Metaphors are not just poetic devices restricted to literature, but part of the fabric of both everyday discourse and of specialist discourse such as medical practice. Two leading or didactic metaphors have shaped Western medicine: since the 16th century, ‘the body as machine’, and since the 17th century, ‘medicine as war’ [2
]. These are metaphors of ‘Force’ rather than ‘Presence’. I will argue that they have forged a medical culture that is no longer fit for purpose: a heroic, masculine, and hierarchical culture that is failing to adapt to an emergent set of healthcare values—patient-centred and team-based, collaborative rather than competitive. Hierarchical, heroic medicine is past its sell-by date. It is time for a medicine in the round that is authentically democratic and embraces the poetic. We need a medicine of hospitality, true to the root of the word ‘hospital’; a medicine of Presence and not Force, shaped by appropriate metaphors. We have outgrown ‘medicine as war’ and ‘the body as machine’. I recognise that it is important to not demonise didactic metaphors. They are not born ‘good’ or ‘bad’ but rather are employed in ways that encompass a moral spectrum. The ‘medicine as war’ and ‘body as machine’ metaphors have driven vital technological and knowledge advances in medicine. However, their transformative energy is spent, indeed there is now a situation of debit.
2.1. The Body as Machine
It is easy to see why the metaphor of the ‘body as machine’ has longevity—it is functional, reducing unpredictable complexity to predictable linearity. This is comforting as it reduces uncertainty or ambiguity. Once the body is configured as a machine, it becomes potentially fixable and can be engineered. Of course, this is extremely helpful in many ways, allowing for a range of interventions from targeted drug therapies to neurosurgery. However, bracketing out the difficult bits such as the mind and emotions–or leaving these to the oddballs, the psychiatrists—reduces the complex and abstracted person first to the literal body, second to the complicated linear machine, and third to its component parts—the liver a chemical factory; the heart a pump.
Of course the heart is a pump, but it is also a major attractor in a dynamic, adaptive, and complex system that is the human body embedded in a yet more complex environment. Poetically and psychosomatically, the heart is the locus of love and courage. The mind is surely more complex than its reduction to the matter of the brain modelled in terms of a computer, or generally as electrical engineering, with sick minds a product of faulty wiring. For example, in pain treatment, machine metaphors are legion and often negative, closing off thinking for patients, where ‘locks’, ‘keys’, ‘wires’, ‘circuitry’, and ‘doorways’ are commonly described [3
The ‘body as machine’ can be traced back to Vesalius’ Fabrica, for three centuries the most influential Western anatomy text, where veins, arteries, and nerves are described as hollow tubes ‘like a pipe’. These conduits supposedly worked through pneumatics, where air gives motion to fluid. Nearly a century later, René Descartes (1596–1650) declared that ‘the body is to be regarded as a machine’, explicitly compared the arrangements of the organs in the body with that of ‘automata’ or ‘moving machines’. Giorgio Baglivi (1668–1706), an Italian physician and scientist famous for distinguishing between smooth and striated muscle, deepened this metaphor. Baglivi saw the body as composed of numerous smaller machines: the teeth as scissors, viscera and glands as sieves, the heart and blood vessels as waterworks, and the stomach a flask. Through his sermons, the 18th century Methodist minister John Wesley (1703–1791)—who had studied medicine at Oxford where Thomas Sydenham was a formative influence—described the body as having ‘a thousand tubes and strainers’, any one of which could get obstructed.
Such metaphors still linger, where the lungs are thought of as ‘bellows’, the urinary tract as ‘plumbing’, the liver as a ‘factory’, the heart as ‘ticker’, and various electrochemical mechanisms passing sodium or calcium ions across cell membranes, as ‘pumps’. The rise of neurophysiology, as noted above, brought with it notions of ‘circuits’, ‘switches’, and ‘transistors’, and the brain is finally compared with a computer. In contemporary personalised medicine, based on the genome, health is described as a function of genetic ‘engineering’.
2.2. Medicine as War and Illness as A Battle
Susan Sontag (1978) famously railed against the use of martial metaphors such as the ‘war on cancer’, suggesting that we abandon use of metaphor in medicine altogether [4
]. This, however, throws the baby out with the bathwater. Metaphors serve various purposes in medicine. The issue is, rather, to shift away from ‘dead’ and stigmatising metaphors to those that vivify.
The war metaphor is so familiar and commonplace in our medical rhetoric that we easily lose sight of its militaristic origins and significance. Notions of ‘fighting’ disease entered Western medicine primarily through the work of Thomas Sydenham in England in the mid-17th century. Prior to that, links between illness and violence metaphors referred to a moral struggle. Where medieval medical texts refer to ‘fighting’ metaphors, these are in the context of fighting sin, so that illness may be metaphorically contextualised as a moral problem. ‘Holy’ and ‘healing’ stem from the same root, where a holy body is a whole body, balanced and well.
Sydenham described medical intervention as if he were vigorously using an assault weapon: ‘I attack the enemy within’, where ‘A murderous array of disease has to be fought against, and the battle is not a battle for the sluggard’. The most famous physician of his day, Sydenham summed up his approach as follows: ‘I steadily investigate the disease, I comprehend its character, and I proceed straight ahead, and in full confidence, towards its annihilation’. Sydenham may have known the poet John Donne’s sermons that included frequent use of ‘illness as violence’ metaphors; and in his writing, such as ‘Devotions Upon Emergent Occasions’, Donne describes his own illness in 1627 as resembling a ‘siege’ and a ‘cannon shot’. Donne thought he was dying from a fever ‘that blows up the heart’, also describing an ‘illness that invades’.
