Metaphors in medicine

Metaphors have been abundantly used in the history of medicine, describing health as harmony, the human body as mechanism, disease as disorder, and interpreting the doctor-patient relationship in terms of paternalism and consumerism. Today, metaphors are widely used by doctors and patients to describe conditions and experiences, such as burning pain, cluster headache, glue ear, whiplash injury or invasive cancer. They also play a special role in facilitating communication. For example, Casarett et al. showed that on average oncologists use at least one metaphor in each conversation with patients with advanced cancer. Agricultural, militaristic, mechanical and sports metaphors are employed to explain the disease and treatment plan. Figurative language is appreciated by patients who regard physicians using metaphors as better communicators who present information in an understandable way (Casarett et al. 2010).

The use of metaphors also flourishes in health policy discourse. In the recent Covid pandemic, policymakers initiated a ‘war’ against the virus, like they previously declared wars on cancer and drugs. Military language frames disease in a specific way, referring to danger, and casualties but also control, discipline and surveillance. In the war on Covid-19, the focus is on the virus as the enemy that should be destroyed, or at least contained, rather than on the context in which infections arise and on possibilities of preventing it to emerge. Ecological metaphors on the other hand underline the connectedness between humans and between humans and nature. In such a manner, metaphors help to make sense of what is happening and give meaning to what we experience.

In addition, metaphors guide actions in specific directions. The use of figurative language is therefore not morally neutral. This is illustrated in an example that we discussed earlier in our editorial about education and the soul of medicine (Ten Have and Gordijn 2019). Popular medical writers such as Groopman (2007), Nuland (2010), and Gawande (2014) often use the soul as metaphor to refer to what characterizes medicine and healthcare. Medicine cannot merely be an objective, scientific, disease-centered approach but needs to attend to the subjective needs of patients who do not only want treatment but also care and empathy. If it fails to attend to these needs, it loses its soul (Ten Have and Gordijn 2019).

In this issue, Fabian-Alexander Tietze (2022) criticizes the use of medical metaphors in philosophy. In this field there is an old tradition of using medical terms metaphorically to elucidate reflection, to diagnose problems as pathology, and to identify the purpose of philosophical thinking as healing of the soul. The contribution argues that medical metaphors are not adequate to evaluate philosophy. At the same time, the use of metaphors in philosophy has significantly changed over time with the growing predominance of legal metaphors in the Enlightenment to provide counterweight to the expert paternalism connected to medical language.

The arguments in Tietze (2022) show important characteristics of metaphors. First, they are inescapable, not merely in language but in thought and action. They are used to comprehend experiences, events, and activities, to understand and “make sense of phenomena in the world in human terms” (Lakoff and Johnson 2003, p.34). Second, metaphorical structuring of concepts and experiences has normative implications. Imagining public health as the fight against microorganisms introduces a discourse of heroes, villains and victims, as well as directive policies of containment, controllability and surveillance, prioritizing the public interest over individual decision-making (Ten Have 2022). Interpreting healthcare as a market and care provision as a business promotes efficiency, competition and profits as primary values. The third characteristic is that metaphors are continuously changing; and perhaps they must. Conventional metaphors that structure the conceptual system of cultures, are not taken for granted but critically examined and regularly revised. Especially in ethics and philosophy, the search is for new metaphors that are imaginative and creative to provide a fresh and better understanding of experiences. Since metaphors are not simply a matter of language or words but are associated with concepts and images, they can generate cultural change: “New metaphors have the power to create a new reality” (Lakoff and Johnson 2003, p. 145). If they are tools to comprehend partially what cannot be comprehended totally, metaphors are particularly important to understand moral experiences and practices. In bioethics, reason should be combined with imagination. This is precisely what metaphors facilitate: imaginative rationality. The images they present are categorized, critically examined, and assessed on what they entail for practical use, i.e. communicating experiences, producing mutual understanding, and providing the ability to modify our world views.