could have prevented a mental illness pandemic in the first place (52). We risk requiring healthcare providers, who already felt unprepared to deal with the experiences their patients were facing prior to COVID (56), to continue to work in circumstances where they may be unprepared, or untrained, as they did during World Wars I and II (43). If we deploy new recruits or members of our healthcare 'militia' to wage a war on mental illness, a system of military metaphors may allow us to do this without ensuring sufficient training, which puts both patients and providers at risk.
In addition, by using military metaphors that justify improvisation, we risk forgetting that, had we funded more housing-first projects, done more to prevent adverse childhood experiences, implemented guaranteed basic income, and decreased domestic violence, it is possible that we may not have been in a position of mental health crisis in the first place. We risk erasing from public consciousness that, prior to the start of the COVID-19 pandemic, our mental healthcare system was already overwhelmed, and many were denied or unable to access effective care (57,58). For example, in 2018, when the provincial standard in Nova Scotia for access to mental healthcare was 28 days, the average wait time for non-urgent services in Cape Breton -several hours from the provincial capital -was 210 days for adults and 80 days for children and adolescents, an improvement over 363 and 157 days respectively in 2017 (57). A report on mental health service access in Ontario, released just prior to the COVID-19 pandemic in January 2020, indicated that youth in York Region, on the outskirts of Toronto, Canada's largest city, faced wait times of up to 919 days, and that approximately 200,000 youth in Ontario with mental illness went without services each year (58). Real time funding towards youth mental health services in Ontario decreased 50% over the past 25 years (58). The urgency and unexpectedness encoded in military metaphors of improvisation means we risk forgetting there were other things we could have done -and could have done better. Evidence therefore suggests that we are not improvising a newly emerging war on mental illness, as the metaphor may suggest.

WAR METAPHORS AND BIOMEDICAL POWER -ENTRENCHING OPPRESSION
Employing military metaphors in COVID-19 rhetoric justified adopting and implementing policies that disproportionately negatively affected women, two-spirit, transgender, and non-binary people. "Just as in wartime, American society during the current pandemic has deemed the critical women's healthcare needs of today as the problems of tomorrow" (6). Intimate partner violence towards women increased, and in at least 11 states in the United States, abortion was deemed a non-essential service to promote public safety (6). Women's healthcare clinics were closed and may not reopen due to the lost income (6). More women than men worked in jobs deemed 'essential', and therefore faced increased risk of contracting the virus (59) 1 . More women than men lost their jobs (59). Women had more work disruption than men due to childcare responsibilities and more women worked from home while also doing full-time childcare (59). These factors all affect women's health. In many places, gender affirming treatment was delayed or put on hold, which can have significant health effects for transgender and gender non-binary individuals (60). In Canada, some gender affirming surgeries were cancelled and postponed indefinitely (61), highlighting how 'non-essential' they are considered within the healthcare system. Because of "war being defined as an emergency in which no sacrifice is excessive" (12, p.99), ignoring the disproportionate effects "acceptable sacrifices" have on the health of women, transgender, two-spirit, and gender non-binary people could be justified. Coincidently, all of these factors may also increase rates of mental illness (60,61).
Similarly, war rhetoric may also serve to disproportionately negatively affect other marginalized groups. Military metaphors are deeply linked with the biomedical model (25,32,46), which tends to lead to technological means of 'annihilating' the threat (25,32,46,47). As framing the problem in biomedical terms leads people to more likely endorse a biomedical solution (44,62), transplanting pandemic military metaphors onto mental illness may therefore increase the perception of the need for biomedical, technological treatment. In mental health, the technological means most often employed is pharmaceutical treatment (63). As with HIV, the social factors contributing to the emergence of illness become obscured when the focus is on fighting through technological means (25). And this may be problematic for several reasons.