Sydenham’s metaphors did not constitute a dominant discourse at the time. Such a discourse was established in modern medicine two centuries later through Louis Pasteur’s ‘biomilitarism’. While early 19th century doctors often used passive language such as plagues ‘laying’ upon people, Pasteur mobilised an unashamedly active, militaristic language, where diseases ‘attacked’ persons. Pasteur’s description of germ theory displaced a previous language of bodily ‘excess of vital forces’ with a language of invading armies laying siege to the body that becomes a battlefield.
Over a century later, medicine as battle is now a naturalised notion, but once had to be established with militaristic zeal. We know, through computer-assisted corpus linguistic analysis, that violence and war metaphors are common particularly in cancer discourse. Yet research tells us that those cancer patients who view their disease as an ‘enemy’ show higher levels of anxiety and depression, a poorer quality of life, higher levels of pain, and less ability to cope overall than those who represent their illness with a more positive meaning. These findings have been replicated for other conditions such as rheumatoid arthritis. Patients encouraged by their doctors and healthcare workers to ‘fight’ their illnesses report suppressing emotional distress as they put a positive ‘face’ on things in order to not upset both family members and clinicians.
A ‘war against cancer’ was first described in a lead article in the British Medical Journal in 1904. This rhetoric was extended to identify the ‘fight against cancer’ as an issue of imperialist domination, where the disease itself was described as ‘darkest Africa’ waiting to be discovered and conquered. Later, cancer cells were identified with Bolsheviks, as ‘anarchic’, threatening the stability of the body. In 1971, Richard Nixon, then President of the United States, delivered a famous speech declaring a war on cancer, where science would ‘conquer’ the disease. At this time, bioscience was replete with martial terms such as ‘killer’ cells and ‘invasive’ species. The gross military metaphor was refined through cellular pathology. As knowledge accumulated about the microorganisms that cause illness, they were described as ‘invading’ the body that produces its own ‘defences’. The body in the early 20th century medicine is configured as a fortress that must be protected from external penetration by germs, or defended from attack. Medicine adopts ‘aggressive’ treatments while the patient is in the line of fire.
Medicine’s hospitality, configured in the hospital, has been forced to adapt to this tough-minded Procrustean bed, so that the hospital itself, and its cells (in particular the operating theatre), become general zones of conflict and specific theatres of war. Violence perpetrated by patients on hospital staff constitutes about three quarters of all workplace assaults and has almost doubled in North America in particular over the past few years [5
]. Hospitals can be considered unsafe and unsavoury places to work if harassment and insult by doctors and surgeons aimed at juniors and other healthcare staff is added to the mix of assaults by patients.
Medicine’s saturation in war-making discourse comes to normalise language such as combating illness, where invading bugs are the enemy in the battlefield of the patient’s body, that is under siege but might be treated with magic bullets. Such metaphors extend to nursing culture that is configured as adversarial, where practitioners use phrases such as becoming ‘fatigued by having to do all these battles’, feeling ‘sabotaged’ ‘taking flak’, and working ‘in the trenches’, while their supervisors have ‘deserted the troops’.
The ‘body as machine’ and ‘medicine as war’ metaphors were aligned to produce a powerful frame of reference in the era after the Second World War, as part of a wider cultural ‘military–industrial’ complex. Many doctors had also fought in WWII, and, in North America, subsequently in the Korean and Vietnam wars. The medical gaze became equated with the martial gaze, the battlefield changing through history from the sickroom of the 18th century to the pathologist’s bench of the 19th century, to the imaging room of the 20th century, and to the DNA sequencer’s computer screen of today. Genome sequencing in particular is used to launch ‘precision attacks’ against different types of cancers, where the old military metaphors of combating disease are back in new guise.
The language of war works within its own logic by eradicating its enemies, so it is difficult to spot alternative metaphors. Martial metaphors are inherently bullying—masculine, power-based, paternalistic, and violent or violating. However, patients may tire of this. A patient with colon cancer says that others configuring his illness as a battle ‘was less than palatable’ because: ‘I had already experienced real war in Vietnam and was not anxious to repeat anything closely resembling that.’ It may be exhausting for already exhausted patients to think that they have a battle on their hands, and the notion of victory may be far from the reality. The patient is stigmatised.
Another danger of the dominant militaristic metaphor is that it engages medicine in an arms race, where the dominant fantasy is that all health problems will ultimately be solved with sophisticated technologies as explosive innovations. Further, this metaphor again encourages militaristic organisational structures such as hierarchies with male dominance linked to the aggressive marketing strategies of Big Pharma. Finally, the militaristic metaphor celebrates control and certainty, where much of medicine is in fact about tolerating ambiguity.
By sticking with, and developing or refining, machine and war metaphors, contemporary medicine operates as if driving a car with the brakes on. How will patients of the future benefit from values, descriptions, and practices that potentially objectify, dehumanise, and stigmatise them and place them in a war zone? Just as medical students learn ‘communication skills’ only to enter practice and interrupt patients on average within 20 seconds of the clinical encounter as a violation of the principle of ‘patient-centredness’, so imagining the body as a machine needing an oil change or a tune up negates the complexity of the illness experience; and perpetuating war metaphors situates patients in a metaphorical landscape not of their choosing.