That Dragon, Cancer—Exploring End of Life Through an Unwinnable Video Game | Humanities | JAMA | JAMA Network
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The Arts and Medicine
October 13, 2020

That Dragon, Cancer—Exploring End of Life Through an Unwinnable Video Game

Author Affiliations
  • 1Dartmouth Geisel School of Medicine, Hanover, New Hampshire
  • 2Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
  • 3Pediatric Hospice and Palliative Medicine, Baylor College of Medicine, Houston, Texas
  • 4Palliative Care, Texas Children’s Hospital, Houston
JAMA. 2020;324(14):1379-1380. doi:10.1001/jama.2020.16060

Game Over” is a familiar expression to video and other gamers, a typical end-play message always followed by the opportunity to try again, from the beginning, to use experience and skills from previous losses to survive a game’s programmed obstacles more successfully. The video game That Dragon, Cancer inverts that standard and always ends in the same way: the enemy triumphs as the player helplessly experiences the death of 5-year-old Joel from brain cancer.

Released in 2016, That Dragon, Cancer was created by Joel’s parents, indie game developer Ryan Green and his wife Amy, to tell his story interactively and thus honor his too-short life. Diagnosed at age 1 with an atypical teratoid rhabdoid tumor and given months to live, Joel lived with his disease for 4 years. Over the course of several vignettes, players progress through his diagnosis, treatment, and death using point-and-click–style mechanics and occasional game styles from other video games (platforming, racing, puzzle solving). Wavering between hyperrealism and fantasy, players experience Joel’s joy playing with a puppy and the horror of being unable to console him, the fantasy of imaginative play and the banality of a cross-country trip to participate in a clinical trial, and more. In short, the game sets out to encompass the fullness of Joel’s life.

In the field of creative media, video games are often relegated to the category of other, and film critic Roger Ebert spoke for many when he wrote “video games can never be art.”1 The central feature thought to distinguish video games from art is competition, regardless of the elegance of a game’s animation or mechanics, an interesting claim in this instance because a cancer diagnosis is often templated by patients and society as competition, a fight, or a battle. But a player invested in winning this game becomes enmeshed in the Greens’ helplessness as Joel’s treatment options narrow. The game personifies the titular dragon as an externalized evil to be slain, but subverts the assumption that dying from a terminal illness is considered losing. In one scene titled “Baby Knight,” Joel literally fights off that dragon, cancer, as his parents explain the process of terminal illness to Joel’s siblings. Through voice-over, it is made clear that surviving is not the same as winning, fighting is not all that is worthy, there is courage in the journey itself, and there is grace in acceptance of fate. Thus, this work defies the classic video game trope of triumph and supersedes any restrictive classification of video games—instead achieving what art does at its best: engendering understanding and a deep compassion for others.

The immersive nature of the game creates several poignant experiences for the player, most evident as the father tries to pacify an inconsolable Joel in its harrowing dehydration vignette. Comforting Joel is presented like a puzzle for the player to solve: tap on a juice-box hoping to satisfy Joel’s thirst, but he quickly vomits and continues crying. Frustration and confusion mount as the player desperately clicks through the scene for a solution, finding nothing to soothe Joel’s full-throated and anguished wail. The lack of an effective option in this scene generates a deeper sense of helplessness than the mere absence of choice. With each futile click, the player’s illusion of agency is shattered as the game establishes a window into the father’s feeling of powerlessness.

Sinister black tendrils symbolize Joel’s cancer in the “Park at the Edge of the World” (from That Dragon, Cancer; IOS version, 2016).

Used with permission from Numinous Games.

The Greens directed every stage of the game’s 3-year development, from story and gameplay to visual and audio design, even utilizing the voice work of Joel’s brothers; a film documenting the game’s development in the midst of Joel’s narrowing treatment options and the family’s increasing responsibilities began touring film festivals in 2015. The idea for the game clearly struck a chord with a community presumably undergoing related struggles at the time, some of whom crowdfunded the project and whose stories appear as artwork lining the walls of Joel’s virtual hospital. By creating an experience of shared loss, the game offers support for parents facing similar circumstances, and its universal themes of loss, fallibility of hope, and the joy and transience of life have inspired high-profile online and print news coverage,2 and gameplay videos that have garnered millions of views online.