First, biomedical problems and pharmaceutical solutions individualize and simplify largely social issues (63), as we saw in the HIV/AIDS epidemic (25,32). When an individualized perspective is taken on illness or disability, this largely absolves the need to respond at a social level (64). This has been widely voiced in arguments against a biomedical conceptualization of disability (65,66). On a social level, when policies are made based on an individualized, and therefore often simplified, understanding of social problems, they tend to continue to marginalize those who are most affected (31). For example, the "War on Drugs" in the United States, in which the systemic issue of drug use was responded to with the incarceration and criminalization of individuals who used drugs, led to Black people being incarcerated at extremely high rates, which destroyed family networks and led to increased poverty (31). When the intergenerational trauma resulting from the social and political move to forcefully place Indigenous people in residential schools is framed as individualized mental illness, it increases the pathologizing of Indigenous people as sick and deviant (67). This justifies the continued denial of cultural considerations in mental healthcare (67). When the increased stress that women face as a result of more frequent job losses and increased caring responsibilities is ignored in favour of a biomedical explanation of mental illness, so are the many ways that misogyny contributes to these larger social problems (68). In the context of mental illness, taking illness to be rooted in the individual, rather than the product of social relations, it is called 'psychocentrism' (69,70), and threatens to further entrench both a Western biomedical perspective and the Western value of individualism (63,70). As such, adopting war metaphors that support the conceptualization of mental illness as biological and treatable by technological means is likely to not only further entrench social marginalization, but also deny the social complexity of mental illness and the variety of ways it is experienced.
Secondly, biomedicine has done a particularly poor job of recognizing the experiences of people who are not white men (22,(71)(72)(73)(74) and/or the experiences of people with mental illness (75)(76)(77)(78)(79). Psychiatric classifications are racially and culturally based, which reinforces racial and cultural stereotypes (67,76,79). The long history of the conceptual relationship between female bodies and hysteria (74) continues to lead to the dismissal of non-male needs in health research and treatment (22). Those experiencing mental illness have repeatedly had their knowledge and experience ignored, erased, and invalidated (42,67,70,78,80). It is not difficult to imagine a post-COVID mental health system that continues to use the DSM-5 as its primary reference text and uses pharmaceuticals as its primary method of treatment to the exclusion of other socially and culturally oriented approaches. I argue, therefore, that it is unlikely that using war metaphors -which further validate biomedicine and with it the patriarchy, White Supremacy, and Sanism -will produce a transformative system capable of effectively challenging these ideologies. If anything, it risks adding urgency and expanding notions of acceptable sacrifices to an already existing problematic system. Furthermore, the war metaphor was used in the COVID-19 pandemic to justify increased monitoring and surveillance (31). Living through the pandemic in Nova Scotia, I observed borders, both provincial and national, became tighter to prevent the "external threat" of increased cases and variants from further burdening our healthcare system. The population was screened and tested prior to being allowed to enter countries, provinces, workplaces, schools, and stores, which then progressed to requiring proof of vaccination. Mask requirements were put in place for both indoor and outdoor public spaces. People Page 18 downloaded phone apps that allowed them to be traced through GPS. These measures were widely accepted to increase public safety and were advertised as "caring for your neighbours". Living through this transition, allowing the government this increased level of power, control, and surveillance prior to the pandemic would have been almost unimaginable, but the war metaphor contributed to making it acceptable (31).
It is important to clarify that I support public health measures to address the pandemic (e.g., promoting vaccination and the use of masks). However, I am critical of the adoption of such practices without interrogating who they are empowering or disempowering and considering who is being asked to sacrifice what. We need to consider that anti-Black Racism constructs Black men as always and already a threat, and that wearing a mask increases the perception of that threat and the likelihood that a Black man wearing a mask will be killed for being Black (7). We need to consider that those who rely on lip reading, and those who face challenges being understood now have an additional communication barrier to overcome that may effectively exclude them from participation in public spaces (7). And we need to consider that white men who refuse to wear masks because their white male privilege makes them feel entitled to being comfortable at all times and in all places (81) puts those who are immunocompromised, those who cannot be vaccinated, those with underlying health conditions, and those who are elderly (who are also disproportionately non-white women) at increased risk of contracting and dying from the virus. The rhetoric of sacrifice that accompanies metaphors of war tends to demand and justify the greatest sacrifice from those who are marginalized, which serves to both support and hide oppressive systems (31,82). It also leaves those with the greatest privilege arguing that the requirement of sacrifice should not apply to them (73).

IMPLICATIONS OF A WAR ON MENTAL ILLNESS
With this in mind, we may postulate what mental healthcare might look like with war metaphors that justify increased control of movement and migration, and increased surveillance. We can predict a "war on mental illness" that justifies tightening our borders and denies entry to those seeking to immigrate to or claim refugee status in Canada to prevent increasing the burden on an already overloaded mental healthcare system. We can predict that this may disproportionately affect those experiencing forced migration due to war and/or persecution, who would be more likely to have experienced trauma that may lead to, or present as, mental illness. We can predict increased surveillance on racialized and impoverished communities, because social factors put them at increased risk of mental illness. We can predict that these communities will face increased stigma due to greater identification of mental illness that results from increased surveillance. We can also predict that the government may remove people from these communities out of fear of the spread of violence and parental unsuitability that is associated with mental illness through stigma (83).
