There are a lot of topics that D&D isn’t ready-made to explore. As best as I can tell, disease (chronic or acute) is one of them.

This line of thought came up for me while talking with my sib about dangerous encounters in a weird fantasy / sci-fi / horror adventure campaign I’m running for some friends. It’s a roughly post-apocalyptic setting, based in The Hub, in which the apocalypse(s) in question took place a variable amount of time ago and in different fashions, depending on where the PCs explore. Some of the perils the PCs face include radiological disasters, and radioactive environments or threats.

My sib, naturally, asked what I’d done on the topic of cancer.

My sib has been the primary caregiver for a loved one dealing with cancer and cancer treatment. They have some fairly distinct and immediate thoughts about how cancer might be modeled in D&D, how it might be treated, and what the long term effects on a PC might be. I—almost immediately—told them that I wasn’t doing any of those things. Instead, I let an effect equivalent to a 2^nd level spell (Lesser Restoration) resolve any short term concerns for the PCs.

When the PCs first encountered a radiological hazard in this campaign and asked me about how I’d handle cancer, I kicked the question back to them. The quick version was: do you want a serious, realistic depiction of cancer in this game? Their quick answer was “no thank you.”

Since then, my players have not asked, explicitly or implicitly, for a game that deals realistically with personal experiences of cancer. I didn’t start running this game in order to explore those things either. Before launching us into that new territory, I’d want to ask my players (again) whether they were on board for wrestling with a realistic depiction of cancer.

You know, I was going to link to yet another post here. Instead, I see from a search of my previous posts that I ought to write more content about consent, playing to your partner’s level, etc. I really thought I’d already written more of those posts by now.

But basically, realistic depictions of cancer and chronic illness are sufficiently outside my expectations of adventure fiction, even adventure fiction with horror. I’d be reluctant to leap into exploring those depictions without the excited approval of the other players (and myself).

For this game I settled on allowing the “cure disease” effect of Lesser Restoration or a paladin’s Lay On Hands to resolve the present threat of cancer (for non-lethal exposures). This still makes curing cancer non-trivial for the general populace: 3^rd level characters are, by my understanding, less than 1/1000^th of the population, and their willingness to spend their time and valuable magical resources curing people may vary significantly. The fact is, the perspective of a PC in D&D is thoroughly skewed by their regular exposure to other individuals with class levels—they have better access to curing weird diseases than the general population. I’m okay with letting PCs spend their own resources to resolve the consequences of their explorations, or barter favors for the services of someone who can do that for them.

Beyond that, the basic systems of D&D 5e are built around the assumed existence of some really wild magical effects. Some 3^rd level spell casters can go invisible, others have limited mind control, and others can knit your broken flesh back together. At higher levels, people expect to be able to fly, or fling lightning bolts, or animate skeletons or (eventually) resurrect the dead. The expected realm of possibilities, the game’s flavor or circle of belief, is just… tonally different from the realistic depiction of the exhausting and painful nature of chronic illness. It can be horrific or challenging, but the D&D I play is still—almost always—about empowerment.

Which brings me back to the thought I had at the top: D&D isn’t ready-made to explore chronic disease. There are variants offered in the DMG that incorporate grievous injuries resulting in loss of limb, but none that introduce more-difficult-to-cure diseases. The DMG even states on p256 that “A disease that does more than infect a few party members is primarily a plot device.” I don’t disagree, but this means that in D&D any such exploration is especially reliant on storyteller skill and player collaboration.

In other words, when it comes to disease you will mostly be making it up as you go.

That’s okay! Making shit up is part of what I love about RPGs, and not every game needs to have WFRP (Warhammer Fantasy RPG) levels of detail for disease, distress, and dismemberment. This system-focus, and the flavor it creates, is just one of the many reasons that WFRP and other Warhammer RPGs feel distinct from D&D. It’s all about what the RPG system pays attention to, and how that influences the stories that game most easily tells.