For all of its virtues, the game distinguishes itself in other ways. It uses a basic visual language of abstract polygonal planes that hearkens back to the earlier days of 3-dimensional computer modeling that may be off-putting for gamers, animated-movie fans, and others accustomed to contemporary life-like computer graphics. It has Christian references and themes that people of other faiths or no faith may find off-putting. And while the game has clearly been meaningful to many families, its role in clinical spaces for health care workers caring for the families of children not responding to treatment is far from clear; its story of inexorable loss could conceivably cause upset and harm as much as healing for families facing rapidly vanishing treatment options or for those grieving the loss of a loved child.

Where the game may have a role in medicine is in training of health care workers. One medical school incorporated the game as part of empathy training for third-year medical students and reported that the students said they preferred video games to standard didactics, and that there was a statistically significant increase in empathy as measured by a validated instrument.3 Evidence suggests that empathy decreases during medical training4—Dr Abraham Verghese has written that “what medical schools need is not to teach empathy, but to preserve it”5—and emotional experiences like the one offered in this game might be a powerful preservative. Not only are video games a medium to which today’s medical trainees are likely to have been exposed,6 but some studies suggest that the unique degree of interactivity video games supply has a more pronounced effect on reward circuits than more passive visual stimulation, such as a movie or painting.7,8 In contrast to virtual training modalities implemented to increase technical experiences, such as robotic surgery or resuscitation simulations,9 there are limited technical training opportunities aimed at enhancing compassion. Interactive digital works such as That Dragon, Cancer are worth investigating as a response.

Although nothing can replace true-life experiences, the heightened realities of art may be the best chance of mirroring them. As poet Ocean Vuong wrote regarding the care of his dying mother, “we try to preserve life—even when we know it has no chance of enduring its body. We feed it, keep it comfortable, bathe it, medicate it, caress it, even sing to it. We tend to these basic functions not because we are brave or selfless, but because, like breath, it is the most fundamental act of our species: to sustain the body until time leaves it behind.”10 In That Dragon, Cancer, the player does the same. We play with Joel, we feed him, we sing to him. And like Joel’s family, we build up the grace to finally let him go.

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Article Information

Corresponding Author: Daniel P. Mahoney, MD, Palliative Care, Texas Children’s Hospital, 6621 Fannin St, W1990, Houston, TX 77030 (dxmahone@texaschildrens.org).

Conflict of Interest Disclosures: None reported.

Additional Contributions: We would like to thank David Farris, MSIS, AHIP, of MD Anderson’s Research Medical Library for preliminary research. Dr Farris did not receive compensation for his contributions to this article.

Additional Information: That Dragon, Cancer from Numinous Games is available to purchase at http://www.thatdragoncancer.com/. The film Thank You for Playing is available at http://www.thankyouforplayingfilm.com/.

References
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Verghese  A.  Empathy: good for doctors and bad for judges. The Atlantic. Published May 27, 2009. Accessed February 15, 2020. https://www.theatlantic.com/technology/archive/2009/05/empathy-good-for-doctors-and-bad-for-judges/18375/
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Duggan  M.  Who plays video games and identifies as a “gamer”? Pew Research Center Internet and Technology. Published online December 15, 2015. Accessed February 15, 2020. https://www.pewresearch.org/internet/2015/12/15/who-plays-video-games-and-identifies-as-a-gamer/
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Cole  SW, Yoo  DJ, Knutson  B.  Interactivity and reward-related neural activation during a serious videogame.   PLoS One. 2012;7(3):e33909. doi:10.1371/journal.pone.0033909PubMedGoogle Scholar
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Bric  JD, Lumbard  DC, Frelich  MJ, Gould  JC.  Current state of virtual reality simulation in robotic surgery training: a review.   Surg Endosc. 2016;30(6):2169-2178. doi:10.1007/s00464-015-4517-yPubMedGoogle ScholarCrossref
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Vuong  O.  On Earth We’re Briefly Gorgeous. Penguin; 2019.
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