We may predict this type of mental healthcare system because when war metaphors were used in the American "War on Drugs" and the American "War on Poverty", this was what happened (31); and we may easily imagine this world because it reflects the one in which we are living, a world in which living with mental illness is "about trying to get by in a world that fears you, that believes you are unfit for your job, that wants to take your children away. A world whose police will kill you because you can't understand instructions" (93, p.XV).

CONSIDERING DIFFERENCE
It is also important to consider in what ways mental illness is different from COVID-19 and the impact this could have on what may become justified if military metaphors become embedded in conceptualizations of mental illness. There is a pervasive conceptualization in which those with mental illness are perceived as violent (79,83,85), and a history of entanglement with behaviour labelled deviant (86)(87)(88)(89). Given the conceptual overlap between 'person with a mental illness', 'violence', 'deviance' and 'war', 'violence', and 'enemy', military metaphors may carry the potential to justify increased violence towards those with mental illness in a way they did not towards those with COVID-19. It is possible that the use of military rhetoric may help build a bridge wherein the notion of needing to fight back against mental illness is conceptually extended to needing to fight back against people with mental illness (90). While this has the potential to be used to justify greater violence towards people with mental illness in general, it may particularly affect those with Black bodies who already experience greater violence due to entrenched stereotypes of violence (79).
It would be unfair, however, to not also recognize the potential benefits that employing war rhetoric may have on improving the lives of those with mental illness; after all, there were benefits to using military rhetoric to conceptualize COVID-19. War metaphors gave the public a way to conceptualize something that was new, and to which they needed to respond with some urgency (6). It convinced people to follow government requests and unite against a common enemy (31). In America, given the narrative of undeniable victory that surrounds World War II in public discourse, using this rhetoric in the context of COVID-19 instilled a sense of optimism (6). And, unlike during the AIDS epidemic, it decreased the use of 'plague' and 'pollution' metaphors, which were then weaponized against those who contracted, and were perceived at greater risk of contracting, HIV (50).
It is possible that these benefits may migrate to mental illness, justifying increased funding to combat a common enemy, decreasing the stigma of mental illness through the recognition that we are all at risk, and instilling a sense of optimism that victory is possible the context of mental illness. Indeed, some of the greatest advances in understanding and treating mental illness occurred in the context of war (43). It is also possible that, given that war justifies the mobilization of significant resources (47), using this metaphor could support efforts to address the social determinants of mental illness. As these occur at a social level, these endeavours may need the public buy-in and support that the war metaphor helps to bolster (31).
There may be benefits at the individual level as well. War metaphors are one of the main ways that people with depression (91) or addiction (92) may conceptualize their experiences. Given the ongoing history of ignoring and invalidating the perspectives of those with mental illness (42,78,93,94), adopting metaphors that align with those put forth by people with lived experience may help to validate their knowledge.
I am not denying that there could be benefits to adopting military metaphors to conceptualize mental illness; what I want to interrogate is who is likely to receive those benefits and who is likely to not. Yes, war metaphors may validate some people's lived experience of mental illness, however if war becomes the dominant metaphor for conceptualizing mental illness, it will also render many people's experiences invalid. Even in the studies cited above, war metaphors were only one of many metaphorical systems people used to conceptualize mental illness (91,92). Some metaphors that reflect lived experience and intentionally challenge the applicability of common metaphors used to conceptualize mental illness (42,95) would continue to be invalidated. Given the conceptual alignment of war metaphors and biomedicine, it is likely that those who conceptualize mental illness in war terms are invested in a biomedical healthcare system to some extent. Those whose experiences become unintelligible are likely to be the people who are worst served by the prevailing biomedical system, who are therefore already vulnerable to systemic harm and silencing (67).
In addition, I am not denying that justifying increased funding towards mental health is inherently bad. I am questioning where, using a military conceptualization of mental illness, this funding is likely to go. Will it go to increased access to individual biomedical treatment, research, and development of new psychiatric drugs? Or, will it go to housing-first initiatives, addressing domestic violence, increasing newcomer community integration, supporting a guaranteed basic income, and culturallyrestorative Indigenous practices? I argue that the former is likely to support white, middle-and upper-class individuals for whom individual treatment is conceptualized as safe, legitimate, and socially acceptable. I also argue that the latter is likely to support those who are Indigenous, newcomers, women, insecurely housed, racialized, and the working poor. The military metaphor tends to support technological over social initiatives (47), and these are more likely to exclude those identifying with marginalized groups (25). Choosing the latter option requires a social orientation towards mental illness, one that is more difficult to conceptualize using a military metaphor system.

WHEN METAPHORS SHAPE THE CONCEPT OF JUSTICE
Healthcare may be constructed on the ethical principles of beneficence, non-maleficence, autonomy, and justice, but how we conceptualize and balance these principles depends, in part, on the metaphorical system within which we are working (96). War metaphors are likely to promote a conceptualization of justice that involves "doing what it takes to win the war" (97). When war metaphors suggest we are on the 'good side', fighting the 'enemy' who is 'bad', actions that may not be considered just within other frames of reference may appear just because of their appeal to the overall just cause of winning the war against evil (98). In the context of war, when what is framed as the just cause of winning the war is given the highest priority, nonmaleficence is given less priority. The justice of victory may even hide the maleficence needed to achieve it, particularly when it disproportionately affects those in oppressed groups and benefits those in power. Bioethics in the context of war may not reflect the values of medicine in non-war contexts (99) and calling something a war when it is not may shift the ethical reasoning in ways that would otherwise be incongruous with medical values. "Whether any particular metaphor is adequate or not will depend in part on the principles and values it highlights or hides" (85, p.18), and while the war metaphor may have had some beneficial use in the COVID-19 pandemic, the principles and values it highlights are likely not a useful framework for making ethical decisions in the context of mental illness.

CONCLUSION
Given how embedded military metaphors are in both medical discourse in general, and COVID-19 pandemic discourse specifically, I argue that it is likely that as we transfer pandemic discourse into the context of a subsequent "pandemic of mental illness", that these metaphors are likely to transfer as well. While there may be some benefits to using military metaphors to gain widespread public support for mental illness initiatives, there may also be many harms. And those benefits and harms may not accrue to the same people.
Metaphors have not only the power to describe, but also to create shared and legitimized conceptualizations of reality, and this reality is biased towards the experiences of those in power. Metaphors therefore entrench a reality in which those in power maintain their power and create systemic ignorance by rendering alternatives inconceivable. Military metaphors used in healthcare shape what is considered ethical, what research is conducted, what treatments are available, what improvisations and sacrifices are deemed acceptable, and what and whose conditions are considered valid by reinforcing the idea of a biomedical problem that is individual and fixable through an arms race of technology. By examining how this metaphor system has been used to justify particular courses of action during the COVID-19 pandemic, it becomes clear that it contributes to justifying putting those who are already vulnerable at the greatest risk. This may include those who are predominantly racialized and/or of a lower class, and those with disabilities who may be immunocompromised, unable to get vaccinated, or silenced or endangered by mask use. These are not-so-coincidentally many of the same people who are least well served by the dominant conceptualization of mental illness and the current medical system. If we adopt a concept of justice reflective of military rhetoric, we risk adopting and acting on a conceptualization of justice that ignores these harms.
Using these experiences as the basis of analysis, we may predict that if military metaphors were to be adopted in the same way to conceptualize a "mental illness pandemic", these same groups would continue to bear the brunt of the sacrifice this metaphor system justifies. This will continue to augment the power of those in positions of privilege in the name of war, and perpetuate a system that pushes for technological and pharmaceutical advances at the exclusion of other possibilities for care. It would create a reality where mental illness becomes a weapon used against those most vulnerable to it. And we can imagine this reality largely because it had already taken hold prior to the COVID-19 pandemic. The alignment of this reality with the reality that military metaphors work to both describe and recreate may make military metaphor use in this context seem natural. But metaphors are not natural: they naturalize. We need to acknowledge what values and ethical concepts are naturalized by the reality that metaphors validate. We thus have a moral obligation to interrogate what is constructed as 'natural' when this involves evoking a kind of justice where some people experience greater harm than others, and to actively seek out alternatives when this is unjust. The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal's standards of excellence.
Reviewer evaluations are given serious consideration by the editors and authors in the preparation of manuscripts for publication. Nonetheless, being named as a reviewer does not necessarily denote approval of a manuscript; the editors of Canadian Journal of Bioethics take full responsibility for final acceptance and publication of an article.